Expert opinion
How does Very Brief Advice (VBA) actually work? Hear expert advice on how to deliver VBA:
- Past successes and advice on how to set up a stop smoking service in your pharmacy
- The effect of tobacco dependency on mental health
- Practical advice for supporting smokers quitting tobacco during the COVID-19 pandemic
Q. Why is Very Brief Advice different?
A. As GPs we are well trained in how to get the best out of a consultation for the person seeing us. We use various behavioural change techniques such as goal setting, helping people to measure positive change and eliciting and building motivation for better health outcomes. What we then naturally want to do with tobacco addiction is apply these skills. However, this work takes time. As part of a Diabetes review we might plan to make time for this but tobacco action tends to be the last 30 seconds of a consultation that is about something else entirely - we don't do annual reviews for people on the tobacco dependency register - so we need an alternative.
That is Very Brief Advice; it doesn't set goals, explore readiness to quit or motivation to succeed. It's something different entirely and that is why we need to train for it. The good news is that the lesson is quick and the intervention is possible in that 30 seconds.
You gather information in an emotionally neutral way, you provide some information about what works and then you find out what they want to do. That’s it!
Q. What is the biggest challenge for GPs when treating patients with tobacco dependency?
A. We feel underconfident in prescribing and as a result we tend to underdose and undertreat. There is still anxiety about quit medicines such as varenicline especially around mental health that is no longer a well-founded worry. Lack of familiarity with a medicine means you are less sure about interactions and contraindications so less likely to prescribe. There has been a lot of discussion recently about nicotine safety because of vaping concerns but any toxicity from vapes or smoked tobacco is never about the nicotine it’s the products inhaled from burning tobacco and whatever harm the diluent in the vape liquid might be causing. As a result people receive nicotine replacement therapy (NRT) at doses way below what they are used to smoking and so they are more likely to return to the substance that gives them that nicotine kick, tobacco.
Q. What is the correct language when using Very Brief Advice?
A. For me it’s usually easy to kick off by referring to what is already in the notes. In the UK we have been recording smoking status as part of a quality improvement scheme since 2003 so for most people the smoking status has been recorded multiple times. So I would say something like: “I can see that last year you said you were still smoking, is it still the same or has anything changed since we last asked?” I can then update them on what medicines and services are available since we last spoke about it. I don’t talk about how smoking is connected to any illness they have as they will know this already. I keep the message positive, we are always finding out more about what works and I bring that in to give a sense of hope. There is no point in forcing, my job is to make it sound possible and be clear that I can help - that is all I really want to get across.
Q. Do you have a 'surprise' story of when you have successfully delivered effective Very Brief Advice?
A. I was seeing a man who I knew was a smoker and I had delivered Very Brief Advice in the past. I saw him for a non-related problem. At the end I delivered Very Brief Advice. He told me that actually he was ready and he was glad I asked. He was in the midst of family court proceedings and wanted to ensure that he was able to spend some time with his daughter. Being a non-smoking Dad was a big motivator for him. It was likely he was going to get shared parenting for his daughter as there were no safeguarding issues but he really wanted to show the family court he wanted to be the best Dad he could be. His daughter was 6 and had been asking him to quit as they had been learning about it at school. All the ducks lined up and it was the right day to have used Very Brief Advice.
Q. Why is Very Brief Advice different?
A. Very Brief Advice is different to the advice many pharmacists are used to providing; it purposely doesn’t explore how many cigarettes/roll-ups a person smokes, nicotine dependency, past quit attempts or even motivation to go ‘Smokefree’ as health care teams couldn’t possibly do that with all smokers that walk into a pharmacy.
The hope is that pharmacy teams will offer Very Brief Advice at every possible opportunity.
When a person brings in a prescription for long term condition e.g. asthma, or if a person is requesting over the counter treatments e.g. cough mixture, cold sore treatments, herbal treatments for insomnia or low mood. It’s the perfect opportunity to naturally ASK, ADVISE and ACT in 30 seconds.
The ‘ADVISE’ part in Very Brief Advice is structured in a way to positively offer a person support and treatment that’s locally available e.g. face to face, telephone, web based or app, alongside treatments.
Q. What is the biggest challenge for pharmacists when treating patients with tobacco dependency?
A. Pharmacy teams in many countries have been offering smoking cessation advice for years. If prevalence of smoking is high in certain population groups e.g. people with mental illness, pregnancy, certain ethnic groups or teenagers then it can be an awkward conversation to have. But if Very Brief Advice is practised first and then carried out routinely, it becomes second nature and simple to do. If 1 or 2 people out of 100 stop smoking as a result of a 30 second intervention I see that as a massive success. The good news is that many smokers expect to be asked and Very Brief Advice is evidence based medicine.
Training (skills and knowledge) and adequate renumeration varies from country to country and also within countries. The footfall of smokers is very high in community pharmacies and if Very Brief Advice was maximised many more smokers would stop. Behaviours change when there is the capability, opportunity and the right motivation.
Q. What is the correct language when using Very Brief Advice?
A. The ‘ASK’ is usually ‘do you smoke?’ but sometimes I vary it in the pharmacy by asking “have you been exposed to second-hand smoke or smoke yourself?” I find it particularly useful to ask when prescriptions for inhalers or antibiotics arrive or cough mixture is bought as passive smoking can trigger/worsen respiratory-related symptoms. The ‘ADVISE’ part is simple and positive as it highlights that support and treatment is available and there’s always something we can do e.g. as a minimum sell NRT products with telephone or web-based support. Ideally we should promote the most effective treatments if they are available and appropriate for the individual e.g. varenicline with more intensive behavioural support (usually involving weekly support sessions by a trained advisor).
Positive body language always helps and if time allows, highlighting that many people who’ve joined the national service (or your own if applicable) have gone on to successfully stop, will instil confidence.
Q. Do you have a 'surprise' story of when you have successfully delivered effective Very Brief Advice?
A. A man in his eighties diagnosed with COPD coming in to the pharmacy for advice on inhaler technique. I carried out Very Brief Advice and he didn’t realise that he could use NRT whilst he was smoking. A few weeks later he unexpectedly told me that he stopped smoking altogether and was happy to carry on using his patch with the inhalator for breakthrough cravings. One year on, he still comes in to see me and says he feels great!
On the flip side, I offered Very Brief Advice to a lady who came into see me after having surgery to remove part of a lung. She told me she wasn’t ready to stop, that smoking is a part of her identity and she understood the risks. I mentioned that when she is ready support and treatment is available FREE on the UK National Health Service.
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