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Very Brief Advice (VBA):
A practical tool to advise your
smoking patients
Dr Alex Bobak
GP Specialist in Smoking Cessation
Wandsworth, London, United Kingdom
The power of nicotine addiction
Inhaled nicotine from tobacco
smoke is as or more addictive
than heroin or cocaine.
Royal College of Physicians. Nicotine addiction in Britain –
A report of the Tobacco Advisory Group of the Royal College of Physicians. 2000.
What % of alcohol or nicotine
users become dependent?
• Alcohol - 10-15%
• Nicotine - 70-80%
NHS Digital. Smoking, Drinking and Drug Use Among Young People in England – 2016.2017.
When talking to a smoker you are
probably communicating with an
addict so you have to be careful
what you say and how you say it
Giving advice to smokers
Advice on quitting smoking
from a healthcare
professional can be one of
the most important triggers for
a quit attempt1
1. Prof Mike Russell 1979
2. Roberts NJ, et al. Health Serv Insights. 2013;6: 79–85.
Very Brief Advice (VBA)
What is the most common advice
which Health Care Professionals
(HCPs) make to smokers?
Advice to stop smoking
WHICH HAS SIMILAR EFFECT TO NO ADVICE
Problems with “advice to stop” Negative message
Nagging
Nothing new
Encourages conflict and denial
Frustrating for both HCP and smoker
Takes longer
Puts you off doing it again
Smokers know they should stop:
83% wish they‟d never
started2
70%want to stop
smoking1
BUT THEY DO NOT KNOW HOW TO STOP!!
1. Bridgwood, A. et al General Household Survey 1998, Office for National Statistics, UK; 2 Jarvis, MJ. et al. British Medical Journal. 2002; 324(7337):608.
Ideas for better advice which we
can give to smokers?
Advice HOW to stop smoking
3 key elements to stopping
successfully:
• Wanting to stop smoking
But for 95-97% of smokers wanting to stop is not
enough1, they need:
• Good quality support
• Evidence based treatments
1) Hughes JR et al. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004; 99(1): 29-38.
The most successful interventions require a combination of
behaviour support and pharmacotherapy
a Estimated 52-week quit rate; b 9–24 and 9–52 week continuous abstinent rateAdapted from 1. West R, Owen L. Estimates of 52-week continuous abstinence rates following selected smoking cessation interventions in England. Version 2. March 2012. Available at: http://www.smokinginengland.info/latest-statistics/. Accessed October 2019; 2. Monthly trends on smoking in England from the Smoking Toolkit Study. Available at: http://www.smokinginengland.info/latest-statistics/. Accessed October 2019. *Accessed through NHS stop smoking services
Long-term quit rates
0%
5%
10%
15%
20%
25%
30%
35%
Unaided OTC NRT Prescription pharmacotherapy
Behaviour support + placebo
Behaviour support + prescription
pharmacotherapy
4% a
7−12% a
11−31% a
10−13% b
4% a
Range
Range
Range
2.3% of attempts2*
Efficacy of Behavioural Support and Pharmacotherapy
BS = Behavioural Support
Var = Varenicline
NRT = Nicotine ReplacementTherapy
Bup = Bupropion
tment
Professor Robert West, figure developed by combining individual relative risk estimates given in Cochrane reviews; bars represent 95% CIs
based on risk ratios versus placebo (for medications) or brief advice/no treatment (for BS); figures for BS + NRT/Bup/Nor/Var involve
multiplying effect of BS and effect of medication
What is Very Brief Advice?
A simple form of advice designed
for busy clinicians to be used
opportunistically in less than
30 seconds in almost
any consultation with a smoker by
telling them how to stop and
directing them appropriately
VBA DELIBERATELY AVOIDS
“CHALLENGING THE ADDICT”
SO DOES NOT:
• advise smokers to stop
• ask how much or what they smoke
• ask if they want to stop
Very Brief Advice (VBA) for smokers
1. ASK: Establish and record smoking status:
“Do you smoke?/Are you still smoking?”
www.nice.org.uk/nicemedia/live/13542/55599/55599.pdf
What comes next is a simple
statement advising that the
best way to stop is with a
combination of
support and treatment, which
can increase the chance of
stopping many times
Very Brief Advice (VBA) for smokers
1. Establish and record smoking status:
“Do you smoke?/Are you still smoking?”
2. Advise how to stop:
“The best way to stop is with support and treatment”
www.nice.org.uk/nicemedia/live/13542/55599/55599.pdf
68%
0 100
Offer to support to stop
Offering NRT
RR 1.68, 95% CI: 1.48-1.89
RR 2.17, 95% CI: 1.52-3.11117%
Created from Aveyard, P et al. Addiction. 2012;107:1066–73
Increase in chance of stopping compared with no intervention/advice
So what next?
We then need to offer
support and treatmentaccording to how the
smoker responds and
what is available locally
Very Brief Advice (VBA) for smokers
1. Establish and record smoking status:
“Do you smoke?/Are you still smoking?”
2. Advise how to stop:
“The best way to stop is with support and treatment”
3. Offer support and treatment:
“When you are ready just make an appointment with [XXX] who
is great!”
www.nice.org.uk/nicemedia/live/13542/55599/55599.pdf
And remember, there are TWO opportunities
to initiate VBA
Opportunistically
at the end of a
consultation
Within a
consultation
linked to a
smoking related
condition
Benefits of Very Brief Advice (VBA):
• Brief! (<30 seconds or it won’t be used)
• Records smoking status (as 70%+ relapse rate)
• Opportunistic (suitable for almost any consultation)
• Positive (or you put them off trying)
• Not confrontational or nagging (not telling them to stop)
• Informative (saying how to stop)
• Engaging (new information)
• Evidence based
• NOT a smoking cessation consult (thats for next time)
• Very simple: MINIMUM EFFORT,MAXIMUM REWARD
Training module on VBA
NCSCT website:
www.ncsct.co.uk/VBA
What happens next
• They come back for dedicated appointments about
stopping smoking…
• This can be delivered by healthcare professionals as Brief
Support and Treatment (BST)
What is brief support and treatment (BST)?
A consultation guide
designed for busy clinicians
to deliver the essential
elements of smoking
cessation in the context of
their routine practice in
standard 10 minute
appointments
BST regime
• 4-6 ten minute appointments
• Over 6−12 weeks
• Weekly or two weekly then less frequently
• Choice of all treatments
• Brief behavioural support
• CO monitoring if possible
Pre-quit
appointment
Quit date
appointment
Follow-up
appointmentsFinal visit
May be the same, if using NRT Over 2–3 months(weekly or two weekly, then
monthly, for a total of about 3
appointments
The Brief Support and Treatment (BST) regime
NRT = nicotine replacement therapy.
Information provided by the speaker, based on clinical experience and knowledge.
Pre-Quit Appointment
1. Congratulate, and brief motivation check
2. Check addiction level
3. List all available treatments and explore choice
4. Agree and record a quit date
5. Check breath carbon monoxide (CO) if possible
6. Prescribe agreed cessation treatment for the first two weeks
7. Arrange follow-up appointment in one or two weeks
8. Get commitment with the “not a puff” rule
Quit Date Appointment
1. Discuss withdrawal symptoms and cravings and how to deal with
them
2. Advise on changing routine / habits
3. Discuss their smoking contacts and how to get support
4. Address any potential high risk situations in the coming week
1. Discuss on-going treatment and progress of cessation
2. Congratulate success and advise on avoiding relapse
3. Ideally, check breath CO
4. Prescribe further treatment until next appointment
5. Arrange next appointment
6. Give encouragement
7. Continue follow-up for 8–12 weeks
Follow-up Appointments
1. Last CO check (if possible)
2. Congratulate on success (hopefully)
3. Remember (yourself) there is a high risk of relapse:
• Advise that „the door is always open‟
• Emphasise you are happy to help again
• A variety of other treatments and approaches are available!
Final Visit
Comparison of NNTs to obtain one long-term quitter
NNT, numbers needed to treat
1. Aveyard P et al. Addiction 2012;107:1066–73 2. Cahill K et al. Cochrane Database Syst Rev 2016;(5):CD006103.
Nu
mb
er
ne
ed
ed
to
tre
at (N
NT
)
Smoking cessation behavioural
support2
To obtain one long-term quitter 51
23 22
11
0
10
20
30
40
50
60
Brief advice NRT+
Bupropion+
Varenicline+
1
Comparison of NNTs to prevent one premature death*
51
23 22
11
102
46 44
22
0
20
40
60
80
100
120
Brief advice NRT+
Bupropion+
Varenicline+
Nu
mb
er
ne
ed
ed
to
tre
at (N
NT
)
Smoking cessation behavioural
support2
To obtain one long-term quitter
To prevent one premature
death
*Over half of all continuing smokers will die prematurely from a smoking-related disease. For every two long term quitters, one premature death is avoided. (Source: NHS England Smokefree Clinician‟s 30 second stop smoking advice. Department of Health.) **Calculated on the basis of the NNT values from the previous slide. NNT, numbers needed to treat. Adapted from 1. Aveyard P et al. Addiction 2012;107:1066–73 2. Cahill K et al. Cochrane Database Syst Rev 2016;(5):CD006103.
1
**
** **
**
Comparison of other NNTs
51 23 22 11
10246 44 22
107
700
1140
0
200
400
600
800
1000
1200
Brief advice NRT+
Bupropion+
Varenicline+
Statins as primary
prevention
Antihypertensive treatment for mild
hypertension
Screening for cervical cancer
To obtain one long-term quitter
To prevent one premature death
MI, myocardial infarction. *Over half of all continuing smokers will die prematurely from a smoking-related disease. AdaptedFor every two long term quitters, one premature death is avoided. (Source: NHS England SmokefreeClinician‟s 30 second stop smoking advice. Department of Health.) **Calculated on the basis of the NNT values from the previous slide. NNT, numbers needed to treat. Adapted from 1. Aveyard P et al. Addiction 2012;107:1066–73 2. from Van Schayck Cahill K et al. Cochrane Database Syst Rev 2016;(5):CD006103. Van Schayck OCP, et al. NPJ Prim Care Respir Med. 2017;27:38. doi: 10.1038/s41533-017-0039-5.
Nu
mb
er
ne
ed
ed
to
tre
at (N
NT
)
Smoking cessation behavioural
support2
To prevent
one death
over 5
years
To prevent
one stroke
or MI death
over 1 year
To prevent
one death
over 10
years
1
3 3
3
