Financial incentives for UK GPs to document smoking cessation support may have boosted record-keeping but failed to increase the delivery of the most effective treatments for patients with cardiovascular disease (CVD), a new study from the University of Oxford suggests.
The research, led by the Nuffield Department of Primary Care Health Sciences and published recently in BMC Primary Care, analysed anonymised general practice records from over 240,000 UK adults who were smoking when diagnosed with coronary heart disease (CHD) or stroke between 1996 and 2019.
It investigated the impact of the Quality and Outcomes Framework (QOF), a pay-for-performance scheme introduced in 2004. The findings reveal a significant gap between the recording of simple advice and the provision of evidence-based treatments, raising questions about whether the incentives are improving clinical practice or encouraging 'box-ticking'.
Quitting smoking after a CVD event like a heart attack or stroke is crucial for preventing further events, yet the study found:
- Education vs effective treatment:
While recording smoking cessation education became common after QOF was introduced (documented for more than 71% of CHD and more than 75% of stroke patients post-QOF), prescriptions for nicotine replacement therapy (NRT) or other medications, and referrals to specialist services – interventions proven most effective – remained much less frequently documented. - QOF Impact:
QOF coincided with increased documentation of advice, but interventions recorded before QOF showed a significantly stronger association with successful quitting. - Mental health disparity:
Patients with co-existing common or serious mental illness were significantly less likely to successfully quit smoking compared to those without mental illness, even when interventions were recorded in their notes.
Lead author Dr Angela Difeng Wu, Postdoctoral Researcher and lecturer based in the department, stated: "Our findings prompt an important question: is the current incentive system truly improving the delivery of effective smoking cessation care, or is it primarily encouraging 'box-ticking' in patient records? While documenting advice is important, it's the evidence-based treatments – medication, specialist support – that give patients the best chance of quitting successfully."
Dr Wu added: "It's particularly concerning that patients with mental health conditions, who often smoke more heavily and face greater challenges quitting, are less likely to succeed even when interventions are recorded. This highlights an urgent need to move beyond simply recording advice and ensure these patients receive intensive, tailored support that addresses their specific needs."
The authors note that as an observational study using electronic health records, it cannot definitively prove causation or capture the nuances of clinical consultations. The finding that recorded pharmacological interventions were associated with lower quitting likelihood in the analysis likely reflects GPs targeting these treatments towards patients perceived as having higher nicotine dependence or finding it harder to quit, rather than the treatments themselves being ineffective. Established trial evidence confirms the effectiveness of stop-smoking medications.
The researchers conclude that financial incentives focused solely on documentation may not be sufficient to improve cessation outcomes, especially for vulnerable groups. They suggest a need to rethink how effective practice is supported and potentially incentivised within primary care to ensure patients receive the support they need to quit smoking.
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The study, "Investigating the association between recorded smoking cessation interventions and smoking cessation in people living with cardiovascular disease using UK general practice data," was published in BMC Primary Care on 1 May 2025.