Impact of contractual financial incentives on the ascertainment and management of smoking in primary care

Background: The April 2004 contract for UK general practitioners (GPs) is an ambitious attempt to produce substantial changes in clinical practice. We investigated the impact of this on delivery of primary care smoking cessation interventions. Methods: We analysed data from patients' medical records that were held within a large database called The Health Improvement Network (THIN). We calculated for each year between 1990 and 2005 and for each quarter-year from 2003 the incidence of recording of smoking status in medical records and, in smokers, the receipt of GPs' smoking cessation advice and prescriptions for nicotine addiction treatments. Findings: Recording of smoking status increased temporarily around 1993-4 and then rose gradually from the year 2000. This rise was more marked from 2003, with an 88% increase between the first quarters of 2003 and 2004. The latter quarter was just prior to the introduction of the GP contract and higher rates of recording smoking status were sustained for the subsequent year. In smokers, there was a broadly similar pattern for the proportion recorded as having received brief cessation advice. However, while there was a sharp increase in prescriptions for nicotine addiction treatments from 2000, no comparable acceleration in this trend from 2003 was apparent. Interpretation: The 2004 GP contract increased primary care rates of smoking status ascertainment and recording of advice against smoking. The public health impact of this contract could be maximized if it also improved GPs' prescribing of nicotine addiction treatments.