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Clinical guidelines

Supporting smoking cessationA guide for health professionals

The role of health professionals

Smoking cessation advice and support from health professionals are key aspects of a comprehensive approach to tobacco control. Health professionals can make an important contribution to tobacco control in Australia and to the health of the community by providing opportunities for smokers to quit. An encouraging environment can be provided in health settings (primary and community care, hospitals, dental, eye care and pharmacies)6,8,2730,42 and in non-health settings (workplaces, prisons, schools, state housing, social welfare services).43,44 All types of health professionals can play an important role – WHO states that involvement in offering smokers advice and assistance with quitting should be based on factors such as access, rather than professional discipline.13 In general practice, primary healthcare nurses (often referred to as practice nurses) can play an important role and potentially upskill to become tobacco treatment specialists.

Health professionals play an important role in educating and motivating smokers as well as assessing their dependence on nicotine and providing assistance to quit. All health professionals should systematically identify smokers, assess their smoking status and offer them advice and cessation treatment at every opportunity.27–30,45 Where a client presents with a problem caused or exacerbated by smoking, it is of vital importance for health professionals to raise the issue of smoking cessation.

There is a range of evidence-based strategies that can improve the implementation of effective smoking cessation intervention in the practice setting.46–49 Providing a systematic approach to smoking cessation is associated with higher levels of success.11 Routine enquiry through waiting room surveys48,50 or use of additional practice staff to provide counselling is associated with higher quit rates.30 Where health professionals are not able to offer support or treatment within their own practices, they should refer smokers for help elsewhere – for example, to Quitline, to one of the increasing number of accredited tobacco treatment specialists (www.aascp.org.au) and to local programs such as the Fresh Start course by Quit Victoria.51

Brief interventions for smoking cessation involve opportunistic advice, encouragement and referral. Interventions should include one or more of the following:7,11,52

  • brief advice to stop smoking
  • an assessment of the smoker’s interest in quitting
  • an offer of pharmacotherapy where appropriate
  • providing self-help material
  • offering counselling within the practice or referral to external support such as Quitline (see Appendix 2), an accredited tobacco treatment specialist or other local programs in your area.

Beliefs that can be barriers to optimal smoking cessation advice

Asking about smoking and offering advice and assistance are key roles for health professionals. Barriers raised by health professionals to engaging in greater efforts to provide smoking cessation advice include:

  • a perception that it is ineffective
  • lack of time
  • lack of smoking cessation skills
  • reluctance to raise the issue due to perceived patient sensitivity about smoking
  • perceived lack of patient motivation.53,54

Table 3 presents evidence in relation to these barriers.

Table 3. Barriers to smoking cessation
Belief
Evidence

Assistance with smoking cessation is not part of my role

Most patients think smoking cessation assistance is part of your clinical role45,55

I have counselled all my smokers

Only 45–71% of smokers are counselled56,57

Smokers aren’t interested in quitting

Nearly all smokers are interested in quitting although some are temporarily put off by past failures. More than 40% of smokers make quit attempts each year and more think about it58

I routinely refer patients for smoking cessation assistance

Referrals to Quitline are low (10–25%)59

I’m not effective

Clinicians can achieve substantial quit rates over 6–12 months, 12–25% abstinence, which have important public health benefits27,43,51

Smokers will be offended by enquiry

Visit satisfaction is higher when smoking is addressed appropriately57,60

I don’t have time to counsel smokers

Effective counselling or referral can take as little as a minute11

 

Evidence

Smoking cessation advice from health professionals is effective in increasing  quit rates. The major effect is to help motivate a quit attempt. Level I. All health professionals can be effective in providing smoking cessation advice. Level I

Recommendation

All smokers should be offered brief advice to quit. Strength A

References

     
  1. Richmond RL. The physician can make a difference with smokers: evidence based clinical approaches. Int J Tub Lung Dis 1999;3:100–12.
  2. Zwar N, Richmond R, Borland R, Stillman S, Cunningham M, Litt J. Smoking cessation guidelines for Australian general practice: practice handbook. Canberra: Australian Government Department of Health and Ageing, 2004.
  3. Zwar N, Richmond R, Borland R, et al. Smoking cessation pharmacotherapy: an update for health professionals (updated 2009). Melbourne: The Royal Australian College of General Practitioners, 2009.
  4. Fiore MC, Jaén CR, Baker TB, Bailey WC, et al. for the Guideline Panel. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, May 2008. Available at http://www.ncbi.nlm.nih.gov/books/NBK63952/ [accessed 20 March 2011].
  5. Raw M, Anderson P, Batra A, et al for the Recommendations panel. WHO Europe evidence based recommendations on the treatment of tobacco dependence. Tobacco Control 2002;11:44–6.
  6. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008, Issue 2. Art. no. CD000165.
  7. Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database Syst Rev 2004, Issue 1. Art. no. CD003698.
  8. Carr A, Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database Syst Rev 2006, Issue 1. Art. no. CD005084.
  9. Rice VH, Stead LF. Nursing interventions for smoking cessation. Cochrane Database Syst Rev 2008, Issue 1. Art. no. CD001188.
  10. Joyce AW, Sunderland VB, Burrows S, McManus A, Howat P, Maycock B. Community pharmacy’s role in promoting health behaviours. J Pharmacy Prac Res 2007;37:42–4.
  11. Richmond R, Butler T, Belcher J, Wodak A, Wilhelm K, Baxter E. Promoting smoking cessation among prisoners: feasibility of a multi-component intervention. Aust NZ J Public Health 2006;30:474–8.
  12. Bonevski B, Bowman J, Richmond R, et al. Turning of the tide: changing systems to address smoking for people with a mental illness. Ment Health Subs Use 2011;4:116–29.
  13. Richmond RL, Makinson RJ, Kehoe LA, Giugni AA, Webster IW. One year evaluation of three smoking cessation interventions administered by general practitioners. Addict Behav 1993;18:187–99.
  14. The Royal Australian College of General Practitioners ‘Red Book’ Taskforce. Guidelines for preventive activities in general practice. 7th edn. South Melbourne: RACGP, 2009.
  15. Zwar N. Smoking cessation: what works? Aust Fam Physician 2008;37:10–14.
  16. Litt J, Egger G. Understanding addictions: tackling smoking and hazardous drinking. In: Egger G, Binns A, Rossner S, editors. Lifestyle Medicine. Sydney: McGraw Hill; 2010.
  17. Reda AA, Kaper J, Fikrelter H, Severens JL, van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database Syst Rev 2009(2):CD004305.
  18. McIlvain H, Crabtree B, Backer E, Turner P. Use of office-based smoking cessation activities in family practices. J Fam Pract 2000;49:1025–9.
  19. Borland R, Balmford J, Bishop N, et al. In- practice management versus quitline referral for enhancing smoking cessation in general practice: a cluster randomized trial. Fam Pract 2008;25:382–9.
  20. National Institute for Health and Clinical Excellence. NICE public health intervention guidance – brief interventions and referral for smoking cessation in primary care and other settings. London: NICE, March 2006. Report no. N1014.
  21. Zwar NA, Richmond RL. Role of the general practitioners in smoking cessation. Drug Alcohol Rev 2006;25:21–6.
  22. Richmond RL, Zwar NA. Treatment of tobacco dependence. In: Boyle P, Gray N, Henningfield J, Seffrin J, Zatonski W, editors. Tobacco: science, policy and public health. 2nd edn. Oxford UK: Oxford University Press; 2010.
  23. Richmond RL, Kehoe L, Heather N, Wodak A, Webster I. General practitioners’ promotion of healthy life styles: what patients think. Aust NZ J Pub Health 1996;20:195–200.
  24. Litt J, Pilotto L, Young R, et al. GPs Assisting Smokers Program (GASP II): report for the six month post intervention period. Adelaide: Flinders University, 2005.
  25. Quinn VP, Stevens VJ, Hollis JF, Rigotti NA, Solberg LI, Gordon N, et al. Tobacco-cessation services and patient satisfaction in nine nonprofit HMOs. Am J Prev Med 2005;29:77–84.
  26. Borland R, Partos TR, Yong HH, Cummings  KM, Hyland A.  How much unsuccessful quitting activity is going on among adult smokers?  Data from the International Tobacco Control 4-country cohort survey. Addiction 2012;(107):673−82. 
  27. Boldemann C, Gilljam H, Lund K E, Helgason AR. Smoking cessation in general practice: the effects of a quitline. Nicotine Tob Res 2006;8:785–90.
  28. Sciamanna C, Novak S, Houston T, Gramling R, Marcus B. Visit satisfaction and tailored health behavior communications in primary care. Am J Prev Med 2004;26:426–30.
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