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7.10 Role of health professional practices

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Smoking cessation, nutrition, obesity, excess alcohol use and physical activity are increasingly seen as essential targets for general practice, hospital and community health services as part of efforts to reduce or manage preventable 'lifestyle' health problems.1 Interventions related to healthcare providers and systems have been shown to improve smoking cessation among people who visit them. Even brief advice from a health professional to quit smoking increases quit rates among patients compared to those not receiving such advice by one to three percentage points.2,3

Reviews show a small benefit of intensive advice and follow-up visits.2,3 Interventions with more than one component, such as those that combine two or more of the elements of the 5As (see below) increase quit rates in primary care settings.3 Primary care provider cessation interventions can assist smokers with alcohol, drug or mental disorders.4 The delivery of smoking cessation intervention to an individual smoker by more than one type of health professional has the potential to increase quitting and readiness to quit.5 Advice from physicians may have a positive impact on the attitudes, knowledge, intentions to smoke and quitting behaviours of adolescents.6

Some doctors or other health professionals may have the opportunity to provide more intensive interventions for smokers or to refer them, if appropriate, to specialist services. (See Section 7.10.8.) There are several effective group and individual programs including Fresh Start (see Section 7.15.1) and Smokescreen.7, 8 Quitline provides a readily accessible specialist service to which health professionals can refer their patients. (See Section 7.14.1.)

Health professionals and healthcare facilities need to take more advantage of opportunities to provide advice to smokers.3,9–11 For health professionals and clinics, factors positively associated with providing cessation intervention and counselling include having a belief that it is their role, perceived self-efficacy to provide counselling, knowledge of community cessation resources and the patient-centeredness of the organisation.10,12 Barriers referred to by healthcare providers include lack of reimbursement, lack of training and lack of resources for follow-up.3,13,14 Systems for routinely documenting smoking behaviour and intervention positively influence the effectiveness of practice.3,15–17 A clinic screening and recording system to identify whether or not a person smokes significantly increases intervention and cessation rates but not necessarily the prescription of cessation medication.3,18 Additional research is warranted to more fully understand the effects of using electronic medical records on health professional and patient behaviour.19

There is limited evidence regarding the influence of financial payment for intervention on the behaviour of providers20 or of reimbursing cessation services for the outcome they achieve. One article discussing the potential risks of adopting a 'payment by results'21 system suggests a number of issues and problems, including:

  • that a certain proportion of smokers who try to stop would have managed to do so by themselves, so not every successful quitter from a service can be attributed to that service
  • providers may 'cherry-pick' easy cases to maximise income
  • the use of other evidence-based smoking cessation interventions that are extremely cost-effective may be discouraged and over-claiming of successes may be encouraged as there is no way of ensuring that smokers are truthful and there is an incentive on the practitioner to report success.

Suggestions for addressing these risks include providers only being paid for successes that are above a threshold that might be expected if no intervention were delivered and that providers be accredited before delivering services.21

There is evidence that the non-smoking status of the health professional positively influences their cessation intervention.22,23 General practitioners who smoke are less likely to ask patients about their smoking and provide cessation advice.24

7.10.1 General medical practices

About 85% of Australians visit a general practitioner (GP) at least once a year.25 This provides an excellent opportunity for promoting smoking cessation. GPs are seen as credible and authoritative on health issues, and their advice is seen as appropriate and acceptable.8, 26 There is also good evidence that even very brief intervention can be effective in prompting quitting.2, 27

Time pressure makes it realistic for most GPs to spend only limited time with most smokers (i.e. a few minutes), which can be incorporated into routine consultations. One widely researched approach that enables this is called the '5As' and has been the basis for recommendations for best practice in the US,3, 28–30 UK31 and New Zealand.32 The Smoking Cessation Guidelines for Australian General Practice based on this approach were developed after extensive reviews of the evidence.33 The guidelines have been updated to incorporate new evidence.34 The recommended procedure is:34–36

  1. Ask. The first step in helping smokers to quit is to identify them. A system for recording the current and previous smoking status of every client (except children) can help quitting by itself, as it signals to smokers that it is important, and almost doubles the rate of clinician intervention, and results in higher cessation. The system used needs to be integrated into the usual record keeping of the practice.
  2. Assess. Assessing a smoker's readiness to change is important. One framework for doing this is outlined in Section 7.6.1.1. Asking, 'How do you feel about your smoking at the moment?' will often be enough to begin such an assessment. For those considering quitting, it is also important to assess level of nicotine dependence. The most widely used approach is the Fagerström Test for Nicotine Dependence in either its full form or one of several shorter versions.
  3. Advise. All smokers should be advised of the importance of quitting in a way that is clear, unambiguous, supportive and non-confrontational, for example: 'Stopping smoking is the most important thing you can do to protect your health now and in the future'. GPs can link this advice to the individual health concerns of the client.
  4. Assist. The assistance provided should be related to the smoker's readiness to change. For example, concrete help to smokers interested in quitting might involve assistance by the GP if time and expertise permit, by other trained practice staff, or by referral to specialised assistance from the Quitline.
  5. Arrange follow-up. Following up those who commit to making a quit attempt can help to keep them on track. A phone call or appointment after one week and one month can provide valuable encouragement, advice on relapse prevention, slip-ups or other issues encountered. The Quitline provides such ongoing support to all who want it. At future consultations, GPs should congratulate those who successfully quit and encourage those who have relapsed to try again, using the 5As process. For those not ready to quit, the issue of smoking needs to be raised regularly at future consultations.

The guidelines can be easily adapted for use by doctors in other settings such as specialist clinics or hospitals or by other health professions. In particular the approach is likely to be useful for:

  • nurses and midwives, whether working in a community setting, hospital, medical or mental health service
  • dentists and dental hygienists: smoking is a significant contributor to oral disease
  • pharmacists and pharmacy assistants
  • drug and alcohol workers: smoking is much more common among their clients, and contributes to poor health outcomes
  • psychologists, especially if working in clinical settings
  • physiotherapists and other allied health professionals.

The use of a stepped intervention is possible and effective in a range of clinical practice conditions,37 but the approach may be less likely to succeed in patients who are ambivalent or who have broader psychosocial problems and who may need more intensive support.38

Despite the inclusion of the 5As in a number of national guidelines, their application in practice is not always complete.3,39 Factors associated with this include workload, perceived lack of remuneration, patients' characteristics and the smoking status of the GP.23,24,40 Few patients visit their doctor with smoking addiction as their main complaint and brief visits are taken up with other problems.16 Many clinics also do not have systems in place that can be used to efficiently apply the 5As in full, but there is some evidence that large healthcare settings can increase cessation interventions by building on an existing electronic health record platform.16 The combined use of self-auditing, feedback and education can improve GP management of smoking cessation.41 Suggested changes to clinical practice to improve tobacco treatment implementation in clinical settings include portraying proven treatments as best care, being ready to deliver the right treatment at the right time, fitting tobacco treatment into clinical team workflows and making every encounter with a patient an opportunity to intervene.42 The use of computer-based interventions alone or in combination with practitioner-delivered advice has been shown to assist the participation of general medical practices in tobacco control.43

7.10.1.1 Role of GP practice nurses

Practice nurses are an addition to general practice settings in Australia. Relatively little is known about their attitudes and beliefs regarding smoking cessation intervention. One UK survey showed positive attitudes overall and highlighted the importance of training in increasing nurses' enthusiasm about giving cessation advice and perceiving such advice to be effective.44 An Australian trial is in progress to evaluate the uptake and effectiveness of a flexible package of smoking cessation support provided primarily by practice nurses and tailored to meet the needs of diverse patients.45

7.10.1.2 Community pharmacists

Pharmacies supply cessation products to a large number of customers and there are opportunities for providing sound advice and support. Pharmacies have potential as health promotion agencies as they are the most accessible healthcare services in the community and are visited by both healthy and sick people.46

Few published studies have assessed the efficacy, effectiveness or cost-effectiveness of pharmacies in smoking cessation. Those published do suggest that trained community pharmacists can deliver cessation interventions and help smokers to quit, and that a counselling and record-keeping program delivered in this setting can be effective.47–50 Pharmacist counselling involving more than one session, combined with NRT, can be effective but many participants do not complete follow-up sessions.51 While specialist-led group services appear to have higher quit rates than one-to-one services provided by pharmacies, the pharmacy services treat many more smokers and both are cost-effective.52,53

Pharmacists report a number of barriers to providing cessation intervention, including fear of negative reaction from customers, their perception of a customer's willingness to discuss smoking, the length of the relationship with the customer, perceived lack of demand and lack of confidence by the pharmacist.54,55

Pharmacy assistants handle many of the smoking cessation enquiries in pharmacies and there are courses available to help them gain the expertise and skills needed to provide relevant and useful advice to help their customers in a quit attempt.

7.10.1.3 Community dental practices

Smoking is a significant contributor to oral disease, including cancer, and cessation is an important element of the treatment of periodontal diseases.56 Smoking prevention and cessation intervention by oral health professionals is effective, but there is insufficient evidence available to assess its cost-effectiveness or to adequately compare different forms of intervention.57

Tobacco use prevention and cessation guidelines have been developed for dental settings. They involve a level of care model based on the 5As, with brief intervention, motivational interviewing and more intensive plans involving pharmacotherapy.58–60 However, implementation of such guidelines is poor.59,61,62 The most prevalent of the 5As activities are 'asking', 'advising' and 'assessing', with 'assisting' and 'arranging' being less frequent.60 Dentists are willing to receive training on smoking cessation interventions, and including training during an academic dental program increases the use of smoking cessation practices within the dental team.63

Barriers to providing cessation interventions in dental settings include lack of time, financial considerations, concern about a patient's interest and resistance and of losing patients, too little training, perceived lack of relevance and experience, lack of knowledge about where to refer the patient for further support and forgetting. 56,63–65 Willingness to intervene is related to periodontal treatment and the presence of smoking-related disease.64 Some research does reveal a lack of knowledge of dental school faculty, staff and students on the negative health effects associated with smoking and lack of confidence in addressing smoking behaviour.66,67 Further research is needed to better understand the factors that affect guideline implementation and to find effective ways to influence those factors.59,61,68–70

Dental hygienists see their patients regularly and there are opportunities for helping them to quit smoking.56 However, recommended smoking cessation interventions are not always provided, with hygienists reporting lack of comfort and confidence in addressing smoking with their patients.71,72

Measures to promote the involvement of dental professionals in smoking prevention and cessation include increased education on the effects of smoking on oral health, brief intervention training, structured advice protocols and greater involvement by dentists, dental nurses and hygienists with patients without acute oral complaints.64,73

7.10.1.4 Other health professional practices

There is limited research related to the efficacy and effectiveness of smoking cessation interventions in other health professional practices. Available information highlights interest in, and opportunities for increased and improved involvement by, many healthcare providers. One small study within podiatrist consultations, for example, showed that providing routine advice to smokers could be significantly improved within budgets and without prolonging clinics.74

Smoking cessation intervention by optometrists is relevant given the association of smoking and eye diseases. Evidence suggests that optometrists currently provide limited cessation support for patients, with barriers to more active involvement being similar to other health professions. However, they do show interest in receiving training in brief intervention.75,76

Cessation as a therapy goal in physiotherapy practices is consistent with the profession's definition and aims to promote health and wellness.77 One review indicates that advice can be readily integrated into physical therapy practice and used to encourage and support smoking cessation.77 Lack of resources and time are key barriers. Therapists' preparedness and self-efficacy regarding smoking cessation need to be increased.78

7.10.1.5 Practitioners of alternative medicine

Practitioners of alternative medicine who incorporate smoking cessation into their treatments include hypnotherapists and acupuncturists. To date, there is no clear evidence to support the use of hypnotherapy, acupuncture or related treatments in their own right as quitting aids.79–82 Treatment may be more helpful when practitioners combine acupuncture or hypnotherapy with counselling or skills training.79,83,84 (See Section 7.18 for information on unproven remedies.)

7.10.2 Role of specialist medical and dental practice settings

Specialist medical and dental practices have an important role to play in smoking cessation interventions. For example, discussion of smoking by paediatricians with mothers can be effective in encouraging quitting attempts.85 Evidence suggests that progress in many relevant specialist areas is limited.

In patients with cardiovascular disease, the benefits of smoking cessation are extremely significant. Australian guidelines recommend that advice on smoking, nutrition, alcohol, physical activity and body weight should be part of routine management of hypertension for all patients, regardless of drug therapy. Smoking cessation is recommended to reduce overall cardiovascular risk.86 However, cardiac health professionals, including lipidologists and cardiologists, need to do more effective smoking prevention intervention for cardiovascular patients.87,88 Surveys assessing the knowledge, interest and attitudes of cardiologists regarding smoking cessation assistance to their patients highlight a lack of commitment to this preventive practice.89 Cardiologists do not always consider themselves the most appropriate person for intervention, but many do not refer smoking patients to cessation specialists or teams for assistance.89 Reasons for cessation being overlooked may include that the advent of effective high-tech interventions for cardiovascular diseases has drawn attention away from secondary prevention. Some professionals cite a lack of time or lack of training in smoking cessation counselling.90 Cardiac rehabilitation health professionals report finding it difficult to work with smokers directly due to the group situation and because patients often deny the dangers of smoking and are reluctant to discuss their smoking or relapse because of the stigma attached to smoking after a cardiac event. They also report feelings of frustration and failure and lack of confidence in dealing with this health issue.91

When doctors provide simple, brief advice about quitting smoking, the likelihood that patients will quit and remain non-smokers 12 months later is increased. US data suggest that smoking cessation is more cost-effective than other preventive cardiology measures.90

Other relevant settings where limited evidence indicates that there is a need and potential for brief cessation interventions to be more fully integrated in routine practice include gynaecological practice,92 paediatric practice,93,94 periodontal practice,95 plastic and reconstructive surgery96 and paediatric dental practice.97 Many of the findings stress the need for further research to highlight and address clinical barriers to providing cessation interventions and training to enhance specialists' knowledge, skills and confidence.

7.10.3 Training health professionals

There is evidence that training clinicians in smoking cessation methods may increase cessation rates.3,20 Training health professionals increases the number of people identified as smokers and advised to quit, especially if prompts and reminders are used.98–101 Health professionals report that training increases their knowledge, skills and confidence and that they are more likely to practise smoking-related interventions.48 100–106 Research shows that medical students retain skills learned and increase and improve their involvement in cessation interventions.107–110 However the inclusion of standardised tobacco curricula in medical schools varies. Information from a number of countries indicates that part of the reason for doctors not being more actively involved in tobacco use treatment may lie with the lack of emphasis on tobacco in their medical school education.111 –113 There is evidence of some increase in the extent of teaching on tobacco in medical schools worldwide over the last decade, but further improvement is required.111,114

Most postgraduate health professional training programs incorporate the 5As approach, stage of change, motivational interviewing and pharmacotherapies and commonly refer to clinical practice guidelines.115 While face-to-face training is predominant, programs are also available online.115 There is a lack of evidence on what educational methods are the most effective in training.115 Not all practising health professionals access cessation intervention training: they report lack of interest, time pressures and competing priorities as major barriers. Overall, smoking cessation education programs for health professionals remain fairly 'ad hoc' and there is a lack of a systematic organised approach to ensure availability and consistency in most countries.115

The systematic, extensive and tailored program developed by Quit Victoria is an example of comprehensive, sustained, Australian health professional training for a range of settings. The program includes face-to-face training and e-learning modules that are accessed by health professionals from across Australia and internationally.i

7.10.4 Referral to specialist smoking cessation services

Specialist smoking cessation services include telephone quitlines, cessation specialists within practices or healthcare centres, group quit courses and individual counsellors. Referral to specialist services is a way of addressing some of the barriers to intervention, including time constraints, reported by a wide range of health professionals. Brief cessation training and technical assistance increases referral by health providers to specialist smoking cessation services.116,117

Clinical practice guidelines for smoking cessation intervention emphasise the utility, efficacy and reach of telephone quitlines. While relatively few smokers are connected to quitlines from faxed referrals, the process may reach populations who traditionally have less access to cessation support.118 There is evidence that GPs referring smokers to an evidence-based quitline service increases smoking cessation, mainly because referred patients receive more external help than patients receiving equivalent assistance within clinics.119 However, acceptance of opportunistic referral within a GP setting may be less acceptable to patients.120 There is some evidence that referral of surgical patients to a quitline for post-discharge help is acceptable to patients and inexpensive.121 Take-up rates improve when the quitline initiates the contact with the patient.121

Few studies have examined ways to promote referral to quitlines by health professionals. One trial using a direct mail campaign to a range of health professionals increased their awareness of the service and future intention to use the referral process.122 Another project implemented a care coordination program that increased quitline referrals by providers.123

7.10.5 Biomedical risk assessment

Giving smokers a biomedical risk assessment of their smoking is a possible strategy for increasing cessation rates.124 This involves demonstrating the effects of smoking (e.g. through measurement of lung function, exhaled carbon monoxide, arterial ultrasounds, lung cancer screening or genetic susceptibility to lung cancer). The quality of studies is mixed and there is little evidence about the effectiveness of most types of biomedical tests.125–127 The use of lung age feedback following lung function measurement has shown significant benefit particularly for patients with high lung age.128,129 However the approach may undermine motivation in smokers with normal lung age.129 Limited evidence shows that people who are referred to a physician because of an abnormal lung cancer screening report more smoking cessation.130 One trial currently underway is assessing the impact of communicating a risk of developing Crohn's disease, a risk that is reduced by stopping smoking.131

7.10.6 Healthcare services

There are many opportunities to implement smoking cessation interventions in hospitals with the potential for significant benefits to patients, including intervention with smoking parents when a child is admitted. Smokers may be more open to help and may find it easier to quit in a situation where smoking is restricted or prohibited. Despite a number of reviews of hospital studies there is an absence of clear evidence as to what is needed in areas of screening, methods of intervention, effectiveness among patient sub-groups, referral strategies, and translating research to practice.132,133 It is evident, however, that without the development of supportive systems, the use of routine effective cessation interventions by all healthcare services is unlikely.134

7.10.6.1 Emergency department and in-patient care (includes role of hospital nurses)

The role of emergency departments (ED) in cessation intervention has received little attention, but has significant potential to encourage quit attempts.135 Tailored interventions in EDs can be effective in prompting initial quit attempts and ED patients are interested in quitting and in receiving support.135–138 High intensity behavioural interventions that start during a hospital stay and include follow-up support for at least a month are effective, regardless of the reason for being admitted to hospital.139 Adding NRT to the counselling may further increase cessation rates.140 Educations programs can be successful for patients with cardiovascular disease141 and chronic obstructive pulmonary disease.142

Nurses are the largest healthcare workforce and are involved in nearly all levels of hospital care. Guidelines for clinical care in some countries recommend that every nurse should consult their patients about smoking.143 Nurses can be effective in delivering tobacco cessation interventions, but lack of appropriate knowledge and/or skill presents a major problem for implementation.144 Advice and support from nursing staff increases the likelihood of quitting, with outcomes being less evident when interventions are brief and provided by nurses whose main role is not health promotion or smoking cessation. Limited evidence suggests that interventions by nurses are more effective with cardiovascular patients.145,146

It may be possible to increase hospital smoking cessation delivery, particularly the provision of NRT, by using a multi-strategic intervention including education of health professionals.147,148 Further research is warranted.

7.10.6.2 Surgical care

Smoking causes a range of adverse surgical outcomes.149 (Link to Chapter 3.15.1) Even short-term smoking cessation prior to surgery may help reduce the risk of postoperative complications.150–153 Patients who smoke should be encouraged to stop smoking at least six to eight weeks before surgery. In the short term, smoking should not be permitted in the 12 hours before surgery.154

Patients facing surgery are interested in quitting and believe their physicians have an important role in their cessation attempts.155,156 Smokers may benefit from an intensive cessation program one month before surgery, and it may help long-term cessation.157–160 However patients are not always well informed about the immediate benefits of quitting to their surgery outcomes.155

Barriers to cessation intervention in surgical care include perceived lack of time for training and intervention and lack of knowledge about referral options such as to quitline services for patients.155 Clinicians also report lack of organisational support, perceived patient objection, lack of systems to identify smokers, perceived inability to change care practices, perceived lack of efficacy of interventions and the cost of providing care as barriers.161 Patients may not have enough pre-operative contact with the hospital to maximise smoking cessation intervention.162

A number of small trials have examined ways to increase the efficacy and effectiveness of cessation intervention before and after surgery. Using computer-based assessment may increase the accuracy of assessing smoking status in pre-operative clinics and encourage cessation.161 Combining GP referral to surgery with referral to smoking cessation support increases cessation referral but there is a need for new strategies to promote cooperation between GPs and surgical departments.162 Clinicians are able to effectively facilitate the use of a quitline by surgical patients,163 and comprehensive interventions incorporating brief advice, counselling, self-help materials, NRT and referral support from a quitline are effective six months post-discharge.161

7.10.6.3 Outpatient care

Outpatient settings offer important opportunities to provide cessation intervention and relapse prevention to smokers, particularly given the evidence that for hospital-initiated programs to be effective they need to continue post-discharge. Smoking cessation intervention by nurses in non-hospitalised patients has benefit,145 programs during rehabilitation are effective164 and interventions offered by surgeons in outpatient clinics can be effective.165 Studies have found some effectiveness of telephone support following an intensive group program in hospital,166 of an interactive voice response system to continue support167 and of the continued use of NRT following discharge from hospital.168 One study found an internet program for smoking cessation during and after inpatient rehabilitation treatment to be effective.169

i For further details see http://www.quit.org.au/resource-centre/training/training-for-health-professionals

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