Despite the majority of patients who smoke wanting to quit, health professionals often underutilise opportunities to provide cessation advice,13,22-25 and smoking cessation is neglected in many clinical guidelines.26 Factors positively associated with health professionals providing cessation intervention and counselling include believing that it is part of their role, confidence in providing counselling, knowledge of community cessation resources, and the patient-centeredness of the organisation.23,27 Having a tobacco cessation ‘champion’ within an organisation can also promote the systematic implementation of cessation interventions and positive outcomes.28 Barriers cited by healthcare providers include lack of reimbursement, lack of training, and lack of resources for follow-up.13,29,30 Additional barriers can include low literacy levels of people who smoke, competing demands, and lack of access to products or services.31 Health professionals who are non-smokers are more likely to deliver cessation interventions than those who smoke.32,33
In 2023–24, more than 4 in 5 Australians (84%) had consulted a GP at least once in the previous year;34 such contacts provide an excellent opportunity for promoting smoking cessation. GPs are perceived as credible and authoritative on health issues, and their advice as appropriate and acceptable.35,36 A Cochrane review last updated in 2013 concluded that even when doctors merely provide brief, simple advice about quitting, this increases the likelihood a person who smokes will successfully quit and remain a non-smoker 12 months later.6
Time constraints mean that GPs spend only limited time with most people who smoke (i.e. a few minutes), therefore brief interventions are well-suited to form part of routine consultations. Guidelines on cessation published by the Royal Australian College of General Practitioners recommend using the three-step brief intervention model37 (sometimes known as the ABC model: ask, brief advice, cessation support):
Receipt of brief interventions is associated with a significant increase in patients' use of counselling and cessation medication,38 and with smoking cessation.39 It is considered best practice in the US,40 UK,41 New Zealand,42 and by the World Health Organization.43
Despite the inclusion of the ABC and 5As in a number of national guidelines, they are not always implemented in practice,13,44,45 or are not implemented in full.46 Failure to implement brief interventions is associated with workload, perceived lack of remuneration, patients’ characteristics, and the smoking status of the GP.33,47,48 A lack of training and confidence can also create feelings of illegitimacy among GPs—particularly early-career GPs49—in relation to their ability to provide cessation interventions, though patients report that they are a legitimate and trusted source of cessation advice.50 Doctors who smoke are less likely than non-smokers or ex-smokers to advise and counsel their patients to quit,47 but can be more likely to refer them to smoking cessation programs.51
Few patients visit their doctor with smoking addiction as their main complaint, and brief visits often focus on other problems.52 Many clinics do not have systems in place that routinely include brief cessation interventions, but there is evidence that healthcare settings can increase cessation interventions by building on an existing electronic health record platform.52 An Australian study found that the combined use of self-auditing, feedback, and education can improve GP management of smoking cessation.53 Suggested changes to clinical practice to improve tobacco treatment implementation in clinical settings include portraying proven treatments as best care, being prepared to deliver the appropriate treatment, including tobacco treatment in clinical team workflows, and taking advantage of every opportunity to deliver an intervention.54 The use of computer-based interventions alone or in combination with practitioner-delivered advice can assist the participation of general medical practices in tobacco control.55
Practice nurses provide additional patient care and support within general practice settings in Australia; however, there is relatively little research on their role in promoting smoking cessation. A randomised controlled trial that was conducted in Sydney and Melbourne evaluated the uptake and effectiveness of tailored smoking cessation support, provided primarily by the practice nurse, and compared it to other forms of cessation support (Quitline referral and usual GP care). Results showed that patients who received more intensive practice nurse intervention were more likely to quit.64 An evaluation of the trial found that it was viewed positively by practice nurses, with most reporting being satisfied with the training and the materials provided.65 Interviews with Australian nurses in GP settings revealed that nurses want to support people in quitting smoking. Nurses cited the ambiguity in their roles in the delivery of smoking cessation care and the emerging issue of vaping as important challenges, highlighting the need for support and clearer guidelines.66 A survey in the UK found positive attitudes among nurses toward providing cessation interventions and highlighted the importance of training in increasing nurses’ enthusiasm about giving cessation advice and perceiving such advice to be effective.67 A systematic review concluded that non-pharmacological community-based nursing interventions (i.e. outside of hospital settings) can effectively change knowledge, beliefs and attitudes among adults who smoke.68
Smoking places a substantial burden on hospitals, and smoking cessation should be systematically embedded in the healthcare system; hospital admission is an ideal time for the delivery of cessation interventions.69 One review highlights that complex and multi-faceted implementation approaches capable of driving system changes are needed to effectively embed cessation care and change clinician behaviour.69 When such interventions are adopted by hospitals, they can lead to improved patient outcomes and decreased subsequent healthcare usage.70,71
The role of emergency department (ED) staff in cessation intervention holds significant potential to encourage quit attempts in patients who smoke.72 However, ED doctors and nurses appear to frequently miss opportunities to offer smoking cessation interventions.73 A multicentre survey of ED providers in the US found that while asking and advising were relatively common, assessing, assisting, and arranging support for patients were low overall.74 ED staff in the US have expressed ambivalence toward the implementation of smoking cessation guidelines. Doctors and nurses agreed that implementing cessation interventions is important, but felt that it is not always practical due to time constraints, the competing demands of acute care, and resistance from patients. They also sought improved role clarity and teamwork when implementing the 5As in the ED.75 New Zealand research found that doctors and nurses in critical care settings held positive attitudes toward and had received training in providing smoking cessation advice, and perceived advising patients to stop smoking as their responsibility. However, patient acuity and level of sickness affected their ability to deliver smoking cessation advice.76
Despite the challenges, interventions in emergency healthcare settings are worthwhile. Cessation interventions in EDs can be effective in prompting quit attempts and ED patients are interested in quitting and in receiving support.72,77-80 A 2014 systematic review concluded that ED visits in combination with ED-initiated tobacco cessation interventions are associated with higher cessation rates,81 and a 2017 systematic review and meta-analysis similarly concluded that ED-initiated cessation interventions are effective in promoting abstinence up to 12 months after intervention.82 Intensive intervention can also improve tobacco abstinence rates in low-income people in the ED.83 A study across two Melbourne hospitals found that although smoking was more prevalent than among the general population, more than one-third of ED patients reported wanting to quit, and almost two-thirds were willing to receive a brief intervention. Face-to-face individual or group counselling was preferred over telephone counselling or a session with a doctor.84
The prevalence of smoking is relatively high among people admitted to hospital, with an Australian and New Zealand study finding that one in five ICU patients currently smoked.85 Both patients and staff report that hospitalisation is an appropriate time to address smoking, so it represents an important opportunity to promote cessation.86 A 2024 Cochrane review concluded that offering hospitalised patients smoking cessation counselling beginning in hospital and continuing for over one month after discharge increases quit rates compared with no counselling . Starting nicotine replacement or varenicline in hospitalised patients also promotes cessation.87 A randomised controlled trial across five Australian public hospitals examined the effectiveness of combining varenicline with NRT lozenges for smoking cessation in hospitalised adults. Self-reported abstinence was higher in the group that received this combination compared with varenicline alone.88 Combining behavioural support with cessation pharmacotherapies is likely to further increase cessation rates among people who smoke who are admitted to hospital,87,89-91 though several studies have noted that NRT should not be routinely provided in the ICU setting.92-94
Despite increases over time in the provision of cessation interventions to hospitalised patients, they are still underutilised.95 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.96,97 Making such interventions a routine part of hospital care could dramatically increase the number of smokers offered smoking cessation support.98 In 2015, a framework for hospital-based intervention was proposed following the NSW Health Smoke-free Health Care Policy, which stipulated that all clinical staff must provide routine brief interventions for all smoking patients. It suggests that: hospitalisation is a powerful teachable moment; all patients should be asked about smoking on admission, and people who smoke should be encouraged and assisted to quit permanently; the most effective interventions include a combination of counselling and NRT; and patients should be followed-up for at least 4 weeks after discharge.99 In Queensland, the state-wide Smoking Cessation Clinical Pathway (SCCP) brief intervention tool was implemented in 2015 and is used by clinical staff in public hospitals to promote cessation among in-patients. Research has shown that this approach appears to increases the provision of cessation interventions and NRT, and can promote both short- and long-term cessation.100
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,101 and the first recommendation in the position statement of the International Society of Nurses in Cancer Care states that nurses must be recognised as and empowered to be critical enablers in the fight against the global tobacco epidemic.102 Nurses can be effective in delivering tobacco cessation interventions, particularly when they receive cessation training and have positive attitudes and high self-efficacy for delivering cessation support,103 but some lack of appropriate knowledge and/or skill.104 A survey of Australian nursing students found that most felt they lacked specific knowledge to help patients quit.105 A review of smoking cessation training in undergraduate nursing students found that it positively impacted knowledge, attitudes/motivation and self-efficacy.106 Nurses who smoke appear less likely to deliver cessation interventions.103 A 2017 Cochrane review found moderate quality evidence that advice and support from nurses could increase people's success in quitting smoking, whether in hospitals or in community settings.107 Additional reviews have similarly supported the effectiveness of nurses in promoting smoking cessation,108-110 with one finding particular benefit of this approach combined with NRT.111 Hospital pharmacists may also be well-placed to deliver cessation interventions to in-patients.112
Patients facing surgery are interested in quitting and believe their physicians have an important role in their cessation attempts.121,122 People who smoke may benefit from an intensive cessation program one month before surgery, and it may help long-term cessation.123-126 However, patients are not always well informed about the immediate benefits of quitting to their surgery outcomes.121 One study of anaesthesiologists and their patients found significant discrepancies between reports of provision of smoking cessation counselling; three quarters of anaesthesiologists stated that they frequently or almost always advised patients about the health risks of smoking, but patient surveys showed that less than one third received advice about the health risks of smoking, and less than one quarter received advice to quit before surgery.127 Research in the US found that, compared with non-surgical residents, surgical residents were less likely to perform cessation counselling and more likely to think that counselling was not part of their job. Both groups frequently missed opportunities to help patients quit. Surgical residents were also more likely to cite a lack of time and formal training as barriers to implementing interventions.128
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 quitline services.121 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.129 Patients may not have enough pre-operative contact with the hospital to maximise smoking cessation intervention.130 Australian research has found similar barriers, but also notes facilitators of cessation care including optimism and empathy among individual clinicians, as well as strong teamwork.131
A number of studies have examined ways to increase the effectiveness of cessation interventions prior to surgery. A 2017 systematic review examined the components of effective cessation interventions for surgical patients. It found that overall, interventions almost doubled the proportion of people who smoke who were abstinent or reduced smoking by surgery relative compared with control (46.2% vs. 24.5%). Components of more effective interventions included a greater number of sessions, face-to-face delivery by nurses, and certain behaviour change techniques.132 Australian researchers found that even a simple preoperative intervention was effective in promoting smoking reduction or cessation up to one year post-surgery,133 and other studies have similarly found that preoperative smoking cessation interventions increase the quit rate at the time of surgery time and longer-term.134,135 One review notes that many studies looking at the effects of preoperative cessation have recruited people who smoke very close to their scheduled surgery, therefore the benefits of preoperative smoking cessation may have not been fully apparent.136
Outpatient settings offer important opportunities to provide cessation intervention and relapse prevention to people who smoke, but are underutilised.137 This is despite the fact that referral to evidence-based tobacco treatment after hospital visits is effective.138 Smoking cessation interventions by nurses are beneficial for non-hospitalised patients,139 and cessation programs combined with routine rehabilitation and care for outpatients are also effective in promoting abstinence.140,141
Community pharmacies may be an underused resource for helping to deliver public health services.142 Pharmacies supply cessation products to a large number of people trying to quit smoking, which creates 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.143 The Pharmaceutical Society of Australia’s guidelines for nicotine dependence support144 recommend that pharmacists should offer brief advice to all people who smoke or vape.
A number of studies and reviews suggest that trained community pharmacists can deliver smoking cessation interventions that are effective in helping people who smoke to quit.142,145-153 A 2019 Cochrane review found low-quality evidence that community pharmacists can provide effective behavioural support to people trying to quit. Findings suggested that more intensive interventions beginning prior to the quit day and comprising weekly appointments increased effectiveness.154
People who smoke report perceiving pharmacist-assisted cessation to be an appealing approach to quitting.155 Australian research that explored the knowledge and practices of community pharmacists found that while their cessation counselling was satisfactory, further education is needed to improve practice standards in terms of matching a patient's history and smoking status to an appropriate product.156
While specialist-led group services appear to have higher quit rates than one-to-one services provided by pharmacies, pharmacy services treat many more people who smoke and both are cost-effective.157,158 An economic analysis of providing cessation counselling training to physicians and pharmacists found that synergistic educational training for both groups could be a cost-effective method for smoking cessation in the community.159 Several additional trials have similarly found that pharmacist-delivered cessation interventions are effective and cost-effective.153,160
Pharmacists report a number of common barriers to providing cessation intervention, including fear of negative reaction from customers, their perception of a customer’s unwillingness to discuss smoking, the short length of the relationship with the customer, perceived lack of demand, and lack of confidence by the pharmacist.161,162 Education and routine training for all pharmacy personnel may increase the implementation and success rates of pharmacy-led smoking cessation services.151,163,164
Smoking is a significant contributor to oral disease and cancer, and cessation is an important part of the treatment of periodontal diseases165 and improvements in periodontal health.166 A review of international evidence concluded that behavioural intervention for smoking cessation involving oral health professionals is effective in reducing tobacco use in smokers and users of smokeless tobacco and preventing uptake in non-smokers.167 A 2021 Cochrane review found very low‐certainty evidence that behavioural interventions delivered by dental professionals can increase quit rates. The evidence was stronger when behavioural interventions were combined with NRT.168 Subsequent studies have also supported the effectiveness of cessation interventions in dental settings.169 Dental patients have reported being receptive to dental practitioners inquiring about smoking behaviour and offering advice on quitting.170-172
In Australia, dentists provide care to many high-risk populations, therefore effective training in and the implementation of cessation interventions is essential.173 Tobacco use prevention and cessation guidelines have been developed for dental settings. They involve a level-of-care model based on the 5As,174 with brief intervention, motivational interviewing, and more intensive plans involving pharmacotherapy.175-177 Brief behavioural interventions complemented by pharmacological treatment—with the participation of the entire dental team—are effective cessation interventions within dentistry.168,178 Behavioural interventions that increase motivation and teach regulatory skills (such as coping strategies to avoid relapse) appear to be the most effective within dental settings.179 However, implementation of cessation interventions is poor.176,180-183 The most frequently delivered components of the 5As are ‘asking’, ‘advising’ and ‘assessing’, with ‘assisting’ and ‘arranging’ being less common.177 A large survey of dentists in the US found that almost all reported that they routinely ask patients about tobacco use, about three-quarters provide cessation counselling, and just under half routinely offer cessation assistance (such as referring on or writing a prescription).184
Barriers to providing cessation interventions in dental settings include lack of time, financial considerations, concern about a patient’s interest and resistance, fear 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.165,172,173,185-190 Dental professionals who smoke are also less likely to provide cessation interventions.191 Willingness to intervene is related to periodontal treatment and the presence of smoking-related disease.186 Some research does reveal a lack of adequate knowledge among dental school faculty, staff and students on the negative health effects associated with smoking and a lack of confidence in addressing smoking behaviour.192,193 Further research is needed to better understand and influence the factors that hinder guideline implementation.176,180,194-196
Dental hygienists see their patients regularly, which provides opportunities for cessation assistance.165 However, recommended smoking cessation interventions are not always implemented, with hygienists reporting lack of comfort and confidence in addressing smoking with their patients.197,198 A survey of Australian oral health practitioners found that while the majority of practitioners frequently screened for smoking behaviour, only about half assisted patients to quit smoking. They reported that lack of knowledge of pharmacological treatments and lack of access to smoking cessation resources are common barriers to providing cessation assistance.199 Intervention within paediatric dental practices could help prevent initiation and increase cessation among young people, however several studies have highlighted low adherence by healthcare providers to recommended screening and prevention interventions for children and adolescents.137,200
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 encouraging greater involvement by dentists, dental nurses and hygienists with patients without acute oral complaints.186,201 Dentists are willing to receive training on smoking cessation interventions, and including training in academic dental and professional development programs increases the use of smoking cessation practices within the dental team.185,202 Dental students generally agree that tobacco cessation counselling is within the responsibility of the dental profession, is within the scope of dental practice, and can be effective.189,203
Specialists have the potential to play an important role in promoting smoking cessation. For example, paediatricians have the opportunity to deliver cessation interventions to parents that can reduce children’s exposure to secondhand smoke and reduce the risk of a range of acute and chronic childhood conditions. However, screening is often inconsistent and there is a need for standardised processes to document secondhand smoke exposure.204 A systematic review found that physician-delivered training in a brief intervention using CEASE principles (Ask, Assist, Refer) may increase smoking cessation counselling, and training in a CEASE course delivered online or a short intervention using the 5As may increase screening in the paediatric setting.7 A meta-analysis of cessation interventions tailored to parents concluded that they are modestly effective, with parents in the intervention conditions about 1.6 times more likely to quit than parents in the control conditions.205 The role of nurses in paediatric settings also offers promise for promoting cessation among parents, however research in Victoria found that this is not a standard part of care.206
There are enormous health benefits of smoking cessation for patients with cardiovascular disease. 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,207 and US data suggest that smoking cessation is more cost-effective than other preventive cardiology measures.208 However, cardiac health professionals, including lipidologists and cardiologists, could implement more effective smoking cessation interventions.209,210,211 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, either.211 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.208 Cardiac rehabilitation health professionals report finding it difficult to work with people who smoke, partly because some patients deny the dangers of smoking or are reluctant to discuss their smoking because of the stigma attached to smoking after a cardiac event. Such professionals also report feelings of frustration, failure, and lack of confidence in managing this health issue.212 Nonetheless, interventions are effective at promoting short- and long-term cessation among cardiopulmonary patients.213
Oncology professionals also have a crucial role to play in promoting cessation among people with cancer; smoking not only causes cancer, but also reduces the effectiveness of treatment and increases the risk of recurrence and death.1 Cessation improves cancer patients’ prognosis (see Section 3.15.4) and smoking cessation care should be provided at all stages of treatment regardless of the type of cancer.214-216 However, a lack of time, knowledge, skills or confidence can impede the provision of cessation interventions. Oncology professionals can worry that addressing cessation will create feelings of worry or guilt and harm their relationship with patients, particularly if the cancer is smoking-related. Training in communication skills and the delivery of interventions in an empathic and non-judgemental manner can help overcome these concerns.217 Studies have shown that professional organisations can help to promote cessation care,218 and that having a team member specifically trained in tobacco treatment can also increase cessation in oncology settings.219,220 Australian research found that while more than nine in ten medical oncologists and radiation oncologists asked about and documented tobacco use, most felt that cessation should be managed by other professionals, highlighting the importance of collaboration and referral pathways.221 Additional Australian studies have found that only about half or fewer multidisciplinary cancer care clinicians provide cessation interventions. The authors emphasise the need for clinician training, particularly in the use of pharmacotherapies, and systems-level changes that embed cessation as part of cancer care.222,223 One study also notes the importance of providing smoking cessation care to oncology patients who have recently quit, to help prevent relapse.214,224 The provision of cessation counselling during routine cancer screenings may also be a worthwhile strategy225 (see also Section 7.21).
Other relevant settings (i.e., specialties that see patients directly affected by or at risk for tobacco-related diseases) where there may be a need and potential for brief cessation interventions to be more fully integrated in routine practice include urological practice,226,227 gastroenterology practice,228 rheumatological practice,229 pulmonology practice,230 gynaecological practice,231 perioperative care (such as by anaesthetists),232,233 periodontal practice,234 plastic and reconstructive surgery235 and paediatric medical practices.236,237 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. See Section 7.12 for a discussion of cessation interventions for people with serious health conditions.
There is limited research exploring the effectiveness of smoking cessation interventions in other health professional practices, although some studies have highlighted 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 people who smoke could be significantly increased within existing budgets and without prolonging consultations.238
Smoking cessation interventions delivered by optometrists are important, given the relationship between smoking and eye diseases. Evidence suggests that optometrists provide limited cessation support for patients, with barriers to more active involvement being similar to other health professions.239,240 An Australian survey of optometrists found that fewer than half reported routinely asking their patients about smoking status, with younger practitioners least likely to enquire about patients' smoking behaviours.241 However, Australians who visit the optometrist report being receptive to discussions about tobacco use.242
Cessation as a goal in physiotherapy practices is consistent with the profession’s aims to promote health and wellness,243 and smoking cessation advice can be readily integrated into physical therapy practice.243 Studies have found that lack of resources, knowledge and time are the main barriers to providing such advice, and suggest that physiotherapists’ preparedness and confidence in providing smoking cessation assistance need to be increased.244,245 Australian researchers suggest that a three-step brief intervention model—Ask, Advise and Help—can overcome these barriers in physiotherapy practice.246
Quitting smoking is associated with improvements in mental health among people with psychiatric disorders.247 Mental health professionals therefore play an important part in supporting smoking cessation. Integrating evidence-treatment for tobacco use disorder into other ongoing treatments represents an important opportunity for increasing cessation, particularly among people with serious mental illness and/or substance use disorders (see Section 9A.3).248 Similarly, social workers often work with disadvantaged and vulnerable groups that have much higher smoking prevalence, who may particularly benefit from the inclusion of cessation assistance into usual care.249
Social and community service organisations are non-government, not-for-profit organisations that provide welfare services, such as accommodation assistance, emergency relief, and financial and relationship counselling, to people who are socially disadvantaged. Given the much higher prevalence of smoking among people who are socially disadvantaged (see Section 1.7), and the contribution of tobacco use to health disparities (see Chapter 9), social and community service organisations are increasingly recognising their role as important settings for implementing cessation interventions.250-252 Such interventions are also cost-effective.253 An Australian trial that examined the effectiveness of behavioural counselling with the option of NRT delivered to highly disadvantaged people who smoke through a community social service by trained case workers found that while it did not increase abstinence rates, it increased quit attempts and reduced consumption.254 The complex needs of highly disadvantaged people who smoke may necessitate tailored and targeted interventions—see InDepth 9A. Staff training and organisational policies that require routine cessation support can help ensure that cessation care is provided to all clients of community service organisations.255
While complementary and alternative medicine practitioners treat significant numbers of tobacco users, they are often not trained in evidence-based strategies. One study developed and evaluated a brief intervention adapted for such practitioners, and found that after three months, there were significant increases in practitioners' tobacco cessation activities, motivation, and confidence in helping patients quit, and comfort with providing information and referrals for guideline-based tobacco cessation aids. This may be an additional channel for reaching people who smoke.259 (See Section 7.18 for information on the use of alternative therapies for smoking cessation).
Training clinicians in smoking cessation methods may increase patients’ cessation rates,13,260 as such training increases the number of people identified as smoking and advised to quit.261-264 Training increases health professionals’ knowledge, skills, confidence, and likelihood of practicing smoking-related interventions.146,262,263,265-271 Such training should include practical guidance, resources and communication skills training for delivering cessation interventions, as well as education on the clinical benefits of quitting.272 Greater assessment of tobacco cessation knowledge during exams may also improve competency in the provision of interventions.273 A review of tobacco curriculum in medical schools concluded that combining concise lecture-based curriculum with role-play or patient interactions builds the knowledge and skills necessary for undergraduate students to provide smoking cessation interventions.274 Brief cessation training and technical assistance also increases referral by health providers to specialist smoking cessation services.275,276 However there is a lack of consistency in cessation training during health professionals’ education.277 Part of the reason that some doctors may not be more actively involved in tobacco use treatment may be due to a lack of relevant training during medical school.278-280 Despite some international evidence of an increase in cessation training in medical schools over time, increased emphasis on addressing tobacco use with patients is needed.278,281 A study examining pharmacists’ training in the US noted the importance of education on cessation interventions given their expanding scope in this area.282 This may also be important in Australia, with recent legislative reforms restricting supply of vapes to pharmacies to facilitate access to vapes for people wishing to quit smoking (see Section 18.13).
Most postgraduate health professional training programs incorporate the 5As approach, stage of change, motivational interviewing, and pharmacotherapies, and commonly refer to clinical practice guidelines.283 However, one review and evaluation of online tobacco dependence treatment courses found that while many excelled in providing effective navigation, course rationale, and content, most failed to meet minimal quality standards and none of the courses evaluated could be ranked as superior.284 Further, 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 can be fairly ‘ad hoc’ and there is a lack of a systematic organised approach to ensure availability and consistency in most countries.283
The Quit Centre provides online cessation training and clinical tools and guidelines for a range of health professionals.56 Cessation training should not only be included during training but should form a core part of ongoing professional development,217 as the knowledge and skills gained during university can often be short-lived.274 Research in the UK found that large-scale upskilling of hospital-based healthcare professionals improved provision of cessation interventions.285
Healthcare providers and policy makers should develop and implement supportive systems, policies and training that embed the provision of cessation interventions as part of routine care.2 Along with training health professionals in smoking cessation interventions, organisational systems for routinely recording client smoking behaviour increase the effectiveness of practice,13,52,286-288 as it increases intervention delivery resulting in increased cessation rates.13,289 The use of electronic medical records can remind doctors and other clinic staff to record tobacco use, to give brief advice to quit, to prescribe medications, and to refer to cessation counselling services. A 2014 Cochrane review concluded that electronic records appear to increase the documentation of tobacco status and referral to cessation counselling,290 and subsequent studies have also supported the role of electronic health records in increasing the provision of cessation interventions.217,219,291-293 Many studies also support the effectiveness of a dedicated smoking cessation ‘champion’ within teams and units, whose role specifically includes promoting and delivering cessation interventions.86,294 Opt-out and proactive interventions and referrals also appear to increase tobacco use treatment and quitting behaviours compared with when patients must opt in.295,296 As well as the provision of cessation interventions, healthcare providers are also well-placed to support adherence to cessation medications, which can predict the success of quit attempts.297
An integrated, comprehensive systems approach to cessation treatment and policy can help improve the provision of cessation care, and increase quit rates.298 Australia currently has no national strategy for tobacco dependence treatment, and many opportunities to provide cessation advice and treatment are missed.299 Such a strategy could include:2,298-303
tailoring and targeting cessation support to best meet the needs of priority and disadvantaged populations (see InDepth 9A).
A number of studies have examined how to increase health professionals’ referrals to Quitline—see Section 7.14.5 for a detailed discussion.
References
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