7.10 Role of health professionals and social services

Last updated: August 2022

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, Section 7.10 Role of health professionals and social services. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2022. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-10-role-of-general-practice-and-other-health-pro 

 

Smoking cessation not only reduces a person’s risk of many diseases and improves health in general, it can also increase the effectiveness of treatments, improve recovery from surgery and illness, and improve rates of survival.1 Experiencing health concerns can also be an important motivator for smokers to make a quit attempt. Cessation interventions should therefore form part of routine care for all types of healthcare professionals, and should be seen as a crucial part of prevention and treatment.2, 3

Interventions delivered by healthcare and social service providers can increase smoking cessation among service users. Even brief, simple advice about quitting increases patients’ rates of successful cessation,4-7 and given that smoking affects almost all parts of the body (see Chapter 3), healthcare and social service providers should integrate brief cessation interventions into routine care. A 2015 review of healthcare interventions concluded that brief advice from a healthcare worker is a globally affordable health-care intervention to promote and assist smoking cessation.6 Such advice should be provided to all people who smoke, regardless of their interest in quitting.8 Advice from physicians can also affect the attitudes, knowledge, intentions, and quitting behaviours of adolescents, thereby promoting both prevention and cessation.9

Reviews show a small, additional benefit of intensive advice and follow-up visits.4, 10 Interventions with more than one component, such as those that combine two or more of the elements of the 5As brief intervention framework (see below) increase quit rates in primary care settings.10 The delivery of smoking cessation intervention by more than one type of health professional has the potential to increase quitting and readiness to quit.11 Some doctors or other health professionals have the opportunity to provide intensive behavioural interventions for smokers or to refer them, if appropriate, to specialist services.(See Section 7.10.8.) Specialist services include telephone services, cessation specialists within practices or healthcare centres, group quit courses, and individual counsellors. Referral to specialist services can address some of the common barriers to intervention faced by other healthcare professionals, particularly time constraints. Quitline provides a readily accessible specialist service to which health professionals can refer their patients. (See Section 7.14.1.) Proactive referral (whereby the healthcare professional sends the person’s details to Quitline so that he or she is contacted by a Quitline staff person) leads to substantially higher rates of utilisation than the provision of simple advice to call.12-14  

In terms of the efficacy and cost-effectiveness of cessation interventions, the ‘number needed to treat’ (NNT, or the number of people who will successfully quit for every person who receives a cessation intervention) is relatively low.15 Table 7.10.1 compares the NNT to prevent one death among clinical interventions delivered in primary care, and shows that the impact of successful smoking cessation dwarfs that of other common clinical interventions.16

Table 7.10.1
Comparison of the number needed to treat (NNT) to prevent one death among clinical interventions delivered in primary care

Intervention

NNT

Smoking cessation

 

Brief advice

40

Intensive behavioural support with:

 

Nicotine Replacement Therapy (NRT)

23*/46†

Varenicline

10*/20†

Statins as primary prevention

107

Antihypertension treatment for mild hypertension

700

Screening for cervical cancer

1140

Mammography

205

Papanicolaou smear

534

Pneumococcal vaccine

716

Note: *NNT to have one person quit smoking; †NNT to prevent one death
Sources: Critchley and Capewell;17 Van Schayck et al.;15 Pipe et al.16

Despite the majority of patients who smoke wanting to quit, health professionals often underutilise opportunities to provide cessation advice,10 , 18-21 and smoking cessation is neglected in many clinical guidelines.22 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.19, 23 Barriers cited by healthcare providers include lack of reimbursement, lack of training, and lack of resources for follow-up.10, 24, 25 Health professionals who are non-smokers are more likely to deliver cessation interventions than those who are smokers.26, 27

This section includes information on the role of: 

See Section 7.11.5.2 for a discussion of the role of health professionals in providing cessation care to pregnant women, and Section 9A.3.6 for the role of mental health professionals in promoting quitting among people with mental illness.

7.10.1 General practitioners (GPs)

In 2020–21, more than 4 in 5 Australians (85%) had consulted a GP at least once in the previous year,28 which provides an excellent opportunity for promoting smoking cessation. GPs are perceived as credible and authoritative on health issues, and their advice as appropriate and acceptable.29, 30 A Cochrane review last updated in 2013 concluded that even when doctors merely provide brief, simple advice about quitting, this increases the likelihood a smoker will successfully quit and remain a non-smoker 12 months later.4

Time constraints mean that GPs spend only limited time with most smokers (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 model31 (sometimes known as the ABC model: ask, brief advice, cessation support):

  • Ask and record smoking status
  • Advise all people who smoke to quit and on the most effective methods
  • Help by offering to arrange referral, encourage use of behavioural intervention and use of evidence-based smoking cessation pharmacotherapy

More comprehensive support can be provided using the 5As approach:31

  • Ask: identifying all patients who smoke
  • Assess: assessing nicotine dependence and barriers to quitting
  • Advise: advising them to quit
  • Assist: offering quitting assistance
  • Arrange: arranging follow-up.

Receipt of brief interventions is associated with a significant increase in patients' use of counselling and cessation medication,32 and with smoking cessation.33 It is considered best practice in the US,34 UK,35 New Zealand,36 and by the World Health Organization.37

Despite the inclusion of the ABC and 5As in a number of national guidelines, they are not always implemented in practice,10, 38, 39 or are not implemented in full.40 Failure to implement brief interventions is associated with workload, perceived lack of remuneration, patients’ characteristics, and the smoking status of the GP.27,41, 42 A lack of training and confidence can also create feelings of illegitimacy among GPs—particularly early-career GPs43 —in relation to their ability to provide cessation interventions, though patients report that they are a legitimate and trusted source of cessation advice.44 Doctors who are smokers are less likely than non-smokers or ex-smokers to advise and counsel their patients to quit,41 but can be more likely to refer them to smoking cessation programs.45

Few patients visit their doctor with smoking addiction as their main complaint, and brief visits often focus on other problems.46 Many clinics do not have systems in place that routinely include brief cessation interventions, but there is some evidence that large healthcare settings can increase cessation interventions by building on an existing electronic health record platform.46 An Australian study found that the combined use of self-auditing, feedback, and education can improve GP management of smoking cessation.47 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.48 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.49

The Quit Centre provides online training to GPs in best practice cessation care.50 Clinical practice guidelines for smoking cessation intervention also emphasise the utility, efficacy and reach of telephone quitlines.51 An Australian randomized controlled trial found that GPs referring smokers to Quitline increased smoking cessation compared with in-practice management.52 Proactive referral—whereby Quitline contacts the patient after receiving his or her details from the doctor—is more effective than simply advising patients to call.12-14   A 2021 Cochrane review concluded that cessation counselling (such as that provided by Quitline), free cessation medications, or tailored written materials may increase cessation rates when provided in addition to standard smoking cessation care in primary care practice.53 Patient-centred approaches may also improve the implementation of cessation interventions. Although patients who are highly engaged during medical encounters are more likely to respond to cessation advice, even smokers with low engagement are more likely to try and quit if they receive cessation counselling.54 Improving communication between patients and providers may promote greater engagement. One study that interviewed smokers about their cessation experiences found that many reported feeling shame, isolation, or disrespect, and frequently expressed wanting honest, consistent, and pro-active discussions and actions in their interactions with primary care providers.55 Australian researchers found that people with chronic obstructive pulmonary disease (of which smoking is the main cause) tended to delay seeking GP care due to anticipated stigma.56 A review of clinician messaging over time concluded that using gain-framed statements such as "Quitting smoking will benefit your health by preventing problems like lung and other cancers, heart disease, and stroke" is more effective than using loss-framed statements such as "Smoking will harm your health by causing problems like lung and other cancers, heart disease, and stroke."57

7.10.1.2 GP practice nurses

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.58 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.59 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.60

7.10.2 Hospital-based interventions

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.61 Despite a number of reviews, there is an absence of clear evidence regarding ideal methods within hospitals of screening, referral, intervention, and tailoring strategies for specific sub-groups.62, 63 In the absence of standardised systems, the implementation of routine evidence-based cessation interventions by healthcare services is unlikely.64 A recent 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.61 When such interventions are adopted by hospitals, they can lead to improved patient outcomes and decreased subsequent healthcare usage.65 , 66

7.10.2.1 Emergency department

The role of emergency department (ED) staff in cessation intervention holds significant potential to encourage quit attempts in smoking patients.67 However, ED doctors and nurses appear to frequently miss opportunities to offer smoking cessation interventions.68 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.69 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.70 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.71

Despite the challenges, interventions in emergency healthcare settings are worthwhile. Tailored interventions in EDs can be effective in prompting initial quit attempts and ED patients are interested in quitting and in receiving support.67, 72-74 A 2014 systematic review concluded that ED visits in combination with ED-initiated tobacco cessation interventions are associated with higher cessation rates,75 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.76 Intensive intervention can also improve tobacco abstinence rates in low-income ED smokers.77 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.78

7.10.2.2 In-patient care

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 was a current smoker.79 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.80 Combining behavioural support with cessation pharmacotherapies is likely to further increase cessation rates among smokers admitted to hospital,81-83 though several studies have noted that NRT should not be routinely provided in the ICU setting.84-86

Despite increases over time in the provision of cessation interventions to hospitalised patients, they are still underutilised.87 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.88 , 89 Making such interventions a routine part of hospital care could dramatically increase the number of smokers offered smoking cessation support.90 In 2015, a framework for hospital-based intervention was proposed following the new NSW Health Smoke-free Health Care Policy, which stipulates 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 smokers 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.91

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.92 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,93 but some lack of appropriate knowledge and/or skill.94 Nurses who smoke are also less likely to deliver cessation interventions.93 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.95 A more recent review similarly supported the effectiveness of nurse counselling for smoking cessation when combined with NRT.96 Hospital pharmacists may also be well-placed to deliver cessation interventions to in-patients, though more evidence is needed regarding the most effective components and intensity of such interventions.97

7.10.2.3 Surgical care

Smoking causes a range of adverse surgical outcomes.98 (See Section 3.15.1) Although longer cessation is ideal,99 even short-term smoking cessation prior to surgery may help reduce the risk of postoperative complications.100-103 Patients who smoke should be encouraged to stop smoking at any time before surgery.99

Patients facing surgery are interested in quitting and believe their physicians have an important role in their cessation attempts.104, 105 Smokers may benefit from an intensive cessation program one month before surgery, and it may help long-term cessation.106-109 However, patients are not always well informed about the immediate benefits of quitting to their surgery outcomes.104 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.110 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.111

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.104 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.112 Patients may not have enough pre-operative contact with the hospital to maximise smoking cessation intervention.113 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.114

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 smokers 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.115 Australian researchers found that even a simple preoperative intervention was effective in promoting smoking reduction or cessation up to one year post-surgery.116 One review notes that many studies looking at the effects of preoperative cessation have recruited smokers very close to their scheduled surgery, therefore the benefits of preoperative smoking cessation may have not been fully apparent.117  

7.10.2.4 Outpatient care

Outpatient settings offer important opportunities to provide cessation intervention and relapse prevention to smokers, but are underutilised. Data from the US show that from 2005 through 2010, more than one-third of hospital outpatient visits had no screening for tobacco use, and among current tobacco users, only one in four received any cessation assistance.118 This is despite the fact that referral to evidence-based tobacco treatment after hospital visits is effective.119  Smoking cessation interventions by nurses are beneficial for non-hospitalised patients,120 and cessation programs combined with routine rehabilitation and care for outpatients are also effective in promoting abstinence.121, 122

7.10.3 Pharmacists

Community pharmacies may be an underused resource for helping to deliver public health services.123 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.124 The Pharmaceutical Society of Australia’s guidelines for smoking cessation125 recommend that pharmacists:

  • provide brief advice (Ask, Advise, Help) and ongoing smoking cessation support
  • provide advice about prescription and non-prescription pharmacotherapy options
  • provide prescription and non-prescription pharmacotherapy and counselling on appropriate use
  • identify and resolve pharmacotherapy-related problems (e.g. interactions with medicines, adverse effects) during follow up.

A number of studies and reviews suggest that trained community pharmacists can deliver smoking cessation interventions that are effective in helping smokers to quit.126-130 123 ,131-133 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.134

Smokers report perceiving pharmacist-assisted cessation to be an appealing approach to quitting smoking.135 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.136

While specialist-led group services appear to have higher quit rates than one-to-one services provided by pharmacies, pharmacy services treat many more smokers and both are cost-effective.137,138 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.139

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.140,141 Education and routine training for all pharmacy personnel may increase the implementation and success rates of pharmacy-led smoking cessation services.132,142,143

7.10.4 Dentists

Smoking is a significant contributor to oral disease and cancer, and cessation is an important part of the treatment of periodontal diseases144 and improvements in periodontal health.145 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.146 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.147 Dental patients have reported being receptive to dental practitioners inquiring about smoking behaviour and offering advice on quitting.148 ,149

In Australia, dentists provide care to many high-risk populations, therefore effective training in and the implementation of cessation interventions is essential.150 Tobacco use prevention and cessation guidelines have been developed for dental settings. They involve a level-of-care model based on the 5As,151 with brief intervention, motivational interviewing, and more intensive plans involving pharmacotherapy.152-154 Brief behavioural interventions complemented by pharmacological treatment—with the participation of the entire dental team—are effective cessation interventions within dentistry.147,155 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.156 However, implementation of cessation interventions is poor.153, 157,158 The most frequently delivered components of the 5As are ‘asking’, ‘advising’ and ‘assessing’, with ‘assisting’ and ‘arranging’ being less common.154 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).159

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.144,150,160-164 Dental professionals who smoke are also less likely to provide cessation interventions.165 Willingness to intervene is related to periodontal treatment and the presence of smoking-related disease.161 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.166,167 Further research is needed to better understand and influence the factors that hinder guideline implementation.153,157,168-170

Dental hygienists see their patients regularly, which provides opportunities for cessation assistance.144 However, recommended smoking cessation interventions are not always implemented, with hygienists reporting lack of comfort and confidence in addressing smoking with their patients.171, 172 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.173 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.118,174

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.161 , 175 Dentists are willing to receive training on smoking cessation interventions, and including training in academic dental programs increases the use of smoking cessation practices within the dental team.160 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.164 ,176

7.10.5 Specialists

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.177 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.5 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. The authors note that further research is needed on how such interventions can be improved.178

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,179 and US data suggest that smoking cessation is more cost-effective than other preventive cardiology measures.180 However, cardiac health professionals, including lipidologists and cardiologists, could implement more effective smoking cessation interventions.181,182 Surveys assessing the knowledge, interest and attitudes of cardiologists regarding smoking cessation highlight a lack of commitment.183 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.183 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.180 Cardiac rehabilitation health professionals report finding it difficult to work with smokers, 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.184 Nonetheless, interventions are effective at promoting short- and long-term cessation among cardiopulmonary patients.185

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). However, a lack of 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.186 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.187 Another Australian study found that only about half of a sample of multidisciplinary cancer care clinicians provided brief cessation interventions, with the authors emphasising the need for clinician training and systems-level changes that embed cessation as part of cancer care.188

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,189,190 gastroenterology practice,191 rheumatological practice,192 gynaecological practice,193 perioperative care (such as by anaesthetists),194,195 periodontal practice,196 plastic and reconstructive surgery197 and paediatric medical practices.198,199 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.  

7.10.6 Allied health professionals

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 smokers could be significantly increased within existing budgets and without prolonging consultations.200

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.201 , 202 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.203 However, Australians who visit the optometrist report being receptive to discussions about tobacco use.204

Cessation as a goal in physiotherapy practices is consistent with the profession’s aims to promote health and wellness,205 and smoking cessation advice can be readily integrated into physical therapy practice.205 One study found that lack of resources and time are the main barriers to providing such advice, and suggested that physiotherapists’ preparedness and confidence in providing smoking cessation assistance need to be increased.206 Australian researchers suggest that a three-step brief intervention model—Ask, Advise and Help—can overcome these barriers in physiotherapy practice.207

Quitting smoking is associated with improvements in mental health among people with psychiatric disorders.208 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).209 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.210

7.10.7 Social and community service organisations

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.211-213 Such interventions are also cost-effective.214 An Australian trial that examined the effectiveness of behavioural counselling with the option of NRT delivered to highly disadvantaged smokers 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.215 The complex needs of highly disadvantaged smokers 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.216

7.10.8 Practitioners of complementary and alternative medicine

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 smokers.220 (See Section 7.18 for information on the use of alternative therapies for smoking cessation)

7.10.9 Training health professionals in smoking cessation interventions

Training clinicians in smoking cessation methods may increase patients’ cessation rates,10, 221 as such training increases the number of people identified as smokers and advised to quit.222-225 Training increases health professionals’ knowledge, skills, confidence, and likelihood of practicing smoking-related interventions.127, 223, 224 , 226-232 Such training should include practical guidance, resources and communication skills training for delivering cessation interventions, as well as education on the immediate clinical benefits of quitting.233 Brief cessation training and technical assistance also increases referral by health providers to specialist smoking cessation services.234, 235 Medical students generally retain skills learned during their training and in turn become more active in cessation interventions.236-239 However there is a lack of consistency in cessation training during health professionals’ education.240 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.241-243 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.241, 244

Most postgraduate health professional training programs incorporate the 5As approach, stage of change, motivational interviewing, and pharmacotherapies, and commonly refer to clinical practice guidelines.245 Although such training is generally delivered face-to-face, there are an increasing number of training programs available online.245 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.246 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 remain fairly ‘ad hoc’ and there is a lack of a systematic organised approach to ensure availability and consistency in most countries.245

The systematic, comprehensive and tailored program developed by Quit Victoria provides cessation training for a range of health professionals. The program includes face-to-face training and e-learning modules that are accessed by health professionals both in Australia and internationally.50 Cessation training should not only be included during training, but should form a core part of ongoing professional development.186

7.10.10 Increasing intervention delivery and referrals

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,10, 46, 247-249 as it increases intervention delivery resulting in increased cessation rates.10, 250 The growing use of electronic medical records has the potential to 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,251 and subsequent studies have also supported the role of electronic health records in increasing the provision of cessation interventions.186, 252

An integrated, comprehensive systems approach to cessation treatment and policy may help improve the provision of cessation care, and increase quit rates.253 Australia currently has no national strategy for tobacco dependence treatment, and many opportunities to provide cessation advice and treatment are missed.254 Such a strategy could include:2 , 253-257

  • expanding cessation treatment coverage and provider reimbursement
  • mandating adequate funding for the use and promotion of evidence-based, state-sponsored quitlines
  • supporting healthcare system changes to embed tobacco treatment as part of routine care
  • increasing smokers’ knowledge of the availability and effectiveness of evidence-based cessation support
  • 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.

Relevant news and research

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