7.10 Role of health professionals and social services

Last updated: October 2016  Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.10 Role of health professionals and social services. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-10-role-of-general-practice-and-other-health-pro

Smoking, poor nutrition, obesity, excess alcohol use, and sedentary behaviour are increasingly seen as essential targets for intervention in general practice, hospital, and community health services as part of efforts to reduce or manage preventable ‘lifestyle’ health problems.¹ 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,^2-4 and given that smoking affects almost all parts of the body (see Chapter 3), healthcare and social service providers should integrate brief cessation intervention into routine care. A 2015 review of healthcare interventions concluded that brief advice from a healthcare worker (and also telephone helplines, automated text messaging, printed self-help materials, and quitting medications) is a globally affordable health-care intervention to promote and assist smoking cessation.⁴ Advice from physicians can also affect the attitudes, knowledge, intentions, and quitting behaviours of adolescents, thereby promoting both prevention and cessation.⁵

Reviews show a small, additional benefit of intensive advice and follow-up visits.^{2, 6} 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.⁶ The delivery of smoking cessation intervention by more than one type of health professional has the potential to increase quitting and readiness to quit.⁷ 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.^8-10

Health professionals often underutilise opportunities to provide cessation advice to smokers.^{6, 11-13} Factors positively associated with 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.^{12, 14} Barriers cited by healthcare providers include lack of reimbursement, lack of training, and lack of resources for follow-up.^{6, 15, 16} Health professionals who are non-smokers are more likely to deliver cessation interventions than those who are smokers.^{17, 18}

This section includes information on the role of:

• 7.10.1 General practitioners (GPs)
• 7.10.2 Hospital-based interventions
• 7.10.3 Pharmacists
• 7.10.4 Dentists
• 7.10.5 Specialists
• 7.10.6 Allied health professionals
• 7.10.7 Social and community service organisations
• 7.10.8 Practitioners of complementary and alternative medicine ; as well as information on:
• 7.10.9 Training health professionals in smoking cessation interventions
• 7.10.10 Increasing intervention delivery and referrals

7.10.1 General practitioners (GPs)

In 2014–15, more than 4 in 5 people (83%) had consulted a GP at least once in the previous year,¹⁹ 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.^{20, 21} A 2013 Cochrane review 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.²

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. One widely researched framework for structuring brief intervention is called the ‘5As’, which is considered best practice in the US,^{6, 22-24} UK,²⁵ New Zealand,²⁶ the Netherlands,²⁷ and by the World Health Organization.²⁸ The guidelines on cessation published by the Royal Australian College of General Practitioners also recommend using the 5As approach.²⁹ Receipt of the 5As is associated with a significant increase in patients' use of counselling and cessation medication.³⁰ The recommended procedure is:^31-22

1. Ask. A system for recording the current and previous smoking status of every client can help promote quitting. Instituting such a system signals to smokers that their smoking is important and it almost doubles the rate of clinician intervention and results in higher rates of cessation. The system needs to be integrated into the usual record keeping of the practice.
2. Assess. Assessing a smoker’s readiness to change is important in appropriately tailoring an intervention (see 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 in order to predict whether they would benefit from using NRT or quitting medications to relieve withdrawal symptoms. The most widely used measure is the Fagerström Test for Nicotine Dependence.
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, providing concrete help to smokers interested in quitting might involve assistance by the GP or other trained practice staff if time and expertise permit, or alternatively by proactive referral to the Quitline.
5. Arrange follow-up. Following up those who commit to making a quit attempt can help to promote sustained abstinence. A phone call or appointment after one week and one month can provide valuable ongoing encouragement and advice.

The Quitline provides such ongoing support. At future consultations, GPs should commend 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.

Despite the inclusion of the 5As in a number of national guidelines, they are not always implemented in practice.^{6, 34, 35} Failure to implement the 5As is associated with workload, perceived lack of remuneration, patients’ characteristics, and the smoking status of the GP.^{18, 36, 37} Doctors who are smokers are less likely than non-smokers or ex-smokers to advise and counsel their patients to quit,³⁶ but can be more likely to refer them to smoking cessation programs.³⁸

Few patients visit their doctor with smoking addiction as their main complaint, and brief visits often focus on other problems.³⁹ 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.³⁹ An Australian study found that the combined use of self-auditing, feedback, and education can improve GP management of smoking cessation.⁴⁰ 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.⁴¹ 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.⁴²

Effective group and individual cessation programs designed for delivery by GPs include Fresh Start (see Section 7.15.1.1) and Smokescreen.^{20, 43} Clinical practice guidelines for smoking cessation intervention also emphasise the utility, efficacy and reach of telephone quitlines.⁴⁴ An Australian randomised controlled trial found that GPs referring smokers to an evidence-based quitline service increased smoking cessation compared with in-practice management, mainly because referred patients received more external help (both groups received equivalent assistance within clinics).⁴⁵ However, another Australian study found that acceptance of opportunistic cessation referral within a GP setting was low among patients, although increased along with the continuum of stages of change.⁴⁶ 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.^8-10

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.⁴⁷ 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.⁴⁸ 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."⁴⁹

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.⁵⁰ 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. Some challenges in managing patient data and follow-up were identified.⁵¹ 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.⁵²

7.10.2 Hospital-based interventions

There are many opportunities to implement smoking cessation interventions with patients in hospitals, and also to implement interventions with smoking parents when their child is admitted to hospital. 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.^{53, 54} In the absence of standardised systems, the implementation of routine evidence-based cessation interventions by healthcare services is unlikely.⁵⁵ However, when such interventions are adopted by hospitals, they can lead to improved patient outcomes and decreased subsequent healthcare usage.⁵⁶

7.10.2.1 Emergency department

The role of emergency department (ED) staff in cessation intervention has received relatively little attention, but holds significant potential to encourage quit attempts in smoking patients.⁵⁷ ED doctors and nurses appear to frequently miss opportunities to offer smoking cessation interventions.⁵⁸ 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.⁵⁹ A study involving ED staff in the US found that they 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.⁶⁰ 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.⁶¹

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.^{57, 62-64} A 2014 systematic review concluded that ED visits in combination with ED-initiated tobacco cessation interventions are associated with higher cessation rates.⁶⁵ Educations programs can be successful for patients with cardiovascular disease⁶⁶ and chronic obstructive pulmonary disease.⁶⁷ Intensive intervention can also improve tobacco abstinence rates in low-income ED smokers.⁶⁸ 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.⁶⁹

7.10.2.2 In-patient care

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.⁷⁰ Adding NRT to the counselling is likely to further increase cessation rates.⁷¹ 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.^{72, 73} Making such interventions a routine part of hospital care could dramatically increase the number of smokers offered smoking cessation support.⁷⁴ 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.⁷⁵

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.⁷⁶ Nurses can be effective in delivering tobacco cessation interventions, but some lack of appropriate knowledge and/or skill, which presents a major problem for implementation.⁷⁷ A 2013 Cochrane review found moderate quality evidence that advice and support from nurses could increase people's success in quitting smoking, especially in a hospital setting.⁷⁸

7.10.2.3 Surgical care

Smoking causes a range of adverse surgical outcomes.⁷⁹ (See Chapter 3.15.1) Even short-term smoking cessation prior to surgery may help reduce the risk of postoperative complications.^80-83 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.⁸⁴

Patients facing surgery are interested in quitting and believe their physicians have an important role in their cessation attempts.^{85, 86} Smokers may benefit from an intensive cessation program one month before surgery, and it may help long-term cessation.^87-90 However, patients are not always well informed about the immediate benefits of quitting to their surgery outcomes.⁸⁵ 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.⁹¹ 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.⁹²

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.⁸⁵ 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.⁹³ Patients may not have enough pre-operative contact with the hospital to maximise smoking cessation intervention.⁹⁴

A number of small trials have examined ways to increase the 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.⁹³ Implementing clinical guidelines that combine GP referral to surgery with referral to smoking cessation support can significantly increase the number of patients that receive such a referral.⁹⁴ Clinicians are able to effectively facilitate the use of a quitline by surgical patients,⁹⁵ and comprehensive interventions incorporating brief advice, counselling, self-help materials, NRT and referral support from a quitline are effective six months post-discharge.⁹³ Referral of surgical patients to a quitline for post-discharge help appears to be acceptable to patients and inexpensive.⁸ A 2015 systematic review concluded 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. The authors highlight that further research is required to develop effective preoperative cessation programmes for smokers awaiting elective operations.⁹⁶

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 1 in 4 received any cessation assistance.⁹⁷ This is despite the fact that referral to evidence-based tobacco treatment after hospital visits is effective.⁹⁸ Smoking cessation intervention by nurses are beneficial for non-hospitalised patients,⁷⁸ and cessation programs combined with routine rehabilitation for outpatients are also effective in promoting abstinence.⁹⁹ One study found that interventions offered by thoracic surgeons in outpatient clinics can be successful in increasing quit rates.¹⁰⁰ Limited evidence also supports the use of telephone support following an intensive group program in hospital,101 use of automated interactive voice response systems to continue hospital-based smoking cessation intervention after discharge,¹⁰² and the continued use of NRT following discharge from hospital.¹⁰³ One study found an internet program for smoking cessation during and after inpatient rehabilitation treatment to be effective in increasing abstinence.¹⁰⁴

7.10.3 Pharmacists

Community pharmacies may be an underused resource for helping to deliver public health services.¹⁰⁵ 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.¹⁰⁶

A number of studies suggest that trained community pharmacists can deliver smoking cessation interventions that are effective in helping smokers to quit.^107-111 A 2014 meta-analysis concluded that pharmacist-led interventions can increase abstinence rates in smokers.¹¹² A systematic review and meta-analysis published in 2016 also examined the effectiveness of community pharmacy-delivered interventions for smoking cessation. Active intervention, comprising behavioural support and/or NRT, was about 2.5 times more effective and cost-effective than usual care.¹⁰⁵ Another 2016 systematic review similarly concluded that pharmacists are able to offer advice, help, and support for smoking cessation with a higher success rate than unassisted quitting.¹¹³ Smokers have also reported perceiving pharmacist-assisted cessation to be an appealing approach to quitting smoking.¹¹⁴

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.¹¹⁵ Findings from a randomised controlled trial showed that pharmacist counselling involving more than one session, combined with NRT, can be effective, but that many participants do not complete the necessary follow-up sessions.¹¹⁶ Similarly, longitudinal research in the US found that more intensive pharmacist-assisted intervention and those in group-formats led to higher quit rates. Difficulties with follow-up were associated with participants' relapse.¹¹⁷

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.^{118, 119} 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.¹²⁰

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.^{121, 122} Education and routine training for all pharmacy personnel may increase the success rates of pharmacy-led smoking cessation services.¹¹³

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 diseases.¹²³ 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.¹²⁴ A randomised controlled trial in Sweden found that even very brief, structured counselling in dental practices led to significant reductions in tobacco consumption (but not abstinence), particularly among smokeless tobacco users.¹²⁵ Further, dental patients have reported being receptive to dental practitioners inquiring about smoking behaviour and offering advice on quitting.¹²⁶

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.^127-129 A 2016 review concluded that brief behavioural interventions complemented by pharmacological treatment—with the participation of the entire dental team—are effective cessation interventions within dentistry.¹³⁰ However, implementation of such interventions is poor.^{128, 131, 132} The most frequently delivered components of the 5As are ‘asking’, ‘advising’ and ‘assessing’, with ‘assisting’ and ‘arranging’ being less common.¹²⁹ 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).¹³³

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.^{123, 134-136} Willingness to intervene is related to periodontal treatment and the presence of smoking-related disease.¹³⁵ 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.^{137, 138} Further research is needed to better understand and influence the factors that hinder guideline implementation.^{128, 131, 139-141}

Dental hygienists see their patients regularly, which provides opportunities for cessation assistance.¹²³ However, recommended smoking cessation interventions are not always implemented, with hygienists reporting lack of comfort and confidence in addressing smoking with their patients.^{142, 143} 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.¹⁴⁴ 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.^{97, 145}

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.^{135, 146} 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.¹³⁴ 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.¹⁴⁷

7.10.5 Specialists

Specialists have the potential to play an important role in promoting smoking cessation. For example, parents/carers generally visit their child’s paediatrician more often than their own, which provides opportunities for paediatricians to deliver cessation interventions and reduce children’s exposure to secondhand smoke. 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.³

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,¹⁴⁸ and US data suggest that smoking cessation is more cost-effective than other preventive cardiology measures.¹⁴⁹ However, cardiac health professionals, including lipidologists and cardiologists, could implement more effective smoking cessation interventions.^{150, 151} 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.¹⁵² 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.¹⁵² 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.¹⁴⁹ 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.¹⁵³

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,¹⁵⁴ rheumatological practice,¹⁵⁵ gynaecological practice,¹⁵⁶ perioperative care (such as by anaesthetists),^{157, 158} periodontal practice,¹⁵⁹ plastic and reconstructive surgery¹⁶⁰ and paediatric medical practices.^{161, 162} 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.

7.10.6 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.¹⁶³

Smoking cessation intervention by optometrists is 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.^{164, 165} 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.¹⁶⁶

Cessation as a goal in physiotherapy practices is consistent with the profession’s aims to promote health and wellness,¹⁶⁷ and smoking cessation advice can be readily integrated into physical therapy practice.¹⁶⁷ 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.¹⁶⁸

Psychologists may also play an important part in reducing the burden of tobacco-related disease through their roles as researchers and practitioners. Integrating evidence-treatment for tobacco use disorder into other ongoing treatments represents an important opportunity—albeit a complex one—for increasing cessation, particularly among underserved populations, including those with serious mental illness and/or substance use disorders (see Section 7.12).¹⁶⁹ 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.¹⁷⁰

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 Chapter 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.^{171, 172}

Although people who are disadvantaged can face complex barriers to quitting, social and community service organisations have the potential to increase service users’ knowledge and use of cessation aids, and to provide direct and tailored support to disadvantaged Australian smokers.¹⁷¹ A study in NSW found that more than half of the service users reported wanting help from staff to quit, with access to free NRT, cash and non-cash rewards, and support and encouragement from staff cited as the most preferred types of help.¹⁷³ The implementation of evidence-based interventions, such as the 5As, brief motivational interviewing, and use of NRT, appears to be acceptable and feasible within social and community service organisations.¹⁷⁴ Staff education, training, and support may further promote the integration of smoking cessation support into usual care.¹⁷⁵

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.¹⁷⁶ (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,^{6, 177} as such training increases the number of people identified as smokers and advised to quit.^178-181 Training increases health professionals’ knowledge, skills, confidence, and likelihood of practicing smoking-related interventions.^{108, 179, 180, 182-186} Brief cessation training and technical assistance also increases referral by health providers to specialist smoking cessation services.^{187, 188} Medical students generally retain skills learned during their training and in turn become more active in cessation interventions.^189-192 However the inclusion of standardised tobacco curricula in medical schools varies. 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.^193-195 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.^{193, 196}

Most postgraduate health professional training programs incorporate the 5As approach, stage of change, motivational interviewing, and pharmacotherapies, and commonly refer to clinical practice guidelines.¹⁹⁷ Although such training is generally delivered face-to-face, there are an increasing number of training programs available online.¹⁹⁷ However, a recent 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.¹⁹⁸ 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.¹⁹⁸ A randomised controlled trial was carried out between 2010 and 2014 in ten US medical schools that compared multi-modal tobacco treatment education (comprising a web-based course and instructor-facilitated training in addition to traditional education) with traditional tobacco treatment education alone. During a clinical examination, students with the additional training were significantly more likely to suggest behavioural strategies to patients and to provide information regarding Quitline. Of the 5As (see Section 7.10.1 above), they also reported higher confidence for Assist, Arrange, and pharmacotherapy counselling.¹⁹⁹

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.

7.10.10 Increasing intervention delivery and referrals

Along with training health professionals in smoking cessation intreventions, organisational systems for routinely recording client smoking behaviour increase the effectiveness of practice,^{6, 39, 200, 201} as it increases intervention delivery resulting in increased cessation rates.^{6, 202} 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.²⁰³

Providing financial incentives to providers is another strategy for shaping their behaviours, including incentives that are dependent upon specific patient outcomes.²⁰⁴ Some potential risks of adopting a ‘payment by results’²⁰⁵ system in the context of smoking cessation may be:

• 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. These risks may be minimised by only paying providers for levels of success above what might be expected if no intervention were delivered, and implementing an accreditation system for eligible providers.²⁰⁵ A study in England examined the effects of paying accredited providers standard tariffs for each smoker who was supported to quit. Results showed that such payments significantly increased the number of people who remained abstinent for four weeks.²⁰⁶

Few studies have examined how to increase health professionals’ referrals to Quitline. 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.²⁰⁷ Another project implemented a care co-ordination program that increased quitline referrals by providers.²⁰⁸

Relevant news and research

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References

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