Guidelines for health professionals in treating tobacco use and dependence

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Quit Victoria
Carlton, Vic

 


The importance of smoking cessation as a public health issue is highlighted in key international and Australian reports. Tobacco smoking is the largest cause of preventable death and disease in Australia and is responsible for the death of approximately 19,000 Australians each year1. For example, continued smoking after a cancer diagnosis is associated with decreased survival, increased risk of recurrence of a secondary tobacco-related cancer and post-operative morbidity, as well as increased side effects of chemotherapy and radiation therapy2. Many of the adverse health effects of smoking are reversible by cessation.

There is international agreement about an effective role for clinicians in smoking cessation, however a number of surveys of Australian health care providers report very low levels of routine provision of smoking cessation advice and assistance to their patients who smoke3,4. The US5, UK6, Scotland7 and New Zealand8 have developed best practice guidelines and recommendations for smoking cessation interventions by health professionals to assist and encourage them to take a more active role in this important health area. Australian guidelines have recently been developed9.

Many health professionals can deliver effective smoking cessation interventions, including medical specialists, doctors, nurses, pharmacists and dentists5. In 2001, as part of the Australian National Tobacco Strategy, a review of evidence and implications for best practice in smoking cessation intervention in health care settings was completed10. The report provides evidence of effectiveness and highlights the role of health professionals, including that:

  • Implementing clinic systems designed to increase the assessment and documentation of tobacco almost doubles the rate at which clinicians intervene with their patients who smoke and results in higher rates of smoking cessation5.
  • Brief cessation advice to smokers from doctors delivered opportunistically during routine consultations has a modest effect size, but substantial potential public health impact11, 5.
  • A major benefit of brief opportunistic cessation advice is to motivate a quit attempt (three-to-five fold increase) and to provide support or referral to aid quit attempts12, 13.
  • Brief cessation advice to smokers delivered opportunistically during routine consultations increases the abstinence rate at six months by 30%.
  • Provision of nicotine replacement therapy enhances the effectiveness of advice from a doctor. Nicotine replacement doubles the odds of quitting and is effective regardless of the amount of advice given.

Key conclusions of the review were that:

  • Asking about smoking status and provision of brief advice independently increase the cessation rate compared to no intervention (Fiore et al 2000). Therefore all health care providers should routinely ask about smoking and provide brief cessation advice and clinic or institutional systems should be established for identification of smokers.
  • Assessment of readiness to quit is a necessary first step in planning treatment5.
  • Clinical practice guidelines have been demonstrated to be an effective means of changing the process of health care and improving health outcomes. Therefore professional-specific brief intervention guidelines for health care providers should be developed and promoted. Development and dissemination of professional-specific brief intervention guidelines to health care providers through their respective peak bodies may be a way to increase the profile of smoking cessation as a relevant issue and to address perceived barriers to implementation.

Australian Guidelines for General Practitioners

Health professionals need guidelines and supporting materials that assist them to effectively engage patients appropriate to their stage of change and materials that will be most effective in encouraging quitting. Smoking Cessation Guidelines for Australian General Practice that aim to provide an evidence-based and practical approach to smoking cessation advice in general practice were launched in June 20049. The development of the Commonwealth funded guidelines was coordinated by GP Education Australia and involved a project team with members from the University of New South Wales School of Public Health and Community Medicine, The Cancer Council Victoria, Flinders University and GP Education Australia.  A wider reference group and comprehensive stakeholder consultation were undertaken, as well as an extensive literature review. The evidence base that underpins these guidelines was drawn from the National Tobacco Strategy publication Smoking Cessation interventions: review of evidence and implications for best practice in health care settings10.

The guidelines are based on the “5As” for brief intervention. This is an evidence-based framework for structuring smoking cessation in health care settings and the basis of the United States clinical practice guideline: Treating Tobacco Use and Dependence5. The “5As” approach has also been used as the basis of revised guidelines for smoking cessation in New Zealand8. The intervention approach for each group of smokers is from the Smokescreen Program14-18.

The Australian guidelines outline a range of interventions from short, minimal cessation advice from general practice, with the option of referral to the Quitline for ongoing cessation support for the patient, to more intensive in-practice management. Advice is provided based on the smoker’s readiness to quit, acknowledging that the smoker’s own motivation to stop is a key issue.

The “5As” for smoking cessation in Australian General Practice are:

Ask: If smoking status is unknown, all patients should be asked ‘Do you smoke?’ and ‘Have you ever smoked?’. A brief smoking history of current smokers should be documented.

Assess: A patient’s motivation and confidence to quit should be assessed using a non-judgmental question such as, ‘How do you feel about your smoking now?’. Assessment of the patient’s nicotine dependence and implications of other health issues are also important.

Advise: All smokers should be firmly advised to quit in a way that is clear, supportive and non-confrontational.

Assist: Assistance should be provided based on the assessment process and can have a variable level of clinician involvement. For example, a very brief intervention could be minimal advice and the provision of a Quit Book and the offer of referral to Quitline or appropriate community services.

Arrange follow-up: Follow-up after advice to quit has been shown to increase the likelihood of successful long-term smoking cessation. This could be done by appointment or telephone, or through feedback from a referral service, with the patient’s permission.

The Australian guidelines include information about special groups including pregnant and lactating women, adolescents, Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, people with smoking related disease, people with mental illness and people with substance-use disorders. The guideline package consists of a desktop flipchart, a practice handbook, Quit booklets and the Quitline referral forms. The guidelines were piloted and tested in 14 general practice settings around Australia, including group and solo practices and those in rural and urban settings.  Analysis of pilot data showed that they were readily useable and improved self-reported practice.

The Quitline referral process is facilitated using the fax referral forms that can also be accessed electronically on Medical Director. The Quitline was found to be an effective quit smoking service for Australian smokers who are interested in quitting19. Callback counselling, such as that provided by some of the state-based Quitline services, is more effective than a single telephone session20.

While these guidelines have been developed for the general practice setting, the evidence upon which they are based makes them relevant to many health professionals. For example, there is a very real opportunity for cancer clinicians to make use of the fax referral process to Quitline to assist their patients who smoke. In addition cancer clinicians could contribute significantly to the development of Quitline protocols and guidelines to ensure that specific issues for cancer patients related to smoking cessation are addressed appropriately.

Guidelines for other Health Settings

In Victoria, evidence-based smoking cessation guidelines have also been produced for other health settings, including for health professionals working with people with mental illness who smoke and pregnant women who smoke.

Smoking reduction and cessation for people with schizophrenia: guidelines for general practitioners was developed in 200121. The project was funded by the Victorian Department of Human Services and Quit Victoria and was a collaboration between SANE Australia, the University of Melbourne Department of Psychiatry and Quit. People with schizophrenia are rarely encouraged to stop smoking, or given support in their efforts to quit,22 although research has shown that the majority are interested in quitting23 and that stopping smoking is possible for people with schizophrenia, especially if treatment is tailored for them22.

The guidelines aim to inform general practitioners about ways to assist people with schizophrenia who smoke to stop, or at least reduce their smoking.

The guidelines are consistent with the “5As” approach and emphasise identifying smokers and assessing readiness to quit. For this population, assessment of the risks of smoking reduction and cessation for the individual smoker are also important for safe smoking cessation, due to the possibility of precipitation or exacerbation of psychotic symptoms, the development of clinical depression and the change in medication effects. Assistance includes writing an individual plan, appropriate use of nicotine replacement therapy, group support if appropriate, and available and frequent monitoring. The guidelines are available at www.dhs.vic.gov.au/acmh/mh/publications.

Quit Victoria has also developed Quitline guidelines for safe smoking cessation for callers with mental illness.

The Three Centres Consensus guidelines on Antenatal Care: guidelines for smoking cessation intervention was completed in 200124.   Funded by the Victorian Department of Human Services, the project was coordinated by the Royal Women’s Hospital, Southern Health and Mercy Hospital for Women. The Cancer Council Victoria and Quit Victoria assisted with the development of the specific guidelines for smoking cessation using an evidence-based method involving the development of search questions, a systematic literature search, critical review and appraisal and integration of the findings with clinical expertise.

The evidence from the literature appraisal indicated that smoking cessation interventions reduce smoking rates, decrease perinatal morbidity and mortality and are cost-effective25Most effective interventions for pregnant women are intensive, have multiple formats (eg. brief counselling, self-help resources), have multiple contacts, including follow-up, are not group sessions and include the partner. The evidence on nicotine replacement therapy was insufficient to develop guidelines.

The most accurate method of identifying pregnant smokers is to use a multiple-choice answer format, “Which statement best describes you now?”, rather than a yes/no format25. The guidelines were informed by clinical expertise, are brief, use the “5As” framework and include the level of evidence to support each step and references. The over-arching guideline is to routinely offer smoking interventions to all women who smoke or have recently quit.

In the maternity-care setting Guidelines for Shared Maternity Care Affiliates was also developed in 2002 by the Mercy Hospital, the Royal Women’s Hospital and Sunshine Hospital and included smoking cessation intervention guidelines also based on the “5As” strategy26. The “shared care” model is one in which a low-risk woman is cared for by both hospital staff and a community-based antenatal carer, a GP, obstetrician, or community-based midwife.

Despite the important role health professionals can play in smoking cessation intervention, there are a number of barriers reported by doctors to providing opportunistic smoking cessation advice, including lack of time and pessimism about the effectiveness of encouraging patients to quit. Evidence-based, best-practice guidelines that offer a choice of strategies from brief smoking cessation intervention and referral to support services (such as the Quitline) for ongoing support for the patient, to more intensive assistance by the clinician or practice, can help to address these barriers.

References

1. Ridolfo B, Stevenson C. The quantification of drug-caused morbidity and mortality in Australia in 1998. Canberra: Commonwealth Department of Human Services and Health; 2000.

2. Sarna LP, Brown JK, Lillington L, Rose M, Wewers ME, Brecht ML. Tobacco interventions by oncology nurses in clinical practice: Report from a national survey. Cancer. 2000 Aug 15;89(4): 881-889.

3. Young JM, Ward JE. Implementing guidelines for smoking cessation advice in Australian general practice: opinions, current practices, readiness to change and perceived barriers. Fam Pract. 2001 Feb;18(1) 14-20.

4. Wiggers JH, Sanson-Fisher RW. Practitioner provision of preventive care in general medical consultations: association with patient educational and occupational status. Soc Sc Med. 1997 Jan;44(2):137-146.

5. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville (MD): US Department of Health and Human Services, Public Health Service; 2000.

6. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Health Education Authority. Thorax. 2000 Dec;55(12): 987-999.

7. ASH Scotland and Health Education Board for Scotland. Smoking cessation guidelines for Scotland. [monograph on the Internet]
 Available from: http://www.hebs.scot.nhs.uk/tobacco/professional/cessation_guidlines/guidelines.htm

8. National Health Committee; New Zealand Ministry of Health. Guidelines for smoking cessation. Wellington:New Zealand Ministry of Health; 1999. www.nzgg.org.nz

9. Borland R, Cunningham M, Litt J, Richmond R, Stillman S, Zwar N. Smoking cessation guidelines for Australian general practice. Canberra: Commonwealth Department of Health and Ageing; 2004.

10. Miller M, Wood L. Smoking cessation interventions: review of evidence and implications for best practice in health care settings. Canberra:Commonwealth Department of Health and Ageing; 2001.

11. Sippel JM, Osborne ML, Bjornson W, Goldberg B, Buist AS. Smoking cessation in primary care clinics. J Gen Intern Med. 1999 Nov;14(11): 670-676.

12. Russell MA, Wilson C, Taylor C, Baker CD. Effect of general practitioners’ advice against smoking. British Medical Journal (1979). 2: 231-235.

13. Kreuter MW, Chheda SG, Bull FC. How does physician advice influence patient behavior? Evidence for a priming effect. Arch Fam Med. 2000;9(5):426-433.

14. Richmond RL, Austin A, Webster IW. Three year evaluation of a programme by general practitioners to help patients stop smoking. Br Med J (Clin Res Ed). 1986 Mar 22;292(6523):803-6.

15. Richmond RL, Webster I, Elkins L, Mendelsohn C, Rollnick S. Smokescreen for the 1990s: a stop smoking programme for general practitioners to use with smokers. 2nd edition. Sydney: NSW Department of Health;1991.

16. Richmond R, Kehoe L, Webster I, Wodak A, Heather N. General practitioners promotion of healthy lifestyles: What patients think. Aust N Z J Public Health. 1996 Apr;20(2):195-200.

17. Mendelsohn C, Richmond RL. The nicotine patch: guidelines for practical use. Modern Medicine of Australia 1994.37:105-112

18. Richmond RL. The physician can make a difference with smokers: evidence based clinical approaches. Int J Tub Lung Dis 1999;3(2);100-112

19. Wakefield M, Miller C. Evaluation of the National Quitline Service. In Hassard K (ed). Australia’s National Tobacco Campaign. Evaluation Report Volume One. Canberra:Commonwealth Department of Health and Aged Care; 1999.

20. Borland R, Segan C, Livingston P, Owen N. The effectiveness of callback counselling for smoking cessation: a randomized trial. Addiction. 2001Jun;96(6):881-889.

21. Strasser K, Moeller-Saxon K, Meadows G, et al., Smoking cessation in schizophrenia, General Practice Guidelines. Aust Fam Physician. 2002; 31: 21-24

22. Addington J. Group treatment for smoking cessation among persons with schizophrenia. Psychiatr Serv. 1998 Jul;49(7):925-928.

23. Addington J, el-Guebaly N, Addington D, Hodgins D. Readiness to stop smoking in schizophrenia. Can J Psych. 1997 Feb;42(1):49-52.

24. Three Centres Consensus Guidelines on Antenatal Care Project, Mercy Hospital for Women, Southern Health and Women’s & Children’s Health 2001

25. Trotter L, Montague M. Promoting smoking cessation among pregnant women: routine antenatal care guidelines. In Letcher T, Trotter L. (eds) Quit Victoria Research and Evaluation Studies No. 11: 2000-2001. Melbourne: Victorian Smoking & Health Program; 2002.

26. Guidelines for Shared Maternity Care Affiliates, Mercy Hospital for Women, The Royal Women’s Hospital and Sunshine Hospital 2002.

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