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| Journal of the New Zealand Medical Association,
25-June-2010, Vol 123 No 1317
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Smoking cessation education
increases interventions in a New Zealand hospital: World No Tobacco Day
revisited
Stephen Vega, Iwona Stolarek
Following ‘World No Tobacco Day 2007’, the
New Zealand Medical Journal published an editorial by two Christchurch
respiratory physicians, Lutz Beckert and Roland
Meyer.1 They drew attention to a marked lack of
spending on smoking cessation aids (particularly nicotine patches) in
Christchurch Hospital. For the year 2006, only $759.60c was spent on nicotine
replacement therapy (NRT) by the surgical services and $5075.68c by the medical
services, perhaps reflecting a lack of attention given to smoking cessation by
clinical staff.
The problem of smoking is such a significant one in health
terms that Beckert and Meyer compared failing to provide attention to a
patient’s smoking to that of failing to provide attention to a
patient’s elevated blood pressure. Beckert and Meyer advocated doctors to
address smoking cessation as a part of their clinical practice and went on to
ask that “health professionals to show a commitment to the issue of
smoking cessation initiatives and tobacco control by acquiring the relevant
knowledge and skills; and by influencing hospital managers, district health
board chief executive officers (CEOs), and policymakers to continue to make
further gains across the entire health sector.”
Tobacco smoking is a leading cause of preventable death and
disease. Indeed, New Zealand’s Ministry of Health estimates 5000 people
die from exposure to tobacco in New Zealand every
year.2 The cigarette is now a chemical cocktail
filled with additives to enhance the rapid delivery of nicotine to the
bloodstream and modify the taste of burnt
tobacco.3,4 By the time they reach the age of
17, teenage smokers in New Zealand already express regret at having taking up
smoking.5
Despite declining smoking rates, healthcare professionals
need to be aware that there is still a large population of smokers who are
heavily addicted, and that there are new recruits being added everyday.
Māori, in particular, are affected by very high rates
of smoking, with 43% of adult Māori currently
smoking.2 If smokers do not quit early enough,
many will add themselves to the health burden of long-term
conditions—defined as the chronic conditions—such as chronic
obstructive pulmonary disease (COPD) and cardiovascular disease (CVD),
“that have a significant impact on the lives of a person and/or their
family, whānau (extended family), or other
carers.”6
In 2007 a Health and Disability Commissioner’s (HDC)
report recommended that district health boards (DHBs) review their smokefree
policies and become more assertive in their treatment of smokers by providing
nicotine patches on admission.7
Hutt Valley District Health Board (HVDHB) is resolute in its
commitment to smoking cessation and tobacco control initiatives. Our health
professionals and managers have responded to the HDC report and the Ministry of
Health initiatives, to make attention to smoking a part of regular clinical
practice. In 2007, HVDHB agreed to put smoking cessation training in place and
to review its existing Smokefree Policy.
The aim of this paper is to review the usage of nicotine
replacement therapy (NRT) at HVDHB as a reflection of the success of these
measures.
MethodsHutt Valley Hospital is a 290-bed district general
hospital 15 km from Wellington. Junior doctor staffing includes 25 house
surgeons, 17 first years and 8 second years. In June 2007, as part of a
programme of educational and training initiatives, quarterly training sessions
on smoking cessation commenced for all house surgeons.
In July 2007, monthly effective brief intervention
(EBI) training for smoking cessation, open to all staff, commenced. Smoking
cessation training was also provided on an ad-hoc basis as the need
arose—e.g. when the HVDHB mental health unit went smokefree in March 2008.
All smoking cessation education sessions are based on the New Zealand
Guidelines for Smoking Cessation.8
In addition, the review process for the HVDHB Smokefree
Policy began July 2007. During a year of consultation the Smokefree Policy went
through a rigorous process of comment and critique from the clinical board,
clinical heads of department, the nursing development unit and the executive
management team. The original Smokefree Policy instructed the human resources
personnel to inform staff and contractors that the hospital and its grounds were
smokefree and suggested disciplinary action against staff who were found in
breach of the policy.
The revised Smokefree Policy has become a treatment
model, rather than a business model, targeting clinical staff interventions and
suggesting best practice for smokers based on the New Zealand Guidelines. The
new revised Smokefree Policy ensures that appropriate levels of care and support
are in place for patients, staff and visitors who smoke and recommends treating
the patient for acute nicotine withdrawal with NRT. In addition it provides
clinical staff with the steps to be taken to keep a patient safe when they
insist on smoking.
Many of the changes in the policy were a direct result
of input from senior clinical staff and the management team, demonstrating a
high standard of commitment to the treatment and care of people who smoke.
The new policy was approved in May 2008. The active
engagement of staff appears to have contributed to a significant culture shift;
one where staff became open to training and discussions about smoking, and are
now routinely asking about and freely providing NRT to their patients.
Other contributing variables that were likely to have
increased the delivery of smoking cessation were: the support of the senior
medical staff responsible for adult teaching, the introduction of Quit Cards in
February 2008 and the introduction of the subsidised NRT lozenge on 1 September
2008.
Quit Cards, which had been used by Quitline as a
substitute prescription for NRT, were initially restricted for use by health
professionals who had undertaken specific two-day training. From February 2008
Quit Cards were approved for use by anyone who had prescribing rights, including
hospital doctors and midwives.
To assess the impact of these initiatives a review of
the usage of NRT was made for a period prior to and following the above
educative initiatives to see if any measurable change had occurred. Data was
gathered from Hutt Hospital pharmacy showing the use of inpatient NRT. Rather
than look at cost, we looked at the total number of NRT units used in each year.
All forms of NRT, whether a patch or a lozenge, were counted as a single unit.
The total numbers dispensed in the hospital were counted and as Hutt Hospital
Pharmacy supplies NRT only for inpatients, the numbers dispensed were assumed to
reflect inpatient use.
ResultsIn 2006, prior to the introduction of educational and
training initiatives, 768 NRT units were provided to inpatients. After the
training started in mid 2007, the volume of NRT units used rose by 85% for that
year compared to 2006 , as shown in Table 1. In 2008, patches, gum, lozenges and
inhalers were provided, however the inhaler was not subsidised and was only
offered to patients in the mental health unit. The volume of NRT used in 2008
rose by another 161% compared to 2007; a fourfold increase in NRT use over 2
years (Table 1).
DiscussionTeaching around smoking cessation started in mid-2007. Since
that time each quarter’s intake of new house surgeons has had the
opportunity to attend a teaching session, and in total approximately 70 house
surgeons have attended, this comprises more than 80% of all new house surgeon
staff. Smoking cessation training for house surgeons is on their general roster
of adult teaching and although not compulsory it is recommended that they
attend. House surgeons received a 45-minute training session, which was a
shortened version of the EBI training, with an emphasis on the delivery of NRT.
The aim of this training is to clarify that smoking is a
significant health issue, that smokers are addicted to nicotine, and most will
need treatment for abrupt withdrawal when admitted to hospital. For the same
period 96 staff attended EBI sessions, 31 of these were clinical hospital staff
and the remainder in allied health. Of the clinical staff one was a doctor, two
were physiotherapists and the others nurses. Trainees are recruited through a
staff intranet bulletin, a circulated hard copy human resources bulletin and by
word-of-mouth.
Our results show that NRT usage has increased from 768 units
in 2006 to 3712 units since education and training structures have been put in
place. It is interesting to note that the combined use of nicotine gums and
lozenges is greater than the patch for 2008. This is somewhat against the data
from Quitline and might be due to the emphasis provided in training that the
oral nicotine preparations provide much more immediate relief from withdrawal
than the patches.9
These data suggest that smoking cessation awareness has
grown and that more staff are undertaking more smoking interventions with their
patients. Further, as interventions only started midway in 2007, the increase
for that year shows that rapid improvements can be achieved. As the main
interventions in 2007 were educational, prior to changes in smokefree policy, we
can see that a smoking cessation programme for house surgeons can significantly
impact on NRT usage. However, the total spend on NRT for 2008 was only $3676.63,
out of a pharmacy budget close to 3 million, a very small cost for a large gain,
and clearly there is potential for further gains to be made.
We have not used Quit Cards as a measure of smoking
cessation activity, though they may have contributed to staff awareness of this
issue. Quit Card activity has been difficult to measure because Quit Cards have
been directly distributed to health professionals and therefore given to both
outpatients as well as discharged inpatients.
We attribute the overall increase in use of NRT to the
delivery of smoking cessation education, the success we have had with changing
the emphasis of our Smokefree Policy to a treatment model, our mental health
unit becoming smokefree and also to a positive work environment where the staff
have actively engaged with these measures. Although it may be difficult to
demonstrate, one aspect of our success might have been the removal of barriers
to smoking cessation, by suggesting smoking cessation as a treatment option,
rather than a counselling session.
An earlier in-house pilot study had shown that perceived
barriers did exist, e.g. a lack of time to do cessation counselling. Previously
brief interventions for smoking cessation had been modelled on the Stages of
Change and smokers readiness to quit.
This model appeared too detailed, we therefore took view
that the smoking cessation approach to patients should be made from a clinical
treatment model—i.e. providing treatment for abrupt nicotine withdrawal,
rather than providing smoking cessation counselling. We were also of the view
that the responsibility for treating patients for nicotine withdrawal was the
duty of all clinical staff rather than a specific smoking cessation person or
team.
Evidence suggests that advice from a health professional
will help a smoker to quit; that NRT is an effective aid to quitting, and that
spontaneous quit attempts are often more likely to succeed than planned quit
attempts and it is this evidence and the New Zealand Guidelines that has guided
our approach.10,11,12
On a national scale, if all health providers were to apply
the New Zealand Guidelines approach to smoking cessation and increase the use of
NRT, this could have a significant impact on reducing chronic disease in New
Zealand. The Ministry of Health supports this approach and has developed the ABC
Framework for Tobacco. 13 The aim of the ABC framework is to
assist all health professionals to Ask about smoking, offer
Brief advice to quit and provide Cessation
options including NRT and referrals to cessation services such as Aukati Kai
Paipa and Quitline.
At a local level ABC training that includes the
“relevant knowledge and skills” for smoking cessation, will be made
widely available this year to all health professionals, both online and through
the Smokefree DHB Coordinators.
More recently the Ministry of Health published the first
results of the Health Target report and HVDHB came bottom of the table for
target 5; “Better help for Smokers to Quit”. The measure for the
Health Target is the number of admitted patients who are documented, and then
identified and coded, as smokers who have received advice to quit.
The HVDHB Health Target result appears to reflect a lack of
documenting and coding of smoking status rather than a lack of will to engage
with the process of helping smokers, as evidenced by our increasing NRT usage.
For the year 2009 our NRT usage has continued to increase (by another 47%),
suggesting the issue with our Health Target is the capture of information
regarding smokers receiving advice to quit.
As a result HVDHB has revised its electronic discharge
summary to better capture patient smoking information and advice to quit,
although this still cannot ensure the complete accuracy of documented and coded
data.
At HVDHB we plan to continue to monitor NRT usage not only
to assess the ongoing impact of educational and policy changes, but to help
interpret our Health Target. This year we will broaden the delivery of our work
to include our primary care services.
It is important not only to acknowledge World No Tobacco Day
31 May, but also to address smoking cessation throughout the year by providing a
strong level of care and support to patients who smoke and provide the resource
that enables them to quit.
Competing interests: None.
Author information: Stephen Vega, Smokefree
DHB Coordinator; Iwona Stolarek, Consultant Physician; Hutt Valley District
Health Board, Lower Hutt
Acknowledgement: We thank the staff at Hutt
Hospital pharmacy for their assistance with data for this article.
Correspondence: Stephen Vega, Smokefree DHB
Coordinator, Hutt Valley District Health Board, Private Bag 31-907, Lower Hutt
5040, New Zealand. Fax: +64 (0)4 5709211; email: stephen.vega@huttvalleydhb.org.nz
References:
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