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| Journal of the New Zealand Medical Association,
15-April-2005, Vol 118 No 1213
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Can Quit Practice: a comprehensive smoking cessation
programme for the general practice team
Deborah McLeod, Elizabeth Cornford, Susan Pullon, Kawshi de
Silva, Corrianne Simpson; for The Can Quit Practice Group
Smoking continues to be a significant cause of morbidity and
premature mortality.1 Since 1985, tobacco
control measures introduced in New Zealand have included banning tobacco
advertising, increased taxation, discouraging the sale of tobacco to young
people, smokefree workplaces and public areas, and smoking cessation
services.2
The Quitline, a national smoking cessation telephone
counselling service, was established in 1999. Subsidised nicotine replacement
therapy (NRT) is available to smokers through an exchange card system from the
Quitline or from healthcare providers who have received recognised training, and
maintain adequate recording and reporting systems. Smoking cessation guidelines
based on a frequent brief intervention model have been disseminated to all
primary care providers in New Zealand.3 The
guidelines stress that there is ‘good evidence that even brief advice from
health professionals has a significant effect on smoking cessation rates.’
(pg3). Free training programmes for health professionals have been made
available nationally.
However, while GPs appear to be in an excellent position to
deliver a focussed brief intervention, the smoking cessation activity provided
as part of ‘usual’ care is variable. While many GPs ask about
smoking, less record smoking status in patient
notes4 and further questioning or follow-up of
smokers is inadequate.5 Barriers to providing
smoking cessation advice and support have been reported as lack of GP time,
patients’ resistance and remuneration
issues.4,6
Extending the role of the PN has been recommended as a way
of overcoming some of the barriers facing GPs who undertake health promotion
work and helping to realise the health promotion potential of general
practice.4 This recommendation is based upon
evidence that individual smoking cessation advice and counselling given by
nurses to their patients is an effective
intervention,7 and that nurses gain
satisfaction from the counselling role.
In response to the evidence and the above recommendation,
the Can Quit Practice Programme was established. The specific objectives were to
increase the frequency and effectiveness of brief intervention for smoking
cessation within general practice; to provide PNs with appropriate knowledge,
skills and support so that they could advise smokers and support them through
quit attempts; and to develop an effective infrastructure to implement smoking
cessation initiatives.
This paper describes the Can Quit Practice Programme and an
evaluation of the Programme.
MethodsSettingThe
general practice team is the most widely used health professional group, and
four out of five New Zealanders visit their general practice at least once each
year.8 At the time of the study, funding for GP
and PN care was predominantly fee-for-services. Patients were able to choose
which general practice they attended and were usually able to see the
practitioner of choice within 48 hours. GP consultations were typically 12 to 15
minutes in length. PN typically had shorter consultations, often in open-plan
treatment areas.
The Can Quit Practice ProgrammeProgramme
structure—The Can Quit Practice Programme encompasses two main
activities: brief intervention; and the provision of more time-consuming smoking
cessation advice and support including assessment, quit advice and follow-up.
The practice quit advisor(s), typically a trained PN(s), provides the smoking
cessation advice and support. The Programme is consistent with evidence-based
guidelines, and was developed after extensive consultation with GPs, PNs, Maori
smoking cessation providers, members of the Quit Group (a national smoking
policy group), and a nurse experienced in providing smoking cessation support.
Specialised training, clinical guides, and resources were developed for the
Programme. The training is provided at two levels with each level taking one day
(Table 1). CS provides training through a mix of formal teaching, video clips
and practical sessions, including role-plays and case studies. Training began in
May 2001.
Programme
delivery—The GP or PN utilises brief intervention in the context of
a consultation, records smoking status on the patient’s notes, and refers
patients who are thinking about changing their smoking (or who need to quit for
health reasons) to a PN who has been trained as the practice quit advisor.
The brief intervention strategy is based on the '5As'
of smoking cessation:
The provision of smoking cessation advice and
support by the practice quit advisor incorporates the Prochaska and DiClemente
transtheoretical model of change and motivational interviewing principles. The
transtheoretical model of change, describes smoking cessation as a dynamic
process with change occurring through a series of
stages.9 Motivational interviewing is ‘a
directive, client-centred style that helps clients to explore and resolve their
ambivalences about quitting.’10
Practitioners working within the ‘spirit’ of motivational
interviewing, aim to increase a smoker’s self-efficacy, and to avoid or
de-escalate patient resistance through strategies such as refraining from
judging or contradicting patients, or pushing for change
prematurely.11
Programme
implementation—The Can Quit Practice Programme was implemented in
the greater Wellington area (Wellington, Porirua, and Hutt cities and the Kapiti
Coast) in the lower North Island of New Zealand. Smoking cessation co-ordinators
at GP organisations in the locality assisted in planning the Programme. All 114
practices in the locality were posted an invitation to participate and were
offered free training. The postal invitation was supplemented with telephone
calls and practice visits. After the training sessions, practices were offered
extensive implementation support, which included one or more visits to the
practice. The visits were scheduled at times when as many of the general
practice team as possible were available. Different strategies to implement the
Programme were discussed to find the most suitable approach for each general
practice. Assistance was provided to set up recording and recall systems.
Programme evaluationQuantitative
evaluation—The first 14 practices fully implementing the Programme
were asked to participate in a quantitative evaluation to assess changes in
smoking cessation activity by participating practices, and quit rates for
patients registering with the Programme for quit support. Smoking cessation
activity was evaluated by surveying all patients who had attended each practice
on a randomly selected day before, and after, the Can Quit Practice Programme
had been implemented (the pre- and post-implementation surveys).
Patients were mailed a questionnaire about whether they
recalled being asked about their smoking, alcohol consumption, and physical
activity during their practice visit. Patients, who described themselves as
current smokers, were asked about their readiness to quit. Pre-paid addressed
envelopes were included and one reminder letter sent to non-responding patients.
In addition to the questionnaire, the notes of sampled patients were audited to
determine if their smoking status was recorded.
Quit rates were audited by comparing patients from the
pre- and post-implementation survey who ‘thought they should quit’
or were ‘actively doing things to quit’, with consecutive patients
registering in the Can Quit Practice Programme by completing a registration
form. Consent was sought from patients to forward a copy of this registration
form to the researchers. Patients were followed up and interviewed by telephone,
and their smoking status ascertained at 3, 6, and 9 months after registration.
Two reminder calls were made, and follow-up by fax or mail attempted, for
patients who could not be reached by phone.
Qualitative
evaluation—The aim of the qualitative evaluation was to explore the
relevance of the training, resources, and ongoing support from the perspective
of clinical staff providing smoking cessation advice and support. The
qualitative evaluation consisted of interviews with personnel from a wider range
of practices than the quantitative evaluation, including those who had declined
to participate in the training. A sample of 22 individuals was purposively
chosen to provide a mix of PNs and GPs with varying levels of prior training and
practice commitment to smoking cessation activities and who belonged to
different general practice organisations, and worked in practices of different
sizes and with different ethnic and socioeconomic patient profiles. Interviews
were conducted between June and September 2002.
Three interview schedules were developed to
accommodate: participants who had received Can Quit Practice training and worked
in an accredited practice; those who had received Can Quit Practice training but
their practice had not implemented the Programme; and those who had declined to
participate in the training.
Interviews with Programme participants were most
commonly face-to-face and were carried out by EC. Topics covered included
smoking cessation activity within the practice, perceptions of the Programme,
and barriers and facilitators to participation. Barriers to participation were
explored in telephone interviews with those not participating in the Programme.
All interviews were recorded and transcribed verbatim. Transcriptions were
checked for accuracy by the original interviewer.
Data from interviews were supplemented with field notes
kept by EC, which included observations, details of key events, and data
gathered from contact with PNs and GPs.
Data
analysis—Questionnaire responses and audit data were entered into a
Microsoft Access 97 database then exported into EpiInfo for analyses.
Significant and recurrent themes were identified from
qualitative data (interview transcripts and field notes). Data were then
categorised and coded according to those themes. Validation of the themes,
categories and coding was done through a process of independent analysis and
subsequent agreement of results.
The Wellington Ethics Committee approved the
research.
ResultsParticipation in the quantitative evaluationTen of the
14 (71%) practices invited to do so participated in both the pre- and
post-implementation baseline surveys, although post-implementation data from one
practice went missing and was unable to be replaced. Six of the 10 practices
participated in both the pre- and post-implementation notes audits. Practices
not participating in the evaluation claimed to be too busy to do so. Responses
were received from 169/347 patients (49%) to pre-implementation questionnaires,
and from 167/328 (51%) to post-implementation questionnaires. All 27 patients in
the pre- and post-implementation surveys who identified as current smokers
(including 7 who were thinking about quitting, and 11 who were actively
quitting) were followed up to assess their progress.
Participation in the qualitative evaluationIn total 16 PNs and three GPs were
interviewed from 16 practices. Interviews could not be arranged with the other
three GPs from the original sample, although none explicitly declined to
participate.
Participation in the Can Quit Practice ProgrammeBetween May 2001 and October 2002,
48 PNs and 9 GPs from 39 of 114 (34%) general practices received training in the
Can Quit Practice Programme. Forty-six of the 114 practices in the locality
already offered a structured brief intervention programme.
While personnel from 15 (33%) of these 46 practices
participated in the training, they only partially implemented the Programme.
Personnel from 24 (35%) of the remaining 68 practices participated in the
training. Seventeen (71%) of these 24 practices (with a total of 65,300
registered patients) went on to fully implement the Programme and receive Can
Quit Practice accreditation.
Accredited practices included a broad spectrum of practice
types, including those providing care to populations with a high percentage of
patients with health subsidy cards. The acceptability of the Programme to this
group was confirmed by the demographic profile of 85 consecutive patients
registering for quit support from the 14 practices participating in the
evaluation; 21 (60%) of the 85 patients held health subsidy cards; and 21 (25%)
were Maori, 9 (11%) were Pacific, and a further 11 (13%) identified with ethnic
groups other than New Zealand European.
Recruitment to training was time intensive. Direct
approaches (such as invitations to individuals and faxes to practices) were
particularly effective. Participation in the training allowed practices to apply
to be registered providers of subsidised NRT, and this was an important aid to
recruitment. Free training and continuing education credits for attending were
not remarked upon by the attendees as recruitment strategies, possibly because
these have become standard practice in New Zealand. As the Programme progressed,
the general level of awareness of the training increased and recruitment became
easier, with contact being initiated by the practices in some cases.
A key motivation for participation in the training was to
improve the smoking cessation advice and support that could be offered to
patients. It was not necessary to promote the value of smoking cessation with
health professionals, as they were familiar with the health benefits of
quitting. Barriers to recruitment for training included perceptions that the
majority of patients making quit attempts would continue or return to smoking,
and lack of time to attend the training.
Those persons who participated in the training confirmed its
relevance and value, and commented on the usefulness of the training manual and
assessment guides12 as ongoing references. The
practice quit advisors, in the main, reported enjoying the counselling aspect of
the work; and smokers participating in the Programme valued the support that
they had received. Both PNs and GPs reported extending their use of motivational
interviewing techniques to other aspects of their clinical practice. A common
theme was the usefulness of the transtheoretical change model as a framework for
health professionals to use to understand their patients, and the value of the
concept for patient education and encouragement:
I
think people, if they know there is a process and they’re working through
a process, they’re much more likely to keep on keeping on
[PN]
Despite the perceived usefulness of the change model, only
two of the participants reported using the wheel or ‘cycle of
change’ resource13 regularly for
assessment and for patient education.
Many practices found the implementation visits useful,
although the Can Quit Practice team almost always initiated the visits. The
visits provided the opportunity for the practice team to talk among themselves,
receive information about the Programme and how it had been implemented
elsewhere. The internal organisation of the practice, including the role of the
PN, was a significant factor impacting on successful implementation. Without
some autonomy, freedom from reception duties, and sufficient uninterrupted time
to do the work, PNs working as practice quit advisors could not provide adequate
quit support and the Programme could not be implemented.
Implementing the Can Quit Practice Programme in a range of
general practices confirmed that all aspects of the Programme needed to be
flexible enough to be adapted to the different characteristics of each general
practice in which it was being implemented.
The impact of the Can Quit Practice ProgrammeAsking
and recording—In the interviews, participants reported asking about
smoking more often. A patient presenting with a smoking-related health problem
was reported as the strongest trigger to asking about smoking within a
consultation. Other triggers were the smell of cigarette smoke on the patient,
consultations related to pregnancy, and the first consultation with a new
patient. Being busy, or dealing with urgent medical problems or upset patients,
were also times when patients may not be asked about their smoking. There were
no significant differences pre- and post-implementation (chi-squared=0.13,
p=0.719) between patient reports of being asked about their smoking by their GP
(Table 2). However, although numbers were small, there appeared to be an
increase in the extent to which nurses asked about smoking and about alcohol
consumption.
PNs with more professional autonomy, strong views about
smoking, and established relationships with patients, reported asking about
smoking:
I
basically do a lot more talking [than I used to]. Sometimes I might catch the
patient before they go into the [Doctor's] room, so I’m talking to them
about their smoking and whether they want to give up [PN]
Participants in the qualitative evaluation also reported an
improved level and visibility of smoking status recording in the patient’s
notes. Practice-wide and appropriate recording systems were considered to be an
essential adjunct to asking. Several practices with computerised clinical notes
had begun to use READ codes to classify smokers, so that smoking would appear on
a patient's problem list. Computerised alerts that could be set to remind
doctors and nurses to ask patients about smoking were considered to be too
intrusive. However, the pre-and post-implementation audits did not reflect this
perceived increase in recording smoking status in patient notes (Table
3)—but in those notes where smoking status was recorded, it was usually
highly visible during the consultation.
Most (over 60%) patients in the pre-and post-implementation
survey accepted the involvement of PNs and GPs in smoking cessation (Table 4).
Assessing—When
questioned, PNs and GPs stated that they found it relatively easy to assess
their patients' readiness to quit. Most asked simple questions about smoking and
then interpreted how patients responded, as well as considering their actual
response:
I’ll
just ask them. Have they ever thought about talking to someone about stopping
smoking, about how ready they might be, whether they feel ready now, or have
they tried in the past. And usually they’ll say 'Oh I’ve tried three
or four times' [in a depressed tone of voice] or something like that.
There’s not many who have never tried. Not many. And if I can, I pursue it
then. There are different ways. Would you like to come back and speak with me?
Or have you got the time now? Or–depends on the situation.
[PN]
Advising, assisting, and
arranging follow-up—In practices where the Can Quit Practice
Programme had been implemented patients were referred to the practice quit
advisor for smoking cessation advice. Consultation with the practice quit
advisor might be immediate if the advisor was available, or an appointment would
be made. Participants generally regarded immediate referrals as an opportunity
to provide information to patients, build rapport, and encourage a return visit,
rather than an opportunity to begin a quit attempt. Subsequent follow-up
strategies varied, but were most commonly opportunistic at the patient’s
next appointment.
Delivering quit
support—There were strong indications that participating in the
training and the Programme had led to real changes in the way patients were
advised; with advice being provided earlier in the change cycle and the benefits
of quitting personalised:
If
you make it a personal benefit that’s related to their situation, I think
that helps make it more important to them, more significant.
[GP]
Providing smoking cessation support was time consuming for
the practice quit advisor, and funding this time was a challenge, especially for
fee-for-service practices. Self-referral and patient-initiated follow-ups were
important strategies for keeping the amount of time spent on quit support within
reasonable bounds. Equally importantly, they were also regarded by many practice
quit advisors as a sign of patient motivation and a sharing of responsibility
with the patient for their quit attempt.
Providing NRT was a significant issue for many practice quit
advisors unfamiliar with prescribing. Many were concerned with the inflexibility
of the exchange card programme and patient perception of NRT as a ‘magic
bullet’. Over time, as PNs gained experience in providing patient
education and assessing and managing different patient requirements, the
problems associated with prescribing NRT decreased.
Quit rates—Can Quit Practice registration data were
provided for 85 consecutive patients from 14 practices fully implementing the
Programme. Quit rates were good: 25.9% at 3 months; 22.4% at 6 months; and 20.0%
at 9 months. Quit rates were lower (5.6%) for the 18 smokers from the pre- and
post-implementation survey sample who had indicated a readiness to quit but were
not registered with the Programme for quit support (Table 5).
DiscussionSmoking cessation is a health
promotion activity that general practices can effectively engage in. Programmes
ranging from frequent brief intervention to more extensive counselling have been
shown to have an impact on quit rates with multiple interventions and
individualised advice on multiple occasions producing the best
results.14 Evaluation of the Can Quit Practice
Programme and an evaluation of the Pegasus Health
programme15 have demonstrated that smoking
cessation programmes based in New Zealand general practice, utilising the skill
mix of GPs and practice nurses, are effective.
Programmes implemented in general practices have the
capacity to reach smokers with few resources or who are unwilling or unable to
access other agencies but who attend general practices for their health care.
The challenge is to encourage and enable health professionals to engage in
smoking cessation activities. In the Can Quit Practice evaluation, practices
reporting they had high proportion of patients who smoked were most enthusiastic
about participating.
The Can Quit Practice Programme was developed to overcome
previously identified barriers to general practice participation in smoking
cessation. Previous initiatives have identified the difficulty of increasing the
rate with which the GP enquires about smoking status with asking being more
likely to occur with adult patients and with patients with smoking related
health conditions.16 The audit of the Can Quit
Practice Programme also failed to provide quantitative evidence for any increase
in asking about smoking and the recording of smoking status in the clinical
notes of patients by GPs.
While it is disappointing that no increase in asking about
or recording smoking status was noted the post-implementation audit occurred
soon after the implementation of the Can Quit Practice Programme. Also far more
practice nurses than GPs attended the Can Quit Practice training but the
quantitative evaluation was based on a sample of patients selected from GP
consultations. An increased rate of smoking status recording may have occurred
over a longer time frame or may have been evident in nurse consultations.
The Can Quit Practice Programme was developed to focus on
the potential of the PN as a health educator and it was this aspect of the
Programme that appeared to be most effective. The evaluation confirmed that PNs
can be effective quit advisors. PNs reported gaining satisfaction from providing
quit advice and support, and patients valued their involvement. With PNs taking
on this role, a significant barrier to providing quit support in general
practice, the lack of GP time, was also overcome. The ongoing availability and
funding of PN time has become the new challenge, albeit one which can be met, if
practices perceive sufficient need within their practice population. This
extension of the role of the PN is also consistent with The New Zealand Primary
Health Care Strategy, which promotes both workforce development and a
multi-disciplinary approach within primary
care.17,18
Training in motivational interviewing was described almost
universally by participants as a useful way of minimising patient
‘resistance’ and of maintaining the clinician’s own motivation
to work with smokers. It was also described by many of the participants as a
valuable approach in other clinical situations. The use of subsidised NRT was
also part of the Programme. While clinicians and patients have regarded
subsidised NRT as a valuable aid to successful smoking cessation, many of the
practice quit advisors stressed the importance of also educating patients about
the limitations of NRT.
A range of implementation strategies and the provision of
ongoing support and problem solving sessions were integral parts of the Can Quit
Practice Programme. Dissemination of clinical guidelines and the provision of
training, either on their own or together, are not enough to bring about changes
in clinical practice.19 The evaluation
confirmed that the implementation visit(s) and a flexible approach to
integrating the Programme into practice activities, was a requirement for
effective implementation. Participating practices employed a range of
strategies, charging regimes, and organisational arrangements for the delivery
of quit support.
The ongoing cost of providing the Can Quit Practice
Programme to general practices would include the costs of a smoking cessation
trainer(s) for the training days, implementation and follow up sessions.
However, adequate administrative support for the trainer in contacting practices
and arranging bookings for training and follow-up sessions is essential. There
is also clearly both a real cost and an opportunity cost with respect to
practice nurse time for practices deciding to implement the Programme. In this
evaluation practices utilised a range of strategies to address this cost
including charges to patients, obtaining external funding and absorbing the
cost. In New Zealand, the introduction of primary health organisations has the
potential to provide a suitable funding structure if the time commitments are
realistically funded.
The Can Quit Practice Programme has met the initial aim of
developing and implementing a smoking cessation programme able to be effectively
delivered within New Zealand general practice. This aim has been achieved by
providing PNs and GPs with specialised training, on-call support and
practice-based implementation assistance, and by actively encouraging practices
to participate. Practice wide commitment, well-organised practice
administration, communication and internal audit systems, and adequate
consultation time for PNs and GPs are essential prerequisites for effective
implementation. Adequate commitment to, and funding for, health promotion and
disease prevention work, not only within practices but also at regional and
national level are essential to facilitate practice commitment to smoking
cessation.
Author information:
Deborah McLeod, Research Director; Elizabeth Cornford, Assistant Research
Fellow; Susan Pullon, Senior Lecturer, Department of General Practice,
Wellington School of Medicine and Health Sciences, University of Otago,
Wellington; Kawshi de Silva, Health Promotion Manager; Corrianne Simpson, Quit
Advisor, Cancer Society of New Zealand, Wellington Division (Inc),
Wellington
Acknowledgements:
The Wellington Division of the Cancer Society funded the Can Quit Practice
Programme and the evaluation—we thank the Society for continuing to fund
training and support for health professionals. We also thank the practice
nurses, GPs, and patients who participated in the Programme and its evaluation
(and who taught us a great deal about the satisfaction and challenges of smoking
cessation).
Correspondence: Dr
Deborah McLeod, General Practice Department, Wellington School of Medicine and
Health Sciences, PO Box 7343, Wellington South. Fax: (04) 385 5995; email: dmcleod@wnmeds.ac.nz
References:
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