Smoking Cessation and Brief Intervention

Original Editor - Lizzie White

Top Contributors - Laura Ritchie  

Introduction

Although smoking cigarettes is on the decline in the UK population, there has been no decline since 2010, as 20% of adults still are smokers[1]. Smoking contributes/causes many health issues, practically affecting every organ system and causing severe damage to the respiratory and cardiovascular systems[2]. In 2011/12, it was estimated that 5% of all hospital admissions for adults over 35 years old, were related to smoking[3] and smoking accounts for approximately 100,000 deaths a year in the UK, as it is the leading cause of preventable deaths[4]. Stopping smoking increases life-span and has positive effects on the body from 20 minutes of stopping- where the pulse returns to normal, up to 15 years- where the risk of heart disease is that of someone who has never smoked[5]. Apart from affecting health, smoking is having a great impact financially. In 2011/12 the government spent £154.6 million on stop smoking medication and services[6]. These statistics clearly show that some intervention is needed; this essay aims to discuss how brief interventions (BI) can impact the percentage of smokers.

Brief Interventions

Simmons et al[7] describes BI as the 5A’s model; ask, advise, assess, assist and arrange. (1) Ask all patients whether they smoke, (2) advise smokers to quit, (3) assess willingness to quit, (4) assist with quitting treatment/referrals and (5) arrange follow-up contact. All staff should implement the 5A’s[7]. The National Institute for Health and Clinical Excellence[8], supports Simmons et al[7] by stating that BI consists of one or more of the following aspects- simple opportunistic advice to stop, patient commitment to quit assessment, offer of behavioural or pharmacotherapy, self-help material/referral to intensive support. NICE[8] also states that BI usually takes between 5 and 10 minutes.

Evidence shows that BI of 3 minutes can be effective[9]. BI often occurs through one or a small number of encounters, unlike other methods of smoking cessation such as intensive intervention, consisting of multiple counselling sessions[10]. Therefore, BI could be used by healthcare professionals (HCPs) who see a lot of patients in a short period of time[10]. As identified by Hjalmarson & Boëthius[11], refusal rates were lower for BI than extended counselling, suggesting extended treatment was less favourable to patients. After a 1 year follow up Hjalmarson & Boëthius[11] found that, there was an inconsequential difference of smoking cessation for in-patients who received BI and those who received extended counselling. Both interventions used the 5A’s model but extended counselling consisted of more sessions. Therefore, this study could conclude that BI is a more effective way of HCPs spending their time to implement smoking cessation as patients are more willing to participate, it is more time effective for HCPs and there is not a significant difference on smoking cessations rates between BI and extended counselling. A strength of the study undertaken by Hjalmarson & Boëthius[11] is that the follow up date to determine cessation rates was one year. Relapse is most common in the period immediately after cessation and as abstinence increases, risk of relapse decreases[12]. The sample size of 770 smokers in Hjalmarson & Boëthius[11] is another strength of the study because there would be a variety of different people, some may have smoked for a year where others may have smoked for over ten years. It would be interesting to see whether the longer term smokers had the same cessation rate as smokers who may not have been smoking as long.

TUDCPGP[9]recommend all clinicians are trained effective BI strategies because the goal is to ensure that every patient who smokes is offered BI at each visit. An et al[13] found that the odds of recent quitting did not significantly increase with BI by one type of HCP. However, being asked by two or more types of HCP did show a substantial recent quitting increase and were more likely to make an attempt to quit. An et al[13] did not provide details of whether the BI occurred before or after patients recently quit, which could mean that one type of HCP’s BI impacted on the decision of the individual and the second was after their decision to quit. A weakness of An et al[13] is that the total number of visits within a type of HCP was not recorded, effectively a nurse could have visited five times, used BI upon every visit and a doctor may have used BI five times on the same patient. Therefore this study cannot make a conclusion on how many times BI should be used. An et al[13] found that advice from more than one type of HCP was uncommon and 37.2% of current smokers who had visited a HCP received no advice to quit. Although An et al[13] did not explore why the patient didn’t receive advice to quit, one possibility is lack of knowledge of the HCP. Raupach et al[14] states that over 90% of medical students thought smokers should be advised to quit, despite their lack of knowledge about cessation methods and approximately only a quarter felt competent to counsel smokers. Although the study Raupach et al[14] was student orientated the findings were consistent over different stages of medical education and showed students lacked relevant information.

Puschel et al[15] conducted a study which compared three groups, one intervention group and two control groups. All three groups received BI in the form of ask, advise and assess. The intervention group (Group A) received an additional smoking cessation programme where motivational discussion was the main strategy for assisting and arranging follow ups. There was two control groups, the first (Group B) had no specific cessation programme and the second (Group C) implemented a new cardiovascular programme where patients with cardiovascular risk factors were advised to quit smoking. Puschel et al., (2008) found that there was no significant difference of smoking cessation rates between groups A and C, however, there was a difference between both control groups, C had a higher cessation rate than B. The cohort of group C was of a higher socioeconomic status than A and B, but post intervention adjustments for this showed no change of results.

The difference between the control groups was the cardiovascular programme implemented in C, however, only cardiovascular risk patients were involved in this. The cardiovascular programme involved advising the patient to quit smoking, which was a part of the BI that all three groups had at the beginning of the study. Due to group C having a much higher cessation rate than group B, cessation could be related to repetition of advising the patient to quit. There is however, the possibility of the Hawthorne/observer effect where subjects modify their behaviour because they know they are being studied, meaning that any positive action (like the cardiovascular programme) has an impact[16]. Due to all three groups having initial BI, the Hawthorne effect may not be a cogent consideration.

Puschel et al[15] found that there was no difference between A and C which could suggest that the first three steps of the 5A approach, ask, advise and assess and repetition of these steps is just as effective as ask, advise, assess, assist and arrange.
Although Puschel et al[15] only studied Chilean women, Chile has a very high smoking rate and low cessation rate, so this study did not limit itself by studying such a specific population. A strength of Puschel et al[15] was that no pharmaceutical treatment was provided, which increases the assumption that BI was the cause of cessation. Another strength was that the knowledge and beliefs of smoking were assessed in all three groups and no significant difference was found, suggesting that one group was not more likely to quit due to knowledge of risks of smoking. However, a limitation of the study by Puschel et al[15] is that the smoking assessment period was only 1-3 months, meaning that information on long term differences was not available.

Clinical Application

As a physiotherapist, in recent clinical practice I treated a lot of patients who had a Coronary Artery Bypass Graft (CABG). CABG is needed when the coronary arteries become blocked due to atherosclerosis[17]. Smoking is a risk factor for atherosclerosis[17] therefore it is vital patients receive BI to make them aware and advise them to quit smoking to prevent the build-up of atheroma, which should decrease the chance of further blockages.

Working on the high dependency unit, I routinely treated CABG patient’s first day post operation to assess their chest and breathing function. As part of my subjective assessment smoking status needed to be known. When assessing a smoker, consideration was needed when asking questions about normal sputum production and cough. I advised the patient to stop and made them aware of the disadvantages of smoking. For recent quitters, I encouraged/praised them and arranged the patient a conversation with their nurse.

Due to only working in this area for six weeks it was hard for me to monitor cessation rates as patients could have been motivated whilst in hospital but not continued when discharged. Although, out of the 24 patients I assessed and used BI with, 22 wanted more information/conversation with their nurse and seemed motivated to quit. The majority had already been advised to quit by HCPs pre or post operation. Some told me they were beginning to understand why they should quit and that their motivation to quit was high due to HCPs BI, which supports TUDCPGP[9] that state smokers believe advice to quit delivered by a physician is an important motivator to quit.
Implementing BI was time effective for myself as a physiotherapist as I included it in my subjective assessment and the BI lasted around 3-5 minutes. I believe that BI worked in the short term with the patients I saw, however, this may differ on a ward where patients have not had major surgery.

Conclusion

In conclusion, it is clear that BI by more than one type of HCP increases smoking cessation and attempts to quit[13]. It has also been suggested that repeated BI consisting of ask, advise and assist is as effective as the full 5A’s model[15]. Therefore, if every HCP used BI in their subjective assessment of their patient, repetition of ask, advise and assist would occur as well as the patient being informed by more than one type of HCP. Evidence suggests that these two changes combined could have an impact on increasing smoking cessation and quit attempts. It has been found that there was no significant difference of smoking cessation rates between BI and extended counselling and patients are more willing to participate in BI lasting a few minutes, rather than extended counselling which lasts longer, as refusal rates were higher in the study by Hjalmarson & Boëthius[11]. TUDCPGP[9] state that BI advice to quit can increase smoking cessation and in the author’s opinion from clinical practice and reviewing the literature, they agree with the TUDCPGP[9] statement.

Recent Related Research (from Pubmed)

References

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