Smoking Cessation
Quality improvement toolkit
Author: Primary Care Quality and Information Service
Date: April 2010 / Version: 1
Status: Final
Intended audience: Public (Internet) / NHS Wales (Intranet) / PHW (Intranet)
The former Public Health Wales Primary Care Quality Team, now incorporated within the Primary and Community Care Development and Innovation Hub, developed a series of quality improvement toolkits to assist practices in collating and reviewing information. From information received, practices still find these toolkits useful, therefore they will remain on this webpage for your ease of reference. Please note, however, that the date of publication is clearly stated in the toolkit and that the evidence within may have changed since publication.
Purpose and summary of document:
This document is for use by general practitioners motivating and supporting patients to quit smoking. The purpose of this toolkit is to support practices to review and reflect on the service they provide and the information they record following patient consultations for smoking cessation
This audit may be of particular interest to clinicians who have seen the recent WeMeReC Bulletin (No 29) and the accompanying education module that was released recently. This audit is designed to reinforce the main points of the Bulletin and to supplement the learning opportunities provided by the case studies.
This toolkit provides patient review criteria and guidance on how to complete a straightforward small-sample audit. Also included are review sections that follow each timed audit phase. These are designed to prompt reflection and comment on the results of the audit process. Completion of this audit would constitute a suitable piece of Continuing Professional Development that could be included within the appraisal process.
Publication / distribution:
· Publication in Public Health Wales document database (Primary Care Quality and Information)
· Link from Public Health Wales e-bulletin
ACKNOWLEDGEMENTS
The Primary Care Quality & Information Service is grateful to the following people for their valuable contribution to the development of this quality improvement tool.
Dr Paul Myres – Wrexham GP, Chairman Primary Care Quality Forum
Dr Chris John – Carmarthen GP and PCQIS Advisor
Dr Geoff Tinkler – Porthcawl GP and PCQIS Clinical Advisor, Chair Advisory Group
Susan Baboolal – Senior Pharmacist / Associate Editor Welsh Medicines Resource Centre
Ann Burtonwood – Business Manager and Partner, Portway Surgery, Porthcawl
Janet Keauffling – Practice Nurse and Nurse Specialist for Homeless People, Swansea
Preface
Quality improvement toolkits
The Primary Care Quality and Information Service (PCQIS) have developed quality improvement toolkits to assist practices in collating and auditing information.
The quality improvement toolkits are evidence based. They should be seen as good practice and cover areas that some or even all practices may not be recording at this stage. It is not expected that all the criteria within the audits will be achieved in year one therefore the PCQIS suggests that the toolkits should be used to aid development within the practice.
It is recommended that in year one the practice consider recording this information prospectively using the data entry criteria and suggested read codes provided, so that these criteria can be successfully audited and improvements highlighted over time.
You can access other quality improvement toolkits that support enhanced services and National Service Frameworks from the Public Health Wales (PHW) website:
Intranet http://howis.wales.nhs.uk/sitesplus/888/page/34030
Internet http://www.wales.nhs.uk/sitesplus/888/page/45127
If you have any queries regarding this document please contact:
Laura Jones, Team Lead - PCQIS
Tel: 01792 607311 / Email:
Contents Page
Acknowledgements 2
Preface 3
Contents 4
1 Introduction and background 5
2 Aims & Objectives 5
3 Methodology 6
4 Audit Criteria 6
5 Interventions 6
5.1 Brief Interventions 6
5.2 Individual Behavioural Counselling 7
5.3 Group Behaviour Therapy 7
5.4 Pharmacology 7
5.5 Nicotine Replacement Therapy 7/8
5.6 Varenicline 8
5.7 Bupropion 8
5.8 Comparison of Drug Treatments 9
5.9 Fagerstrőme Test 10
6 Data Collection Sheet 11
6.1 Data Collection Summary 12
7 Read Codes 13/14
8 Practice Review 15
Appendix A: Brief interventions for smokers in Primary Care 16
Appendix B: BNF Guidance 17
Appendix C: Hints & Tips 18
Appendix D: Useful Contacts 19
Appendix E: Evaluation form 20
References: 21
©2010 Public Health Wales
Material contained in this document may be reproduced without prior permission
provided it is done so accurately and is not used in a misleading context.
Acknowledgement to the Public Health Wales to be stated.
1. Introduction and background
Smoking cessation refers to activities supporting smokers to stop.
GPs should take the opportunity to advise all attending patients who smoke to quit. Those who want to stop should be offered a referral to an intensive support service (Stop Smoking Wales). If they are unwilling or unable to accept this referral they should be offered pharmacotherapy. The smoking status of those who are not ready to stop should be recorded and reviewed with the individual once a year, where possible. 1
Healthcare professionals should identify and record the smoking and/or tobacco use status of all their patients. Helping smokers to quit is an important part of the remit of all primary care staff, and is a component of the Quality and Outcomes Framework (QOF). Carbon Monoxide (CO) validation rates are important markers of data quality in establishing quitter smoking status.1,10
Individuals trying to stop smoking should be advised that relapse is common.3 Factors contributing to relapse include stress, weight gain, high nicotine dependency and mental illness 10
Smoking is the largest single cause of avoidable ill health and early death in Wales.2
A wide range of diseases and conditions are caused by cigarette smoking, including cancers, respiratory diseases, coronary heart and other circulatory diseases, stomach and duodenal ulcers, erectile dysfunction and infertility, osteoporosis, cataracts, age-related macular degeneration and periodontitis. Following surgery, smoking contributes to lower survival rates, delayed wound healing and postoperative respiratory complications 5
Women who smoke during pregnancy have a substantially higher risk of spontaneous abortion (miscarriage) than those who do not smoke. Smoking can also cause complications in pregnancy and labour, including ectopic pregnancy, bleeding during pregnancy, premature detachment of the placenta and premature rupture of the membranes.5
The health risks for babies are substantial. Those born to women who smoke are on average 200–250g lighter than babies born to mothers who do not smoke. The more cigarettes smoked, the greater the probable reduction in birth weight. This can increase the risk of death and disease in childhood: smoking in pregnancy increases infant mortality by about 40% and more than a quarter of the risk of sudden unexpected death in infancy is attributable to smoking 5
2. Aim
To improve the quality of care and deliver an effective service that encourages patients who attend the practice to stop smoking.
2.1. Objectives
To encourage patients who smoke to quit
To review the therapies offered to patients to help them stop smoking
To review the interventions offered to those patients wanting to stop
To maximise the advice and support offered to patients who have quit smoking but then relapse.
3. Methodology
3.1 Involve all relevant Primary Health Care Team (PHCT) staff from the outset.
3.2 Suggest a 20 patient random sample. See inclusion / exclusion criteria for guidance with regard to patient selection and the data collection period.
3.3 Practices are recommended to complete the Data collection summary.
This sets out criteria taken from evidence based practice
3.4 Practices should use the audit results as the basis of a discussion by the PHCT. It is suggested that practices use the Practice review form to reflect on the findings of the audit and implement the necessary changes to ensure quality improvement. The practice might like to share its results with other practices to compare progress.
3.5 It is suggested that practices re-audit annually to ensure that any changes
considered to be necessary are having a positive effect on patient care
4. Audit Criteria
Inclusion Criteria: All patients > 15 years old who are recorded as current smokers within the last fifteen months. Of those please exclude the following;
Exclusion Criteria: All patients who have a record of current smoker, but who began smoking cessation medication within the last 3 months.
1 All patients are assessed and advised to stop smoking1,2,3,5,11
2 All patients who want to stop smoking agree a stop date and are offered in house counselling or a referral to support services such as “Stop Smoking Wales (SSW)” 1,3
3 Smoking status of all patients unwilling to stop are recorded & reviewed annually 11
4 All patients refusing referral are offered pharmacotherapy and ongoing support 1,3
5 All patients on pharmacotherapy are reviewed after one month & smoking status recorded1
6 All patients on pharmacotherapy are reviewed after three months & smoking status recorded1
7 All side effects of pharmacotherapy within the last 12 months are recorded (see 5.8)1
5. Interventions
5.1 Brief Interventions
Brief interventions for smoking cessation involve opportunistic advice, discussion, negotiation or encouragement and referral to more intensive treatment, where appropriate. Discuss the 5 ‘A’s Ask, Advise. Assess, Assist and Arrange. They are delivered by a range of primary and community care professionals, typically in less than 10 minutes12
A 30-second very brief confidence-boosting advice offers encouragement in time constrained practices (Ask, Advise, Act). The package provided depends on a number of factors including the individual’s willingness to quit, how acceptable they find the intervention and previous methods they have used. It may include one or more of the following: 5,10
• Simple opportunistic advice
• An assessment of the individual’s commitment to quit
• Offer of pharmacotherapy and/or behavioural support
• Self-help material
• Referral to more intensive support e.g. Stop Smoking Wales Services
5.2 Individual Behavioural Counselling
Individual behavioural counselling involves scheduled face-to-face meetings between someone who smokes and a counsellor trained in smoking cessation. Typically, it involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy.5
5.3 Group Behaviour Therapy
Group behaviour therapy involves scheduled meetings where people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks following the quit date). It is normally combined with pharmacotherapy.5
5.4 Pharmacotherapy
The recent WeMeRec Bulletin (No 29)3 and the accompanying education module on smoking cessation may be of particular interest to clinicians reviewing this topic
For patients who have expressed a desire to stop smoking: NRT, varenicline or bupropion, as appropriate. NRT, varenicline or bupropion should normally be prescribed as part of an abstinent-contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date (target stop date). Typically, this will be two weeks of NRT and three to four weeks of varenicline or bupropion 5 The type of therapy to use depends on a number of factors including: whether a referral has been made and appropriate support mechanisms are in place to aid the quit attempt; contraindications and potential adverse effects; the client’s personal preferences and previous experience of smoking cessation aids; the likelihood that they will follow the course of treatment; and their level of dependence.3
Subsequent prescriptions should be given only to people who have demonstrated, on re-assessment (e.g. by CO testing), that their quit attempt is continuing. 5
5.5 Nicotine Replacement Therapy (NRT) (All forms); Patch, Gum, Spray, Inhalator, Tablet, Lozenge 6,7,8,12
Nicotine replacement provides a ‘clean’ source of nicotine in a different way from smoking. Healthcare professionals should consider prescribing a combination of NRT patches with other NRT products such as gum, inhalers or nasal spray in appropriate clinical circumstances, particularly if the patient’s smokes 10 or more cigarettes a day 5 and in combination with intensive behavioural support as first-line treatments (where clinically appropriate). However NRT should not be offered in combination with Varenicline or Buprprion5
For pregnant women and breastfeeding mother’s who smoke, particularly those who do not wish to accept the offer of help from the “Stop Smoking Wales Service” discuss the risks and benefits of NRT. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription.5
Advise pregnant women using nicotine patches to remove them before going to bed.
Breastfeeding mothers should avoid using patches at least one hour before feeding their baby
Pregnant women must be encouraged to quit as soon as possible.5
NRT in all forms can be used for young people from 12 years – 17 years 5
NRT can be used in patients with cardiovascular disease or respiratory disease (see 5.8) 5
Adverse reactions are not generally serious. Specific effects are observed with different formulations, e.g. 24 hour patches have been associated with sleep disturbances and skin reactions and throat irritation has been reported with oral agents.
Patients with chronic disease should be treated with caution (see 5.8) when starting therapy.
5.6 Varenicline (Champix) Prescription only 6,7,8,12
Should normally only be prescribed as part of a programme of behavioural support in adults 4
Should not be offered to patients under 18 years to pregnant or breastfeeding mothers.5
Varenicline is not recommended for people who have end-stage renal disease 9
There have been reports of depression and suicidal ideation associated with the use of varenicline 9 Varenicline should be discontinued immediately if agitation, depressed mood or changes in behaviour that are of concern for the doctor, the patient, family or caregivers are observed, or if the patient develops suicidal ideation or suicidal behaviour.
Can be offered to patients with cardiovascular disorders subject to clinical judgement.5
Stopping varenicline is associated with increased irritability, nausea and insomnia. To prevent relapse dose tapering should be considered.
5.7 Bupropion (Zyban) Prescription only 6,7,8,12
First developed to treat depression, bupropion was found to help smokers stop by altering neurotransmitters in the brain which seemed to relieve withdrawal symptoms. Bupropion should normally only be prescribed in combination with behavioural support.