Encouraging Smoking Cessation

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Background

Smoking rates have been steadily declining in New Zealand for at least a decade. However, 15.5% of New Zealand adults still smoke tobacco daily.* In addition, within certain groups smoking rates remain high: daily smoking is reported in 36% of Maori adults and 28% of adults living in the most socioeconomically deprived areas.*

Reducing the rate of smoking has large individual, population and economic health benefits for New Zealand. General practice is well placed to help people take the first step toward smoking cessation. Enquiring about smoking status in adolescent and adult patients in the practice and offering brief smoking cessation advice and support to those patients who are current smokers is considered good practice, and best incorporated as a routine aspect of primary care.

Ask, Brief advice, Cessation support

Ask, Brief advice, Cessation support (ABC) has become the standard of care for helping people to quit smoking. The ABC format can be easily integrated into everyday healthcare practice, so that smokers are presented with every opportunity to quit.

  • Ask whether the patient smokes
  • Give brief advice and make an offer of help to quit
  • Provide evidence-based cessation support

There is no set manner in which the brief advice to quit needs to be given. Most clinicians would agree that the brief advice should be personally relevant to the patient and describe the benefits to be gained from smoking cessation.

Nicotine replacement therapy is useful for almost everyone who smokes

NRT can be safely used by almost anyone who wants to quit smoking. NRT approximately doubles a person’s likelihood of quitting. No one NRT product is more effective than any other and patient preference should be the primary consideration in treatment choice. However, heavier smokers do benefit from a higher steady-state dose (e.g. 24 hour 21 mg patches and 4 mg gum).

The individual benefits of smoking cessation

For younger patients it can be helpful to use the incentive that those who quit before the age of 35 years will have a normal life expectancy. For older patients it can be helpful to remind them that quitting increases life expectancy by reducing the risk of diseases such as lung cancer, cardiovascular disease and chronic obstructive pulmonary disease.

* Ministry of Health. The New Zealand Health Survey – Annual update of key findings 2012/2013. MoH, 2013. Available from: http://www.health.govt.nz/system/files/documents/publications/new-zealand-health-survey-annual-update-2012-13-dec13.pdf (Accessed May, 2014).

Audit Plan

Summary

The audit involves sampling two groups of patients from your practice. The first group is used to calculate the percentage of patients who have had their smoking status recorded. The second group is a sample of current smokers and is used to calculate the percentage of patients who smoke who have been offered smoking cessation advice and support within the practice.

Criteria for a positive result

A patient is considered a “positive result” for the purposes of the audit if:

  • Group 1 – They have their current smoking status recorded in their patient notesn
  • Group 2 – They were given brief advice on smoking cessation with the last 12 months, AND; they were offered smoking cessation support within the last 12 months

Recommended audit standards

Given that smoking is one of the most significant modifiable risk factors encountered in primary care, recording smoking status for all patients and ideally offering quit advice to every person who smokes are important goals in primary care. For the purposes of this audit, a recommended standard would be for 90% of patients to have their current smoking status recorded, and for 80% of current smokers to have been given brief advice and support within the previous 12 months.

Audit Data

Eligible people

This audit has two sample groups: all patients (age 15 years or over)* currently enrolled within the practice are eligible for Group 1, and all current smokers enrolled in the practice are eligible for Group 2.

* 15 years has been selected as the lower age for this audit, however, some clinicians may choose to use a lower age cut off depending on their patient population

Identifying patients

Two samples need to be identified for this audit. The first sample group can include any patient aged 15 years or older enrolled within the practice. The second group can include any current smoker enrolled in the practice. The first group can be randomly selected from the patient population aged over 15 years. The second group can be identified by running a query through the PMS for patients coded as current smokers.

The most widely used read codes for current smokers are 1373, 1374, 1375 and 1376. The relevant ZCPI code is ZPSA10.

Sample size

It is recommended that for both groups, 20 – 30 patients are randomly selected and audited.

Data analysis

Use the data sheet provided to record your and calculate your percentages.

Identifying opportunities for CQI

Taking action

The first step to improving medical practice is to identify where gaps exist between expected and actual performance and then to decide how to change practice.

Decide on a set of priorities for change and develop an action plan to implement any changes.

It may be useful to consider the following points when developing a plan for action.

Problem solving process

  • What is the problem or underlying problem(s)?
  • Change it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Review

Monitoring change and progress

It is important to review the action plan at regular intervals. It may be helpful to review the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?
  • Following the completion of the first cycle, it is recommended that practitioners complete the first part of the CQI activity summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practitioners complete the remainder of the CQI activity summary sheet.

Claiming MOPS credits

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement - CQI) for allocation of MOPS credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current MOPS programme.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the MOPS Online credit summary, under the Audit of Medical Practice section. From the drop down menu, select the audit from the list or select “Approved practice/PHO audit” and record the audit name in “Notes”, the audit date and 10 credits.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).