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Clinical Audit - Encouraging Smoking Cessation

Smoking rates have been steadily declining in New Zealand for at least a decade. However, 13.1% of New Zealand adults still smoke tobacco daily. Reducing the rate of smoking has large individual, population and economic health benefits for New Zealand.

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Smoking rates have been steadily declining in New Zealand for at least a decade. However, 13.1% of New Zealand adults still smoke tobacco daily.* In addition, within certain groups smoking rates remain high: daily smoking is reported in 31% of Maori adults and 20% of Pacific peoples. Adults living in the most socioeconomically deprived areas are 3.5 times more likely to be a daily smoker than those living in the least 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.

*Ministry of Health. 2019. Annual Data Explorer 2017/18: New Zealand Health. Available from: (Accessed May, 2019).

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.


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 notes
  • 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.

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.

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.

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

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

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

  • Identifying barriers can provide a basis for 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

Monitoring change and progress

It is important to review the action plan developed previously 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 the doctor completes the first part of the Audit of Medical Practice summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, 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 practices complete the remainder of the Audit of Medical Practice summary sheet.

Claiming credits for Te Whanake CPD programme requirements

Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).

Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.

To claim points go to the RNZCGP website:

If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the RNZCGP website).

N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.

Published: 4 July 2018 | Updated:

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