Australia: the healthiest country by 2020
National Preventative Health Strategy – the roadmap for action

Key action area 6: Ensure all smokers in contact with health services are encouraged and supported to quit, with particular efforts to reach pregnant women and those with chronic health problems

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The sheer number of people who once smoked but now do not – around 4.3 million Australians in 2007 – shows that quitting is possible, but it can be a very difficult process nevertheless.[126] Succeeding requires a great deal of determination and the adoption (conscious or not) of strategies to overcome withdrawal and triggers to smoke.

Smoke-free policies not only protect patients and staff from second-hand smoke, they also allow governments and healthcare institutions to reinforce how seriously they regard the health risks of tobacco use. Asking patients about their smoking enables health professionals to personalise those risks, often at highly ‘teachable moments’ when patients are suffering a serious illness or health incident. Clear advice from a concerned professional can motivate a patient to quit, whether the advice comes from a doctor,[127] dentist,[128] nurse[129] or other health professional, and whether it occurs in practice rooms, in a community health centre or in a hospital.[130]

Action 6.1
Ensure all state- or territory-funded healthcare facilities (general, maternity and psychiatric) are smoke-free, protecting staff, patients and visitors from exposure to second-hand smoke, both indoors and on health service grounds.

Clear advice from health professionals
As demonstrated as long as 30 years ago, because doctors see a large proportion of smokers each year, even small effects can contribute significantly to reducing population prevalence.[131] Small effects of treatments are clinically significant because of the very large health gains that accrue from stopping smoking.

Action 6.2
Ensure all patients, each time they consult a health professional in private or public, community, general practice or institutional settings, are routinely asked about smoking status and if smokers are advised to quit in line with guidelines developed for relevant professional groups.[132, 133]

Efficacy of treatment
A very large body of research now confirms that an individual’s chances of quitting can be increased by taking medications that lessen withdrawal symptoms[134, 135] or reduce the reinforcing effects of tobacco-delivered nicotine.[136-140] There is also overwhelming evidence that a structured program of cognitive behavioural advice and coaching can also be helpful, regardless of whether the assistance is provided one to one,[141] over the phone[142] or in a group[143] (in the community or through work).[144] Well-designed brochures help some people, but this is not enough for most.[144] Success rates are better where advice can be personalised.

This can be achieved through telephone helplines or through computer technologies (such as the QuitCoach[145] available through the Australian Government’s website), which can be delivered at a much lower cost than printed materials. Programs delivered through peoples’ computers or web-enhanced mobile devices using e-mail, text messaging, live calendars and message boards are also likely to be cost-effective.[146] Structured programs generally achieve greater success with increasing contact: four to eight sessions optimises chances at reasonable cost.6 [148-150] People are also more likely to quit successfully if they use a combination of approaches. Adding medication to counselling (or vice versa) increases success rates.7
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Action 6.3
Improve quality of use of pharmacotherapies and services demonstrated to assist with smoking cessation.

An integrated, cost-effective system of services and availability and subsidy of treatments
We need a combination of services, training, referral arrangements, remuneration and subsidies that will work together in the Australian context to provide evidence-based services and treatments for anyone who wants this assistance or is likely to benefit.

Referrals by professionals to quitlines
Many health practitioners routinely ask patients about their smoking status and offer prescriptions for anti-smoking medications; however, there is scope to greatly increase follow-up and referrals to Quitlines and other supports where these would be helpful.

Hospitals in New South Wales and Queensland have developed systems to identify all patients who smoke and advise them to quit, as well as offering NRT to help them comply with smoke-free policies. Much could be improved in these systems,[151] and much more could be done in other jurisdictions.

Quitlines are now advertised on every cigarette pack as part of required consumer information. Mass media advertising also drives calls to the Quitline.[152, 153] However, the Quitline is still an under-utilised service in Australia, partly because of a lack of understanding about what the service offers,[154] and more could be done to promote its use.

For several years, governments in the United Kingdom,[155] the United States,[149, 156] New Zealand[157] and Australia[133, 158] have periodically updated and promoted detailed clinical guidelines for doctors on how best to treat tobacco dependence. An important innovation in the Australian clinical guidelines[133] is the offer of two evidence-based strategies for providing cessation assistance: within the consultation, and/or referral to specialist cessation services. GPs can use fax-referral forms to trigger a phone call to their patients from a trained Quitline adviser. For referrals, the Quitline calls the smoker and discusses options for assistance, which allows callers to be directed to or offered the most appropriate form of support.[159]

GP referral to the Quitline has improved patients’ chances of quitting.8 [161] In a Victorian pilot program, referral to the Quitline has resulted in cessation rates two to three times that which resulted from efforts to encourage GPs to provide in-practice management.[162] The effect was due to the smokers getting extra help to quit from outside the practice, while receiving the same amount of help from within it; the combination of the extra help increased both the number and success of quit attempts. The beneficial effect on quitting in the referral condition was sustained over time. The findings add to the growing body of evidence that health professional referral of patients who smoke to evidence-based Quit services is effective and acceptable to smokers.[163, 164]
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Action 6.4
Increase the availability of Quitline services, expanding the modes of delivery of advice and support, and tailoring services for high-need and highly disadvantaged groups, including pregnant women and their partners, people with chronic health conditions, those who do not speak English and people with mental illness. Ensure that funding is provided in line with increased demand generated by advertising, improved health warnings and greater activity by health professionals.

Subsidy of treatments
Data from the International Tobacco Control Study suggests that smokers in Australia as well as the United States, United Kingdom and Canada who use quit-smoking medicines are more successful in sustaining cessation than those who do not.[165]

Use of quit-smoking medicines is highly related to price.[166] Providing access to subsidised pharmacotherapy is a powerful method of increasing usage of quit treatments; it also increases the proportion of quit attempts that are successful.[167]

In 2008 a large-scale demonstration project across six states in the United States reported that smokers doubled their success rates when given subsidised NRT and access to a Quitline, with savings in healthcare costs justifying full Medicare coverage of low-cost NRT and referral to Quitline services.[168]

Although available on the PBS, varenicline and bupropion may have some serious side effects, and both are contraindicated for some patients. Good clinical practice for many patients would be to encourage use of NRT; however, NRT products are not affordable for many patients. Patches are already subsidised for Indigenous smokers and veterans, but several other highly disadvantaged groups – in particular people living with mental illness – would benefit from PBS listing or some other form of subsidy for NRT products.

Action 6.5
Ensure that nicotine replacement therapy is affordable for all those for whom it is clinically appropriate.

Financial incentives
Financial incentives within healthcare settings have been primarily directed towards providers. With significant potential co-benefits for individuals and governments, and some encouraging results and experiences from such initiatives overseas,[169-171] it may also be appropriate to consider incentives directed towards smokers and potential smokers.

Action 6.6
Explore whether financial incentives might be effective in helping people to quit or stay non-smokers.

6 For further details on the effectiveness of pharmaceutical and behavioural interventions, see the frequently updated meta-analyses published by the Tobacco Addiction section.
147 Lancaster T, Stead LF, Cahill K, R. W, Aveyard PN and R. HJ. Cochrane Tobacco Addiction Group. 2008 (2008 Issue 2): Available from: www.mrw.interscience.wiley.com/cochrane/clabout/articles/TOBACCO/frame.html
7 For further detail see the US Department of Health’s clinical guidelines: www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf.
8 Referrals from other health professionals, however, have been less successful.
160 Young J, Girgis S, Bruce T, Hobbs M and Ward J. Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: a randomised trial in Australian general practice. BMC Family Practice. 2008;9 16. Available from: www.biomedcentral.com/content/pdf/1471-2296-9-16.pdf


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