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Tobacco: One of the big issues (Part 1) |
The top four causes of disease burden (combination of mortality and morbidity) in Australia are ischaemic heart disease, stroke, lung cancer and COPD.i Given that these are all influenced by tobacco, it is not surprising that tobacco is the largest preventable cause of death, disease and disabilityii. Clearly tobacco has to stay high on our list of concerns as health practitioners. The AIHW estimates that tobacco accounts for 12.1% of all male burden of disease and 6.8% for all the female burden of disease.1 Put another way, a teenager who smokes and does not quit has a one in two chance of dying as a result of smoking.iii
The NRAHS has recently developed a draft Tobacco Action Plan 2003-2006, and a smoke free health care policy. A feature of the latter is a policy for the management of nicotine dependence for all inpatients. These developments will be of some interest to us as GPs and hence worthy of some comment here.
The opening quote in the Tobacco Action Plan is a worthy one: “...smokers aren’t the problem. Tobacco is the problem. Smokers can be part of the solution even if they can’t quit at this time [eg.] by smoking outside and not in the car.” (Paparangi Reid, public health physician and Maori researcher)
The plan focuses on five key areas:
- Community awareness and education.
- Smoking cessation.
- Availability and supply of tobacco products.
- Marketing and promotion of tobacco.
- Exposure to secondhand smoke.
In each of these there is a mixture of advocacy (for changes in the big picture) and regional plans for action where this is possible.
The proposed new initiatives include (not exhaustive):
- Tobacco media strategy;
- Increasing awareness among NRAHS staff;
- Increasing the skills of community based health professionals in supporting people to quit (including GPs);
- Focused service delivery for target high risk groups (children, young people, people with mental illness, Aboriginal and Torres Strait islanders, pregnant women and new parents);
- Cessation support for NRAHS staff;
- Proactive management of nicotine dependent inpatients;
- A range of advocacy actions for tobacco control.
Smoke free inpatients
The smoke free health care policy includes guidelines for the management of nicotine dependent inpatients. This is a commendable step in proactive health care, probably also triggered by the occupational health issues for staff exposed to environmental smoke. The gist of it is that all inpatients will be asked about their smoking status before admission to identify nicotine dependent patients. Those who need it will be offered brief intervention and pharmacotherapy (nicotine replacement therapy - NRT), and advice to those interested in continuing cessation on discharge.
A feature is that appropriately trained nurses will undertake this, rather than requiring doctor initiation. This is based on the experience from trial hospitals in NSW where it needed to be nurse initiated and protocol driven to get significant uptake (personal communication, Annie Kia, NRAHS).
A difficulty that comes to mind is that patients will have to get their own supply of NRT quickly after discharge, or go ‘cold turkey’, or smoke. Not everyone leaving hospital will have a spare $30 for a week’s supply of patches but may more easily be able to procure cigarettes. I don’t see any major ethical problem with this since smokers face this situation day to day. However there is a possibility that some positive aspects of NRT may be diminished by repeated ‘failed’ attempts associated with hospital admissions. On the other hand, familiarisation with NRT may improve acceptability and confidence for future cessation attempts with NRT. There does not appear to be any literature reporting the evaluation of equivalent inpatient policy on overall long-term cessation rates.
As a GP
The review of evidence undertaken for the National Tobacco Strategy is a valuable collation and distillation of the large body of research about tobacco interventions (Miller and Wood 2002) and is recommended for anyone wishing to dig into the detail. Spending some time helping our patients to quit is one of the most cost effective interventions we can do as GPs (Miller and Wood 2002). This is true for very brief advice as well as for longer, more complex counselling. More time spent on advice and support for cessation increases the likelihood of cessation (Fiore, Bailey et al. 2000). The addition of nicotine replacement therapy (NRT) approximately doubles the likelihood of cessation over brief or longer advice/counselling alone. (Miller and Wood 2002)
Most smokers expect their doctor to advise them to quit as part of good health care and most smokers want to quit. We should not feel as though we are being inappropriately intrusive when raising the importance of quitting.
Part 2 of this article will look at nicotine replacement therapy, including discharge and follow up issues; its use in cardiovascular disease; conflict between PI , guidelines and best practice; use in lactating mums; multiple NRTs at same time; and new NRT products and their costs.
Dan Ewald is the division’s GP executive manager of population health.
References
Fiore, M., W. Bailey, et al. (2000). Treating tobacco use and dependence: clinical practice guideline. Rockville, US department of Health and Human Services, Public Health Service.
Miller, M. and L. Wood (2002). Smoking cessation interventions. Review of evidence and implications for best practice in health care settings., Commonwealth of Australia.
i Mathers C, Vos T, Stevenson C. The birden of disease and Injury in Australia. AIHW, 1999. AIHW cat No PHE 17.
ii Ridolf B, Stevenson C. The quantification of drug caused morbidity and mortality in Australia, 1998. AIHW cat No PHE 29. Canberra: AIHW, 2001.
iii English DR, Holman CDJ, Milne EG, et al. The quantification of drug caused mortality and morbidity in Australia. Commonwealth Department of Human Services and Health. Canberra AGPS, 1995
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