In the latest of his series on efforts to reduce smoking in NZ, Martin Johnston looks at the role of encouragement from outsiders such as health workers in helping smokers to quit.
It is a decade since New Zealand formally adopted the idea that regularly suggesting to smokers that they quit helps them to give up the habit.
Yet despite the health sector's universal endorsement of the policy, few health workers complied with the recommendation to "provide brief cessation messages at nearly every encounter".
The guidelines were updated in 2007 and now recommend that all smokers be advised to stop smoking at least annually, in a discussion that need last no more than 30 seconds.
But the hope, says a Health Ministry report, is still that "every clinician asks every smoker at every visit about quitting".
Their performance is patchy, although midwives appear to be in the lead.
It is a simple mantra, now boiled down to the "ABC" formula: Ask if the patient smokes, give smokers Brief advice to quit, offer Cessation therapies or a referral to a specialist service such as Quitline.
Quitline is a state-funded phone counselling service. Smokers can call toll-free to get support and advice and be sent exchange cards to obtain subsidised nicotine replacement therapy.
Quitline says one in five of its clients is remains smoke free after six months, a far higher rate than for those who give up without any help.
GPs, practice nurses and midwives are frontline quit-smoking practitioners and many iwi health services offer specialist quit-smoking help.
Persistence pays off. The researchers and policy specialists who wrote the smoking cessation guidelines for the Ministry of Health say that because smokers need on average 14 attempts to give up long term, they need regular, repeated help and encouragement to keep on trying.
The 2007 guidelines state that, of smokers who would not otherwise have stopped smoking:
- One in 40 will quit for at least six months after receiving brief quit-smoking advice from a health worker,
- One in 20 will quit for this long after receiving face-to-face quit-smoking support,
- One in 14 will quit for at least six months after completing a course of nicotine replacement therapy.
The quit rates are slightly better again with the medicines bupropion and nortriptyline (both state-funded) and varenicline (not funded).
Yet despite the mounting evidence for the role of brief advice from health workers in helping patients quit, and the effectiveness of smoking cessation therapies, only one district health board met Health Minister Tony Ryall's updated tobacco control target in the league tables published in November.
The ministry explained that it was because the target was new that only Wairarapa DHB complied with the requirement that 80 per cent of hospitalised smokers were given advice and help to quit.
The target will rise progressively to 95 per cent by 2012 and, from July, primary health organisations will be required to comply in respect of their clinics' patients.
The Auckland and Waikato health boards between them have put more than 1000 health workers through training on how to provide better quit-smoking help to patients.
It is surprising that hospitals, before the new targets, had not done more to help people quit, as more than $1.5 billion a year, much of it from the public purse, is spent on health care for illnesses caused by smoking.
No one yet knows the extent to which GPs and midwives are complying with the guidelines.
College of GPs deputy president Dr Tony Townsend said that in his Whangamata practice, "over a period of say a year, we would hope that everybody gets asked their smoking history or gets it updated. It's difficult to know whether we do that satisfactorily for all patients in a year".
Smokers should be gently urged to quit at every consultation unless other health matters were more pressing, but it was hard to know the extent to which this happened because it was not always recorded.
"My impression would be that smokers are asked at more than 50 per cent of consultations."
College of Midwives research suggests the smoking rate among heavily addicted women drops by 38 per cent during pregnancy.
The research report says the reduction may be attributable to "continuity of midwifery care and its provision of smoking information and referral to smoke-free support programmes".
A midwifery adviser at the college, Alison Eddy, said it had been heavily involved since 2000 in educating midwives, with joint venture partner Smokechange, to provide help to quit smoking.
Midwives' performance in helping their patients to quit is subject to scrutiny through the Midwifery Council's periodic checks on all aspects of their practice.
Ministry surveys show that most smokers would not start smoking if they could turn the clock back, and many are trying to quit.
They also found barriers to success in quitting include lack of knowledge on the safety of nicotine replacement therapy and "a residual belief that will power is the key to quitting".
The director of the Tobacco Control Research Centre at Auckland University, Dr Marewa Glover, said smokers were less likely than non-smokers to believe that proven therapies like nicotine replacement patches worked.
In some Pacific groups, smokers were even sceptical about the claims that tobacco caused lung cancer and could kill them.
"The tobacco industry says everybody knows smoking causes lung cancer. We're finding they don't know," Dr Glover said.
Some of these groups had been poorly served in the provision of health information.
"There's a lot of work to do if we have to go back and educate populations about the ill effects of smoking, let alone about proven, effective methods available to help them."
* For help to stop smoking: Quitline at www.quit.org.nz or 0800 778 778 and Aukati Kaipaipa at www.aukatikaipaipa.co.nz
