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• W2017012614 abstract "Current estimates suggest that cigarette smoking causes the premature deaths of 5,000,000 people per year globally (Mathers & Loncar 2006) and in developed countries alone accounts for two million deaths per year (Peto et al. 2006). Preventing young people from starting to smoke would be effective at reducing this figure, but would not be significant until after 2050 (BMJ 2000 Anonymous). Strategies aimed at smoking cessation are necessary to reduce tobacco related mortality in the medium term (BMJ 2000 Anonymous). This commentary centres on a study by Sarna et al. (2009) investigating hospital nursing smoking cessation intervention measures in the USA. The study is of particular relevance to those of us in other regions who are also struggling with the global epidemic of long term health conditions, many of which are strongly associated with cigarette smoking. This paper returns to some of the findings of the Sarna study and reflects upon their increasing relevance to the role of acute nurses on the public’s health. Nearly 23% of men and 21% of women in England smoke (General household survey 2007). Most smokers in countries such as the UK and the USA report that they want to stop and intend to stop at some point (Aveyard & West 2007). The rate of attempts at stopping is high (78 attempts per 100 smokers per year in the UK), with many smokers making several efforts in a year (The Office for National statistics (ONS) 2007). Nearly half of all smokers expect not to be smoking within the year but only 2–3% each year actually stop permanently (ONS 2007). Current approaches to smoking cessation recognise that cigarette smoking is not a simple habit, but a complex physiologic addiction that requires a multi-facated intervention scheme from a variety of sources in order to encourage lifestyle change. As Sarna et al. (2009) explain, just such an approach is being facilitated in the USA and involves Government funded resources, including the national telephone quitting helpline, which has been shown to increase quit rates. Other countries have also adopted, wholly or partially, the World Health Organization (WHO) framework convention on tobacco control. In England, the Government has established a comprehensive National Health Service (NHS) stop smoking service providing counselling, support, nicotine replacement therapy and pharmacological assistance on prescription for those who wish to quit. The Department of Health funded research (DOH 2005) show that about 15% of people using government funded assistance remain non-smokers at 52 weeks and, when compared to no formal intervention, are up to four times as likely to succeed. These initiatives have cost £112 million over the past two years (DOH 2008) which equates to £173 per person in 2007/08, an increase of eight per cent from 2006/07and there appears to be commitment to continue with this support in the foreseeable future. This appears to be a significant amount, although the WHO point out that generally governments spend less than one-fifth of 1% of the money collected in tobacco taxes each year on tobacco control activities (WHO 2007). However, it appears that current cessation support resources exist within an atmosphere of increasing recognition by the UK government that they wish to share responsibility of smoking cessation by raising public health awareness and implementing strict health protection and legislative measures. In fact, Ash (2008) believe that public support for tobacco control interventions has never been higher in the UK and are pressing for a new national tobacco control strategy with more ambitious targets for change. Similar to the USA, registered nurses comprise the largest group of healthcare professionals in England and are ideally placed to offer tobacco cessation interventions to patients throughout all clinical areas. As stated by Sarna et al. (2009), evidence does indicate that nurses are effective in providing cessation interventions (Sivarajan Froelicher et al. 2004, Persson & Hjalmarson 2006, Wewers et al. 2006, Rice & Stead 2008). In fact, providing advice to smokers to stop smoking more than doubles the cessation rate (Bao et al. 2006). However, in England, there appears to be the lingering opinion that health promotion belongs to the remit of community and practice nurses, and not those in hospitals or acute settings. This opinion appeared to be reinforced in 2004 when the General Medical Services contract for general practice (the quality and outcomes framework) began to measure GP achievement against the recording of smoking status and providing cessation advice or referrals. Also, increasing numbers of accredited trainers who work within the community encouraging smokers to stop smoking and referring them onto specialist services has begun to be rolled out from 2007 (DOH 2004). There is a growing awareness that this disparity between cessation interventions in the community and in hospitals needs to be addressed. Whitehead (2005) suggests that this disparity forms only part of a wider problem, stating that hospital based nurses have failed in their role as health promoters despite this being a major World Health Organisation policy for over 10 years. One approach is to characterise health promotion work in the context of ‘brief interventions’. In England, National Institute for Health & Clinical Excellence (NICE) (2006) released guidance on ‘brief interventions’ and how opportunistic contacts with patients can be utilised to assess, offer support and refer onwards. Search of the Cochrane Tobacco Addiction Group trials register in September 2007 (http://www.ncbi.nlm.nih.gov) found that simple and brief advice can increase cessation by up-to an additional 3% compared with the unassisted rate. More intensive interventions were found to have a small additional benefit. The key to the brief intervention policy is that it reaches the wider population and is thought by some to be the key in persuading more smokers to try to stop (West 2005). It is pertinent, therefore, that the nurses surveyed by Sarna et al. (2009) were all hospital based and it is significant that they found the frequency of cessation interventions by these nurses to be ‘suboptimal’. In addition, Sarna et al. (2009) found that of these nurse-initiated interventions, only about 20% referred onwards, arranged or recommended further resources or support systems. Again a criticism levelled by Whitehead (2005). The focus of the Sarna et al. (2009) article is the way these interventions are co-ordinated and structured. They describe the model advocated in the USA of the ‘Five A’s’ (ask about tobacco use, advise to quit, assess readiness to quit, assist with quit efforts, and arrange for follow up). Although they explain that some have suggested shortening this to ‘ask, advise, refer’ (Zhu et al. 2002, Schroeder 2005) for busy or inexperienced clinicians. This is similar to the National Institute for Health & Clinical Excellence (NICE) (2006) model advocated for health professionals in England who also state that the smoking status of all smokers who are not ready to stop should be recorded and reviewed with the individual once a year where possible. The NICE model requires the NHS to work as a seamless service in referral and review of patients and needs considerable co-operation of all health professionals, some reorganisation of work practices, establishment of monitoring systems and the recognition of their role as health promoters as well as recognition of the importance of including smoking cessation within busy clinical environments. In fact, as Whitehead (2005) noted, acute based nurses need to see themselves as part of the surrounding community and not just view their work as being relevant to their own setting. In Sheffield, South Yorkshire (UK), a training programme for nurses is being rolled out on how to implement the ‘brief intervention’ initiatives. Initially this was delivered to those deemed to be in clinical areas with the greatest opportunity to implement smoking cessation into their routine working practices. For example pre-admission nurse practitioners who now include this as part of the patients’ preparation for surgery. It is currently being expanded to include nurses in other areas, although at present it is deemed to be ‘patchy’. The University of Sheffield, School of Nursing and Midwifery already invites the smoking cessation team onto many of the post registration training modules, especially the long term health conditions modules such as chronic obstructive pulmonary disease, stroke and diabetes and also the practice nurse training days. There are currently discussions to include tobacco cessation training to student nurses on future pre-registration cohorts. Of the nurses surveyed by Sarna et al. (2009), interestingly it was the advanced practice nurses and clinical nurse specialists who were most likely to intervene and refer onwards to further support agencies or resources. It was also noted that those who were least educated were the least likely to intervene. There is the recognition that the reasons for these findings warrant more research but would indicate that education, training and confidence all play a part. The Sheffield example can provide us with an exemplar, where it is hoped that by introducing pre-registration students to the concept that smoking cessation is a responsibility of all nurses, the role will become routine practice, regardless of setting. In addition, this will address some of the issues highlighted by Sarna et al. (2009) and increase the number of successful ‘brief interventions’ by both acute and primary care nurses, with effective referral onwards onto other resources and support." @default.
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• W2017012614 title "Commentary on Sarna L, Bialous SA, Wells M, Kotlerman J, Wewers ME & Froelicher ES (2009) Frequency of nurses’ smoking cessation interventions: report from a national survey.Journal of Clinical Nursing18, 2066–2077" @default.
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