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Nurse clinics supporting the implementation of smoking-cessation strategies
By Margaret Dempsey, APNA Project Officer, Building Nurse Capacity
Source: APNA Primary Times Summer 2021 (Volume 21, Issue 2)
Registered nurse and APNA member Ellen Gvozdenko has identified the need to implement smoking-cessation strategies to address alarming tobacco-dependence rates within her local community. Working at Interchange Health Co-operative in Greenway, ACT, Ellen applied to participate in APNA’s Building Nurse Capacity project to establish a Smoking-Cessation Nurse Clinic.
The Interchange Health Cooperative is member-owned and offers bulk-billed general practice services. The organisation has a focus on supporting underserved communities, particularly people dependent on drugs or alcohol, recently incarcerated people, and members of the LGBTQI+ community. Many patients experience complex health needs, have poor healthliteracy levels, and are on low incomes.
Tobacco smoking remains the leading preventable cause of death and disease in Australia.1 It claims the lives of around 24,000 Australians every year. Tangible and intangible costs associated with smoking tobacco are estimated to cost Australia almost $137 billion annually.2 These data, along with alarming local statistics – 36% of adult patients accessing health care at Interchange Health Co-operative are smokers, compared with 13.8% across Australia – spurred Ellen to address the issue of tobacco dependence.
"36% of adult patients accessing health care at Interchange health Co-operative are smokers, compared with 13.8% across Australia."
Initial planning saw Ellen search the Royal Australian College of General Practitioners (RACGP) guidelines on smoking cessation3 and liaise with the Cancer Council ACT4 to source resources for practice staff. She then developed an initial assessment form based on the RACGP guidelines, and the team was equipped with supporting tools, including the Cost of Smoking Tool, which is used to calculate the financial cost of smoking for an individual.5 Patients were also offered the option to sign up for additional support through the ACT Quit Line service. Interchange Health’s onsite pharmacist (Wei Xu) has further supported the team with the procurement of nicotinereplacement therapy (NRT) products and the preparation of smokingcessation starter kits. Referrals to the nurse clinic are generated from GPs and self-referral is also an option for patients.
Patients who attend the nurse clinic are initially seen by Ellen or Wei Xu, who conduct brief intervention strategies using the 5As behaviour-change model6 :
- Asking patients about their tobacco use
- Assessing level of smoking, degree of dependence and willingness to change using a motivational interviewing model and discussing what has happened in previous attempts to quit
- Advising patients, including providing education and developing a tailored quit plan
- Assisting patients with NRT, if clinically appropriate
- Arranging ongoing follow-up and support, including a faceto-face review 1 week later with the nurse and, in some cases, an appointment with a GP to prescribe ongoing NRT or smoking-cessation medication, if required.
Australia’s primary health-care funding model and nurse clinic models rely on a team approach to care with the nurse leading the coordination of care. Nurses are well placed to provide education to help patients implement smokingcessation strategies, and also to coordinate referrals to relevant services. Spirometry testing allows health-care professionals to diagnose lung diseases and start treatment for people who have previously been untreated. Feedback from these results can further motivate patients to quit smoking. For patients where NRT requires further consideration, including pregnant women or those on antipsychotic medications, Ellen liaises with a general practitioner to seek medical clearance. Interpretation of spirometry test results, assessment and discussion of any underlying lung disease or other comorbidities, management of medications and comorbid mental health and drug and alcohol problems continue to be undertaken by the GP.
Ellen utilises the waiting time during spirometry appointments to discuss smoking-cessation strategies with patients: ‘Where possible, I book a spirometry appointment to coincide with the second smoking-cessation visit. I do this because in spirometry, there is a gap in the middle of the appointment where you have to wait for the Ventolin to take effect, so I discuss smoking-cessation during that time,’ she says.
"We've had a least two patients come in and say 'I've quit smoking', which is awesome in itself."
Ellen promotes the SmokingCessation Nurse Clinic by wearing a badge that elicits conversation and questions from patients. This economical marketing approach extends across the practice team with GPs, nurses, and administrative staff at Interchange Health also sporting badges to promote this new service, substantiating the concept that successful nurse clinics rely on a robust team approach to planning, implementation, and evaluation.
Tobacco dependence is a chronic relapsing disease and Ellen is passionate about providing individualised support to assist patients with their attempts to quit. She acknowledges the challenges associated with the condition and works with patients to help them identify and deal with their personal triggers. To date, 30 patients have received individualised smokingcessation support, with four patients indicating they are not ready to proceed further. Fourteen patients have completed the smokingcessation program and 2 patients have quit smoking.
‘We’ve had at least two patients come in and say, “I’ve quit smoking!”, which is awesome in itself. The feedback I have received is that patients who have come through the clinic feel supported and they have benefited from having the NRT products demonstrated to them.
They also leave the appointment with sample NRT products. The face-toface appointments allow patients to discuss their triggers and they can ask me any questions or clarify any misunderstandings they might have. The follow-up appointment allows patients to provide feedback on the NRT products they have tried, and they have the option to sample other products.’
Note: Registered nurse and APNA member Ellen Gvozdenko is pictured just above.
1 Cancer Council Australia, ‘Smoking and tobacco control: National position statements’, Cancer Council Australia website, n.d., accessed 21 October 2021. https://www.cancer.org.au
2 National Drug Research Institute (NDRI), Curtin University, ‘Identifying the social costs of tobacco use to Australia in 2015/16’, NDRI website, May 2019, accessed 21 October 2021. https://ndri.curtin.edu.au
3 Royal Australian College of General Practitioners (RACGP), ‘Royal Australian College of General Practitioners guidelines on smoking cessation’, RACGP website, updated 29 September 2021, accessed 21 October 2021. https://www.racgp.org.au
4 Cancer Council ACT, https://actcancer.org/, n.d., accessed 21 October 2021.
5 Quit, ‘Cost of Smoking Tool’, n.d., accessed 21 October 2021. https://www.quit.org.au
6 Royal Australian College of General Practitioners (RACGP), Smoking, nutrition, alcohol, physical activity (SNAP): A population health guide to behavioural risk factors in general practice, 2nd edn, RACGP, Melbourne, 2015. https://www.racgp.org.au