The National Institute for Health and Care Excellence says hospitals have a duty of care to help all patients who smoke to stop and has issued guidance on this
Smoking has huge financial and health implications, yet there is no standardised method of identifying and referring hospital patients to local stop smoking services in England. This article summarises new National Institute for Health and Care Excellence guidance on supporting people to stop smoking in acute, maternity and mental health services, and also explains the national referral system.
Citation: Gilbert L, McIlvar M (2014) Hospitals’ duty of care in smoking cessation. Nursing Times; 110: 4, 22-24.
Authors: Liz Gilbert is smoking cessation delivery manager and a member of the National Institute for Health and Care Excellence guideline development group; Melanie McIlvar is operations director; both at National Centre for Smoking Cessation and Training.
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The National Institute for Health and Care Excellence has published new public health smoking cessation guidance specifically for secondary care (NICE, 2013).
The new guideline sets out how to support people using acute, maternity and mental health services to stop smoking, and recommends actions health professionals can take. These include promoting cessation before planned admissions, having stop-smoking interventions immediately available, offering behavioural support after admission to hospital and making all NHS secondary care settings completely smoke free.
A number of diseases are caused by smoking including heart disease, cancers and respiratory diseases, all of which have financial implications for the NHS and wider society. Smoking is responsible for over 460,000 hospital admissions in England each year, and is the biggest avoidable cause of inequalities in health. Smoking in pregnancy causes up to 5,000 miscarriages and stillbirths each year, and increases the risk of premature birth and low birthweight. In children, secondhand smoke causes sudden infant death syndrome and middle ear disease, and exacerbates asthma.
A Cochrane review confirmed the positive impact of implementing stop-smoking services for inpatients. This systematic review found that stop-smoking programmes aimed at inpatients with support for at least one month after discharge are effective, regardless of admitting diagnosis (Rigotti et al, 2008).
Patients who remain smoke free during a stay in hospital will heal more quickly and are less likely to be readmitted. In addition, patients are more receptive to smoking-cessation support while in hospital, and are often more motivated to stop smoking following admission (Department of Health, 2009).
Aims of the guidance
This guideline gives specific recommendations on how to initiate and maintain a cultural change in an organisation. It states that NHS hospitals should help all patients who smoke to stop both before and during a hospital stay, as well as ideally remaining smoke free after their hospital treatment.
The overall aims of the guideline are to ensure patients who smoke are identified, that offering support to stop smoking is part of routine practice, and that for clinical staff to feel this is part of their duty of care. Evidence suggests that patients already expect this care, with 95% of patients expecting to be asked if they smoke by a health professional (Slama et al, 1989).
The guideline aims to make it unacceptable to smoke anywhere in NHS hospitals or grounds, encouraging the health service to lead by example. It states that NHS hospitals should provide everyone with verbal and written information about the hospital’s smoke-free policy before their appointment, procedure or hospital stay, and that this should include the short and long-term benefits of stopping smoking and details of the support available.
A clinical or medical director should be assigned as the lead on stop-smoking support and smoke-free policy for the organisation. This lead person should promote stop-smoking support for patients and staff and ban staff-facilitated patient smoking breaks and the sale of tobacco products in secondary care settings. They should also ensure smoke-free plans include removing shelters or other designated outdoor smoking areas, and ensuring staff, contractor or volunteer contracts do not allow smoking during working hours or when in uniform or on hospital business.
The guideline states that NHS hospitals should provide intensive support for people using secondary care services, and discussions about past and current smoking behaviour should be included in a personal stop-smoking plan (see Box 1). This should also include providing immediate access to licensed nicotine-containing products, such as nicotine replacement therapy patches or gum, or other pharmacotherapies.
Box 1. Patient experience
I’d smoked for 40 years when I collapsed with fluid on my lung, and was admitted to the Royal Bolton Hospital as an emergency.
I was in hospital for two weeks, and the nurses gave me patches so I wouldn’t have problems with cravings. I didn’t smoke the whole time I was in hospital but I did start again when I was discharged. Soon after I got home, I had a call from Helen, the stop-smoking adviser. I started seeing her every week and, with her help, I gave up for good in July – about two months after I’d first had support in hospital.
I feel so much healthier now. I never would have given up without the help that I’ve had, so I hope that now other patients will also get the chance to quit smoking for good.
Angela Lomax is a patient who stopped smoking with help from her local hospital
The guidance also notes that patients’ healthcare providers or prescribers need to be alerted to changes in smoking behaviour, as doses of other medications may need adjusting.
Smoking is especially common among people with mental health problems; while one in five of the general population smokes, this figure rises to one in three among people with longstanding mental illness and to 70% of people in psychiatric units. The guideline highlights and emphasises how people with mental health problems who smoke can successfully stop when provided with the right support.
The law states that people cannot smoke inside enclosed or mostly enclosed workplaces, but in mental health units patients are often allowed to smoke in hospital grounds.
Most of the reduction in life expectancy among people with serious mental illness is attributed to smoking. It also increases the doses required of psychotropic drugs, costing an estimated £40m extra per year in the UK.
Research shows that people with mental health problems want to stop smoking as much as those without and are able to stop when offered evidence-based support (Royal College of Physicians and Royal College of Psychiatrists, 2013; Siru et al, 2009; Jochelson and Majrowski, 2006). However, they are less likely to be offered support, with smoke-free policies commonly not well adopted by mental health staff.
Carers and visitors
Secondhand smoke is also highlighted in the guideline, as is the need to provide relatives, carers, friends and other visitors with information about the risks of smoking and secondhand smoke.
This should include advice not to smoke near the patient, pregnant women or children, and not in the house or car. It is important that visitors know smoking is not allowed on the premises and that it is made clear where people can buy nicotine replacement therapies on site.
The national referral system
Offering advice and support to stop smoking is the single most cost-effective and clinically proven preventive action a health professional can take. It is important to keep giving advice at every opportunity, as smokers may take several attempts to stop smoking successfully (Fu et al, 2006).
Patients who are referred to a local stop- smoking service are up to four times more likely to quit (Smoking Toolkit Study, 2001). However, referrals are low and there are a great number of missed opportunities with this highly captive audience (National Centre for Smoking Cessation and Training, 2012).
The national referral system (NRS) developed by the NCSCT has been hugely successful in initiating cultural change within acute trusts. In the initial pilot in 2011, there was a 600% increase in patient referrals to stop-smoking support, and a 400% increase in staff trained to give advice and offer support to patients. The NRS will be implemented in at least 17 acute trusts in England by the end of March 2014.
The system offers a comprehensive approach to supporting patients to stop smoking, by enabling staff to record patients’ smoking status within the electronic patient record, and to make a referral by simply ticking a box. The patient details are then sent securely to the NRS and automatically received by the patient’s local stop-smoking support provider. The system also offers online training on how to give advice to patients and how to make a referral to stop-smoking support.
Stop-smoking support in secondary care settings has developed significantly over recent years. However, this ranges a great deal, from no activity in some acute trusts to established systems and activity in others.
There is currently no standardised method of identifying and referring hospital patients to local stop-smoking services in England. It is hoped that this new guideline will encourage NHS hospitals and other care settings to establish effective systems to offer the best possible support to help patients to stop smoking before, during and after they visit a secondary care setting.
Box 2. National Referral System case study: Barts Health Trust
Why did you decide to implement the National Referral System?
As the largest trust in England, we see 1.5 million patients each year at Bart’s Health. Our public health vision is to improve the health of our patients and reduce inequalities by promoting healthy lifestyles. Our first priority is to reduce the number of patients who smoke. The prevalence of smoking in East London is significantly higher than the England and London averages, especially among black and minority ethnic communities.
It was becoming increasingly evident that frontline clinical staff’s knowledge of local stop-smoking support varied, and we decided that practices needed to be standardised to support staff in making every contact count with patients, and encouraging them to see this contact as an opportunity for health promotion. This is typically seen as a teachable moment to provide health improvement advice to smokers, and offer a referral to local stop-smoking support.
To ensure stop-smoking referral pathways were robust and streamlined, we decided to implement the national referral system (NRS).
How did the trust decide how implementation would be made?
In September 2012, we identified a member of the public health team to manage local implementation. Approximately 80% of their workload was focused on the implementation of the NRS.
Initially, the project manager worked closely with Liz Gilbert, the NCSCT’s smoking-cessation delivery manager. They both devised the implementation plan and identified key players and teams within Barts Health who would be integral to the plan’s implementation.
Support at director level was part of the process and paramount to the success of the implementation. Both the experience of the NCSCT and the organisational knowledge of the project manager aided successful implementation.
What do you feel were the key learning points from implementing the system?
The power of face-to-face communication with frontline staff has been a key learning point of this experience.
Communication materials such as emails, posters and staff bulletins initiate the implementation and can encourage changes to routine practice. However, it was only when we started to attend team meetings or simply showed up in the departments and asked the “right” questions that we gained a better understanding from the staff perspective.
Through this, we found that sometimes implementation was slower than expected for simple reasons – staff might just not know how to a make a referral or hadn’t received the generic information. Having one-to-one contact meant we could resolve these issues and progress in the use of the system.
The online training in giving very brief advice has been simple and effective. We believe it has given staff the confidence to deliver very brief advice routinely.
Regular feedback, progress updates and case studies have helped to make the referral system more meaningful and relevant.
What have been the key outcomes? Was there value for money?
There has been an increase in the number of referrals across all our hospital sites, notably at Whipps Cross, which has a target agreed with local commissioners to refer 1,770 smokers by March 2014.
The implementation of the system and staff engagement have proved to be successful. From April to October 2013, a total of 1,045 patients were referred from Whipps Cross to local stop-smoking support. This is twice the number of people referred for support by the hospital during the whole of 2012-13, in just seven months.
Because the system can be audited, we are now able to generate more accurate reports to track the number of stop-smoking referrals across the trust.
The NRS has been an effective tool to help staff make a step change towards routine and consistent stop-smoking referrals. We now feel confident that we have a standardised pathway for electronic stop-smoking referrals in place.
This process has been critical to the development of our refreshed Barts Health smoke-free policy and action plan, which is due to be published in 2014.
There are approximately 10,000 frontline clinical staff working for the trust. Since April 2013, just under 10% (733) have been trained to offer very brief advice.
We believe our efforts to support patients to stop smoking represent value for money. The system has been essential for the delivery of the local CQUIN target at Whipps Cross Hospital.
- Smoking carries huge financial and health costs
- Patients are often more motivated to stop smoking and open to cessation support while in hospital
- The guidance aims to help practitioners to identify patients who smoke and offer stop-smoking support routinely
- People with serious mental illnesses are more likely to smoke than others but are less likely to be offered help to quit
- A national referral system pilot resulted in a 600% increase in patient referrals to stop-smoking support
Department of Health (2009) Stop Smoking Interventions in Secondary Care. London: DH.
Fu S et al (2006) Promoting repeat tobacco dependence treatment: are relapsed smokers interested? American Journal of Managed Care; 12: 235-243.
Jochelson K, Majrowski B (2006) Clearing The Air: Debating Smoke-free Policies in Psychiatric Units. London: King’s Fund.
National Centre for Smoking Cessation and Training (2012) Stop Smoking Interventions in Secondary Care. London: NCST.
National Institute for Health and Care Excellence (2013) Smoking Cessation: Acute, Maternity and Mental Health Services. London: NICE.
Rigotti NA et al (2008) Interventions for smoking cessation in hospitalised patients. Cochrane Database of Systematic Reviews; Issue 2, Art no CD001837. DOI: 10.1002/14651858.CD001837.pub.2
Royal College of Physicians and Royal College of Psychiatrists (2013) Smoking and Mental Health. London: RCP.
Siru R et al (2009) Assessing motivation to quit smoking in people with mental illness: a review. Addiction; 104: 719-33.
Slama KJ et al (1989) Community views about the role of general practitioners in disease prevention. Family Practice; 6: 203-209.
Smoking Toolkit Study (2001) Available at: www.smokinginengland.info