The role of physiotherapists in smoking cessation
This Editorial discusses how physiotherapists can inspire attempts to quit smoking by their patients through brief interventions. Q&A with Nia Luxton, whose research was published in the latest issue of the Journal of Physiotherapy.
Is smoking becoming more or less common over time?
In Australia, the prevalence of regular smoking (defined as smoking tobacco at least once a day and includes manufactured (packet) cigarettes, roll-your-own cigarettes, cigars or pipes) has reduced over the decades.
Overall, smoking is becoming less common as shown in the recently published National Drug Strategy Household Survey (NDSHS) 2019, which reported 11.0 per cent of people aged 14 and over smoked daily in 2019, a decline from 12.2 per cent in 2016 (AIHW 2020).
However, smoking prevalence is higher than the national average of 11 per cent in certain areas and among certain population subgroups in Australia.
These include Aboriginal and Torres Strait Islander populations; individuals with lower socioeconomic status or lower educational attainment; lesbian, gay, bi, transsexual and intersex people; culturally and linguistically diverse populations; people who live in remote and very remote areas; people who are unemployed or unable to work; people with mental illness; and homeless individuals (AIHW 2020, Greenhalgh et al 2019).
Are physiotherapists well positioned to intervene to help their patients to quit smoking?
Physiotherapists in Australia and internationally (including physical therapists and respiratory therapists in the United States and in Canada) are in an ideal and novel position to intervene to help patients attempt and maintain a quit attempt.
They are advocates of health and wellbeing across the lifespan, from pregnancy to older age, and often have repeated contact with their patients as inpatients, outpatients and in the community.
Physiotherapists routinely promote physical activity and prescribe exercise, provide advice on how to improve their general health and educate patients on how to reduce their risk factors for developing cardiovascular disease, cancer and chronic pain for example.
Yet they less routinely ‘intervene’ to help a patient’s quit attempt for a number of reasons, despite patients expecting smoking cessation to be addressed as part of their health advice (Kunstler et al 2019).
Furthermore, three successive Physical Therapy Summits on Global Health have highlighted that physiotherapists/physical therapists around the world are well positioned to become leading health professionals to promote health and wellbeing, and routinely integrate lifestyle assessments, interventions and referrals to other health professionals and support services into their practices (Dean et al 2019).
To achieve this, physiotherapists will need specific competencies in areas such as smoking cessation, nutrition and exercise, to ensure they can confidently and consistently promote health and help prevent the rise of chronic, non- communicable diseases.
What have physiotherapists been advised to do in the past to encourage their patients to stop smoking?
Physiotherapists in Australia do not have their own professional guidelines. In the past, physiotherapists have been advised to deliver the gold standard ‘5As’ (Ask, Assess, Advise, Assist, Arrange) approach (Fiore et al 2008) to smoking cessation.
The 5As guidelines can be found in various sources including state or territory health department websites such as NSW Health; state smoking cessation services such as Quit Victoria, a program of Cancer Council Victoria; or other professional bodies’ guidelines such as the Royal Australian College of General Practitioners or the Australian and New Zealand College of Anaesthetists.
However, while the 5As guidelines are evidence based and comprehensive, they also require time and expertise to implement, a knowledge of available smoking support services and an ability to provide follow-up care to effectively help a patient maintain a long-term quit attempt.
Why do physiotherapists not follow those guidelines?
Physiotherapists nationally and internationally feel that part of their role is to ask patients about their smoking habits and recommend they stop smoking, yet do not feel confident to provide patients with advice and information about how to stop smoking (Bodner et al 2011, Pignataro 2017, Luxton et al 2019).
This is primarily due to physiotherapists’ lack of knowledge of 5As guidelines, up-to-date cessation interventions and resources such as behavioural counselling, pharmacotherapy and support services and a lack of time; and to a lesser extent a fear of intrusion into a patient’s privacy, a perceived patient’s lack of desire or ability to maintain a quit attempt, and a perception of their own ineffectiveness.
How can we get around those barriers?
Physiotherapists feel underprepared to engage in a smoking cessation discussion and implement the smoking cessation guidelines.
These barriers can be addressed in a number of ways. Firstly, current physiotherapy university curricula should be redesigned and developed to include health- promoting skills and competencies that include the background to and content of smoking cessation guidelines (Bodner et al 2020).
Secondly, even if physiotherapists feel they have the skills to advise and educate patients about the benefits of smoking cessation, they do not have the self-efficacy.
To address this there is a need to provide training for physiotherapists to develop their self-efficacy in delivering cessation guidelines to enable their patients to quit in the most effective, timely and personalised way.
Finally, physiotherapists’ workplaces, such as hospitals and healthcare facilities, are by law in Australia smoke-free, a policy that creates a unique opportunity to assist patients (and staff) to quit in a supportive environment when motivation to quit is high.
However, in Australia policy compliance is inconsistent with poor signage, a lack of enforcement, limited availability of nicotine replacement therapy (NRT) for patients and a lack of mechanisms for monitoring compliance (McCrabb et al 2017).
Physiotherapists’ workplaces can address the barriers previously mentioned by providing time to participate in the training, supporting the role of physiotherapists as champions of smoking cessation, and demonstrating ‘top down’ organisational support, which is key to the successful implementation of smoking cessation interventions in health services (Wiggers et al 2016).
Was the need for simpliﬁcation the only reason that the guidelines for allied health professionals were updated?
No, there were a number of reasons for the recent update in guidelines by The Royal Australian College of General Practitioners and their inclusion of the brief intervention model of Ask, Advise, Help (AAH) created by Quit Victoria (RACGP 2019).
The first edition of the guidelines were published in December 2011 and were updated in 2012 and 2014.
Since that time, there has been much research into smoking cessation interventions and pharmacotherapy, the role of nicotine-containing e-cigarettes, and advice for groups with high smoking prevalence.
Furthermore, the barriers of lack of time and knowledge to successfully implement the 5As were also addressed by recommending health professionals, such as physiotherapists, adopt a three-step brief intervention model.
The AAH model enables physiotherapists to screen (Ask), provide advice and information on the best way to quit (Advise) and then proactively Help people to access best practice tobacco dependence treatment in their diverse health and community settings.
What do the guidelines say about e-cigarettes?
E-cigarettes are a contentious issue in the area of smoking cessation.
There has been a rapid increase in e-cigarette use globally since their introduction into the market in the mid-2000s, and the NDSHS (2019) reported that among people in Australia aged 14 years and over, 11 per cent had ever used e-cigarettes, most of whom (60 per cent) reported using e-cigarettes once or twice only; 2.0 per cent reported current use (daily, weekly or monthly); and 1.1 per cent reported daily use (AIHW 2020).
Overall, there is insufficient evidence that nicotine-delivering e-cigarettes are more effective for smoking cessation compared with other best-practice cessation interventions.
However, while preliminary evidence highlights the potential for nicotine-delivering e-cigarettes to support cessation, when coupled with behavioural counselling it is widely recognised that more large-scale evidence is needed (Hartmann-Boyce et al 2016, Walker et al 2020, Hajek et al 2019).
E-cigarette use is not without harm, and there is a lack of long-term studies on the effect of e-cigarettes on the development and/or exacerbation of conditions such as cancer, cardiovascular and respiratory diseases.
However, the RACGP guidelines (2019) have included clear guidance to assist health professionals to engage in a discussion about e-cigarettes if the topic is raised by a patient, guidance which has not previously been available (Luxton et al 2018).
The guidelines recommend that the patient is informed there are no approved e-cigarette products available; the long-term health effects of vaping are unknown; in order to maximise possible benefit and minimise risk of harms, only short-term use is recommended; completely switching to e-cigarettes should occur rather than dual use of tobacco and e-cigarettes, which is regarded as more harmful than either form of cigarettes alone; and a quit attempt with an e-cigarette should be accompanied by behavioural support such as Quitline or a tobacco treatment specialist.
Access Nia’s ‘How do we advise patients about e-cigarettes?’ lecture on demand via the APA website here.
Dr Nia Luxton is a lecturer in the Discipline of Physiotherapy at the Australian Catholic University, a Research Associate at Westmead Applied Research Centre, University of Sydney, and a practising cardiorespiratory physiotherapist. She is an advocate for effective secondary prevention of cancer, cardiovascular and respiratory disease, particularly in the area of smoking cessation.
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