Incorporating Systematic Smokefree Practice
in the Hawke’s Bay District Health Board
HPV Vaccination Programme
report prepared by
David Smith
29 June 2010
Smith Consulting Ltd
phone: (03) 315 7763 mobile: (0274) 311 212 fax: (03) 315 7764
e-mail: smith.consulting@xtra.co.nz
1. Contents
1.
Contents .............................................................................................................. 2
2.
Executive Summary ............................................................................................. 3
3.
Recommendations ............................................................................................... 4
4.
Background ......................................................................................................... 5
5.
Literature Review ................................................................................................. 7
5.1.
HPV ........................................................................................................... 7
5.2.
Smoking Cessation ................................................................................... 8
6.
Description of the HPV vaccination programme .................................................. 9
7.
Key Smokefree Messages ................................................................................. 10
8.
Education plan and resource development ........................................................ 11
9.
8.1.
Education ................................................................................................ 11
8.2.
Resources ............................................................................................... 12
Staff perceptions ................................................................................................ 13
9.1.
Importance of ABC Smokefree Practice .................................................. 13
9.2.
Legitimacy of ABC Smokefree Practice ................................................... 13
9.3.
Clarity of Process Expectations ............................................................... 14
9.3.1. Design ........................................................................................... 14
9.3.2. System/Process ............................................................................ 15
9.4.
Education ................................................................................................ 15
9.5.
Resources ............................................................................................... 16
9.6.
Roles ....................................................................................................... 16
10.
Client Perceptions.............................................................................................. 17
11.
Preliminary Audit – April 2010 ........................................................................... 18
11.1. Results .................................................................................................... 18
11.2. Comments ............................................................................................... 18
12.
Appendices ........................................................................................................ 20
12.1. APPENDIX 1 - Bookmark Resource........................................................ 20
12.2. APPENDIX 2 - Recording Sticker ............................................................ 21
12.3. APPENDIX 3 - Session Outline – 20 minute presentation ....................... 22
Page 2 of 23
2. Executive Summary
Smokefree ABC practice was formally incorporated into the HPV screening programme
following initial discussions between the team’s manger and the HBDHB Maternal, Child
and Youth Services smokefree coordinator. The rationale was that smoking was directly
linked to increased risk of HPV infection and subsequent cervical cancer and that brief
smokefree intervention by health professionals is an effective strategy in supporting those
who currently smoke to become smokefree. Consultation among the HPV team yielded
support for this proposal and arrangements were subsequently made to proceed.
This report provides information that suggests that the experience of the HPV team in
delivering smokefree ABC practice within the vaccination process has been acceptable
and professionally satisfying. It also provides strong indications that students accept the
smokefree ABCs as a legitimate part of the routine. Further, the description by staff of the
response of some students in accepting advice and cessation support indicates that some
students are not just hearing the information but are choosing to act upon it.
The HPV team described the first period of activity to which this report primarily relates
was intended as an opportunity to achieve ‘proof of concept’. The report provides detail
suggesting that the concept has indeed been proven. In particular, this can be interpreted
from the HPV team’s decision to implement a systematic recording process for
documenting smokefree ABC practice. The comments provided by members of the HPV
team interviewed during the course of this review also strongly support this.
This report recommends the continuation and strengthening of the delivery of smokefree
ABC practice within the HPV programme and recommends further evaluation of the
impact of the programme on the thinking and behaviour of students.
Page 3 of 23
3. Recommendations
Based on the information gathered during the course of developing this report, the
following recommendations are made:

That smokefree ABC practice continue to be formally included as part of the HPV
vaccination process

That further investigation takes place to gain a closer understanding of the
response of those students receiving vaccinations to smokefree screening, advice
and cessation support. Specifically, to determine if and what impact these have on
the thinking of the students and on their subsequent smoking behaviour

That the Ministry of Health be encouraged to consider the formal inclusion in its
HPV programme resources of information on the risks of smoking and the benefits
of being smokefree particularly as they relate to cervical cancer

That further investigation takes place to understand the factors that lie behind the
recently obtained audit results indicating high levels of screening of smokefree
status and substantially lower levels of the provision of brief advice and cessation
support

That the smokefree education provided for members of the HPV team be reviewed
to ensure it effectively addresses learning needs encompassing knowledge relating
to smoking and smoking cessation; to the procedures that will be followed in the
HPV programme; and to ensure team members achieve confidence in the practical
delivery of those requirements
Page 4 of 23
4. Background
99% of all cervical cancer is caused by genital infection with human papillomavirus (HPV).
HPVs are common viruses that are spread through skin to skin contact. Some types of
high-risk HPV can cause cell changes in the cervix which, if not detected through cervical
screening and treated, over many years can lead to cervical cancer.
Other factors
increase the risk of cervical cancer including genetics, smoking and number of sexual
partners.
The HPV Immunisation Programme is a Ministry of Health initiative which aims to protect
young women from HPV infection and the risk of developing cervical cancer later in life.
Currently, around 150 women are diagnosed with cervical cancer and 60 women die from
it each year in New Zealand. The HPV immunisation is free for girls and young women
born on or after 1 January 1990. It is available through participating schools or from family
doctors, local health centres and some Family Planning clinics.
Girls and young women represent an ‘at risk’ group in terms of initiation of smoking.
Across New Zealand, young women from 17 years of age have the highest prevalence of
smoking. 2006 Census data1 shows that over 40% of 19 year old women in the Hawke’s
Bay smoke. The data further reveal high and disproportionate representation of Māori
women smoking with Māori and Pacifica women also recording the greatest burden of
harm from tobacco related disease and with higher rates of cervical cancer2
Each District Health Board (DHB) has been responsible for developing plans to implement
the HPV Immunisation Programme and in Hawke’s Bay the DHB has established a
designated team within the Public Health Nursing unit. The team has designed and is
implementing a school-based vaccination programme which in 2009 was targeted at
college-age girls. In 2010 the programme will target intermediate-age (Year 8) girls.
During the development of the HPV team’s plans, the team was approached by the
member of the HBDHB Smokefree Team responsible for Maternal, Child and Youth
Services who highlighted smoking as a key factor that increases the risk of cervical cancer
1
2
Jones L. Census 2006 – Knowing our people – smoking trends. Unpublished Report. Hawke’s Bay District
Health Board.
The HPV (Human Papillomavirus) Vaccination Programme. National Implementation Strategic Overview.
http://www.moh.govt.nz/moh.nsf/pagesmh/7893/$File/hpv-national-implementation-strategic-overview.pdf
Page 5 of 23
and described the initiative underway throughout HBDHB for services to routinely address
smoking with all patients. The DHB’s smokefree strategy is an evidence-based approach
in which the smokefree status of every patient is identified and every patient that is not
smokefree is provided brief advice as to the benefits of being smokefree and the risks of
smoking and is provided support to access cessation support including provision of
nicotine replacement therapy and behavioural counseling. This is often referred to as
ABC practice representing: Ask - Brief advice – Cessation. The Hawke’s Bay HPV team
considered this suggestion and decided that it made sense to formally incorporate ABC
practice into the vaccination process. Accordingly, a protocol for implementing ABC was
agreed and the practice was incorporated into the vaccination process. Most vaccinators
working in the HPV team are trained Quit Card providers and were accordingly able to
issue Quit Cards to any participants where that was appropriate and according to the
requirements of the Quit Card programme3.
This report has been prepared to document the process by which ABC practice came to
be formally incorporated into the HPV vaccination programme and to gather feedback
from those involved in the programme as to the perceived appropriateness of its inclusion
and as to impressions of its success.
3
http://www.quit.org.nz/page/providers/QuitCards.php
Page 6 of 23
5. Literature Review
5.1. HPV
Human papillomavirus (HPV) is among the most common sexually transmitted infection 4
and half of all cervical cancers worldwide are attributed to HPV5.
In 2006 Wiley et al6 reported on a randomized clinical trial in which they had sought to
determine the association between tobacco smoking and HPV antibodies among women
with HPV.
Similar findings have been reported more recently by Moralejo 7. Wiley et al
found that HPV-16 infected women who reported increasingly greater levels of daily
cigarette smoking were less likely to test positive for anti-HPV16 antibodies that
nonsmoking women. In fact, they found that women that were not smokefree were twice
as likely as women that were smokefree to test negative for HPV16 antibodies even after
controlling for the effects of other covariates.
In their discussion, they suggested that among young women with HPV16 infection
smoking cigarettes may impair the development of an HPV16-specific humoral immune
response and they went on to state that the data indicated a causal relationship between
smoking and cancer that may be open to behavioural interventions.
Wiley et al stated that their findings supported the need for enhanced public health
messages that convey yet another smoking-related health risk to women. They argued
that as it may take some time to achieve population protection from HPV through
vaccination and immunity, it would also be important to test smoking cessation
interventions as to their impact on immune responses and subsequent long-term risk of
persistent oncogenic HPV infection.
Szarewski et al investigated the effect of cessation or reduction of cigarette smoking on
the course of minor-grade cervical lesions and found support for a link between smoking
and cervical disease suggesting that smoking cessation could have a beneficial effect on
4
5
6
7
Stone KM, Karem KL, Sternberg MR, et al. Seroprevalence of human papillomavirus type 16 infection in the
United States. J Infect Dis 2002; 186: 1396-402
Munoz N. Human papillomavirus and cancer: the epidemiological evidence. J Clin Virol 2000; 19: 1-5
Wiley DJ, Wiesmeier E, Masongsong E, Gylys KH, Koutsky LA, Ferris DG, Barr E, Rao JY, and The Proof of
Principle Study Investigative Group. Smokers at higher risk for undetected antibody for oncogenic human
papillomavirus type 16 infection. Cancer Epidemiol Biomarkers 15 (5) May 2006.
D Moralejo Smoking increased risk of cervical cancer, independent of infection with high-risk HPV types. Evid
Based Nurs 2009;12:122
Page 7 of 23
early cervical abnormalities8. Bishop et al similarly found that where there is a low grade
cervical abnormality, becoming smokefree can result in regression of the lesion9
5.2. Smoking Cessation
The literature is replete with evidence relating to the effectiveness of interventions
designed to assist a person to become smokefree. A seminal report was issued by the
US Surgeon General in 200010. This highlighted, among other things, the importance of
screening the smokefree status of all patients at every opportunity and providing brief
advice and cessation support to those patients that are not smokefree.
This approach also provides the basis of the New Zealand Smoking Cessation Guidelines
200711. These guidelines describe an ABC approach in which every patient is Asked
about their smokefree status, those that are not smokefree are provided with Brief advice,
and Cessation support is provided (or referred) for those wishing to access it.
Since 2004, New Zealand hospitals and other health providers have been increasingly
incorporating smokefree ABC into routine practice. ABC practice has become part of
routine best practice across many health disciplines including doctors, nurses and
midwives, and is being incorporated in other services as well. Hawke’s Bay DHB has
prepared a number of reports on the effectiveness of this strategy, including preliminary
investigation into the effectiveness of routine smokefree ABC in a school dental service 12
and an Audiology service13.
8
9
10
11
12
13
Szarewski A, Jarvis MJ, Sasieni P, Anderson M, Edwards R, Steele SJ, Guillebaud J, Cuzick J. Effect of
smoking cessation on cervical lesion size. The Lancet 1996, Volume 347, Issue 9006, Pages 941-943
Bishop A, Marteau T, Hall S, Kitchener H, Hajek P. Increasing womens intentions to stop smoking following
an abnormal cervical smear test result. Preventive Medicine 41 (2005) 179-185
Fiore MC, Bailey WC, Cohen SJ, et al Treating tobacco use and dependence. Clinical Practice Guideline.
Rockville MD: US department of Health and Human Services. Public Health Services. June 2000.
Ministry of Health. 2007 New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health
Smith DJ. ABC in a Dental Service provided at Wairoa College, 2009. Unpublished report prepared for
Hawke’s Bay DHB Totally Smokefree Project.
Smith DJ. ABC by the staff at the HBDHB Audiology Department, 2009. Unpublished report prepared for
Hawke’s Bay DHB Totally Smokefree Project.
Page 8 of 23
6. Description of the HPV vaccination programme
The Hawke’s Bay HPV vaccination programme, like other programmes throughout New
Zealand, is offered in school settings. The team book to visit schools in advance with an
initial group presentation, usually delivered in an assembly session, during which the
Ministry of Health DVD is shown and spoken to.
There is also an opportunity for
questions. Students take home the consent forms for completion prior to the vaccination
day.
The vaccination is scheduled and usually takes place three to four weeks after the initial
assembly presentation. HPV vaccinations are delivered in a 1:1 setting in which the nurse
follows the vaccination protocol which includes preliminary administrative questions and
administration of the vaccine itself.
Vaccination usually takes place in the school hall
which is set up with a waiting area and a vaccination area. The vaccination area features
individual cubicle spaces with privacy screens separating those receiving vaccinations so
as to ensure privacy of discussions as well as ensuring visual privacy from others.
Participants assemble and wait in the waiting area then enter the cubicle spaces
individually where the vaccination process takes place.
Following their vaccination,
participants are required to wait for twenty minutes in a ‘recovery’ area where they are
monitored for any adverse reactions. After this time, and providing no adverse reactions
have been observed, the participants return to class.
The Hawke’s Bay programme has been modified to incorporate ABC smokefree screening
and discussion as follows:

during the initial assembly session, information on being smokefree and the
inclusion of the smokefree (ABC) discussion within the vaccination process is
discussed including the opportunity for questions and discussion

smokefree ABC screening and discussion are completed during the 1:1 vaccination
which takes place behind the privacy screens.
Screening (A) is completed by
asking the student if she is smokefree with the subsequent discussion (B&C)
following on as per training provided including provision of Quit Card if appropriate
Delivery of the ABC smokefree intervention during the 1:1 vaccination stage was decided
after consideration by the HPV team as described in section 9.3.1 Design below
Page 9 of 23
7. Key Smokefree Messages
The inclusion of ABC practice within the HPV programme was fundamentally designed to
bring a strong smokefree message to programme participants.
The tone of the message was carefully designed to focus on the positive aspects and
benefits of being smokefree, to highlight that becoming (or remaining) smokefree is
important, possible and that support is readily available.
The intended outcome of the messages was to inform the thinking of participants and,
wherever possible, to support them in making positive changes relating to being
smokefree
The following key smokefree messages were identified with one key message related
directly to HPV and several others related to the importance of being smokefree and
support available to assist cessation efforts:
HPV-specific

The body is 50% more likely to resist the human papillomavirus if you are
smokefree
Smokefree-related

Being smokefree is the single most important thing you can do for your health

Effective support to be smokefree (including nicotine replacement therapy and
behavioural support) is readily available
Page 10 of 23
8. Education plan and resource development
8.1. Education
Arising from consultation between the HBDHB Smokefree Team responsible for Maternal,
Child and Youth Services, and the HPV Programme Coordinator, an Education Plan was
developed to ensure members of the HPV team were sufficiently informed as to the
rationale for, and the clinical protocol for delivering, ABC smokefree intervention within the
HPV vaccination process.
The plan was based on an understanding of the educational needs of the team members
and of the need to include components relating to both knowledge and practice. That is,
education which addressed both the evidence-basis for ABC intervention (including
information relating to the benefits of being smokefree and the risks of smoking, the role of
smoking as a risk factor in the development of cervical cancer, and the evidence
supporting ABC practice as an effective intervention14) as well as education to develop the
practical confidence of team members to deliver ABC practice.
Education provided for the HPV team prior to the introduction of ABC smokefree practice
included dedicated input:

a presentation by the DHB’s Smokefree Coordinator for Maternal, Child and Youth
Services designed to provide relevant background relating to smoking, and to
smokefree evidence and practice
together with generic education available to all DHB staff:

a 20 minute, focused-discussion with a member of the smokefree team to further
support understanding about smokefree practice, the Ministry of Health
Performance Targets, HBDHB commitment and goals and referral systems (refer
Appendix 3)

team members were also required to complete the Ministry of Health’s online
smokefree e-Learning module15
14
15
NZ Smoking Cessation Guidelines 2007
https://smokingcessationabc.org.nz/
Page 11 of 23
8.2. Resources
Simple resources were available to support the ABC practice including posters on the
privacy screens separating the vaccination cubicles, and bookmarks to be given to each
girl.
The concept of providing bookmarks emerged in the initial discussions with the Smokefree
Project Leader who facilitated a careful design process.
The bookmark is intended as a
‘take-home’ reminder of the smokefree conversation including simple relevant information
and was designed to “affirm the message that being smokefree is a positive action to
contribute to protection from cervical cancer”.
A careful process of consultation was
undertaken in designing the bookmark which included seeking feedback from 50
secondary school students who were given draft bookmarks. 27 of the 50 samples were
returned with comments which were generally positive and constructive with many of the
practical recommendations addressed in the final product. A copy of the bookmark is
provided in Appendix 1.
A further resource to the initiative was already available to the team by virtue of the fact
that many members of the team were already trained Quit Card providers. Accordingly,
Quit Cards were a resource available to support this initiative.
Page 12 of 23
9. Staff perceptions
Three members of the HPV team were interviewed to ascertain their views relating to the
smokefree initiative.
This included the Programme Coordinator, the wider Public Health
Nursing Team’s Practice and Quality Educator and one of the Registered Nurse Vaccinators.
9.1. Importance of ABC Smokefree Practice
Interviewees were unanimous in their view that ABC smokefree practice is an
important consideration in the provision of health services. Comments included:

important to get it (smokefree message) out there

normalise ABC into practice

develop comfort with practice

people expect you to ask

there is evidence of the effect

I believe in the model of brief intervention

posters (eg It’s Cool to be Smokefree) provide support

smokers ostracised nowadays

a good change
9.2. Legitimacy of ABC Smokefree Practice
Interviewees were even more united in their opinion that ABC practice is a legitimate
and important part of the HPV programme. Comments included:

its even more important

the body is 50% less likely to resist the virus if the person is smoking

the direct link with our issue (HPV) makes it important
The general health benefit in being smokefree was well recognised within the group
with ABC smokefree practice acknowledged as a legitimate activity for health
professionals. The linkage between being smokefree and better outcomes in relation
to HPV was a strong feature of the discussion and appeared to be a key consideration
in the team’s decision to implement ABC smokefree practice as a formal and
systematic component of the vaccination process.
Page 13 of 23
9.3. Clarity of Process Expectations
9.3.1. Design
Interviewees were clear as to the requirements of the ABC process.
This was
particularly so following the extent of involvement of the team in determining how the
ABC would be incorporated into the vaccination process.
Indeed the team was
instrumental in revising the originally proposed process in which the ABC conversation
was to occur during the 20 minute ‘recovery’ period following the administration of the
vaccination. The team determined that it would be more effective to complete the
ABC process during the 1:1 process of vaccine administration.
The rationale for this was based on the team’s experience in providing vaccinations in
school hall settings involving large groups of teenage students. The experience of the
team was that as the students assemble in the common area, and during the 20
minute post-vaccination observation period where the students are once again
assembled in the common waiting area, there is a high level of social interaction
among the students. The team characterised these conversations as often being
animated as a function of the unusual process, the involvement of needles, etc.
Indeed, the team reported that often the students would exhibit considerable bravado
in the face of the process.
This was seen as being un-conducive to the ABC
conversation and accordingly, the team agreed that the ABC conversation take place
during the period of time in which the students are taken individually into privacyprotected spaces for the vaccination. The team’s experience was that during this
time, the students were generally calm, focused and open to the ‘serious-business’ at
hand. The team felt this would be a much more effective opportunity to engage in the
brief smokefree intervention.
Comments relating to the decision to incorporate smokefree intervention with the 1:1
phase of the vaccination process included:

it’s a comfortable setting

it feels intimate

it takes the ‘sniggering’ away

it eliminates ‘group behaviour’

the girls have trust in the vaccination process
Page 14 of 23

it is a time to be professional and serious

it is a safe environment

there is a relationship between the girl and the vaccinator
9.3.2. System/Process
Interviewees reported they, and other members of the HPV team, were clear as to the
requirements of ABC smokefree practice. They felt the process was intuitively simple,
and that it aligned closely with the intent and purpose of the HPV programme in
promoting optimal health.
A simple recording process was agreed and has since been reviewed with the team
determining that a recording sticker will be affixed to each student’s notes. This has
been decided so as to simplify the process requirements of recording and of any
subsequent audit.
9.4. Education
As described above Education provided to the HPV team prior to the introduction of
ABC smokefree practice included a presentation by the DHB’s Smokefree Project
Leader for women’s health services designed to provide relevant background relating
to smoking, and to smokefree evidence and practice. Following this team members
were required to complete the Ministry of Health’s online e-Learning module16.
Interviewees reported that the education provided was entirely adequate and
appropriate. Comments included:

Smokefree coordinator’s support was great

the initial team session was a great opportunity for team input and ideas

education was definitely adequate

there was strong evidence
It was noted by those interviewed that some ‘reminder’ education would be useful
especially in the lead up to the next season of vaccinations. This was considered
useful both in terms of reminding of the ABC approach and also so as to ensure
16
https://smokingcessationabc.org.nz/
Page 15 of 23
continued clarity of process for all team members particularly in light of the proposed
revised recording requirements.
9.5. Resources
As described above, simple resources were available to support the ABC practice
including posters on the privacy screens separating the vaccination cubicles and
bookmarks to be given to each girl.
Interviewees were generally pleased that simple resources were available to support
practice. Comments included:

they are tangible

they are provided free

it’s a good design

they include good information

80% of the girls take them home

they are positive
The vaccination programme includes a Ministry of Health DVD17 which is shown to
groups of students during education sessions held between two and four weeks prior
to the vaccinations being given. Interviewees expressed concern that the information
provided in the DVD does not adequately address issues relating to the risks of
smoking and the benefits of being smokefree and felt that inclusion of this in any
revision of the DVD would support their efforts.
9.6. Roles
The team felt they were clear as to the various roles. In particular there is a high level
of clarity as to the requirements of nurse vaccinators. In addition the team leader was
clear as to her responsibility for supporting the initiative in terms of facilitating
educational opportunities for the team, enabling the team to participate in the planning
process, and in ensuring documentation and other systems were in place.
17
Cervical cancer vaccine – DVD presentation for girls and young women about the HPV Immunisation
Programme. Ministry of Health, Wellington, 2008
Page 16 of 23
10. Client Perceptions
This current review process did not provide for direct feedback from participants in the
HPV programme. Perceptions of participants, as observed by members of the HPV team,
were reported during the team interview. There was close agreement between the three
team members interviewed as to their observations of participant response and
experience.
Comments about the response and experience of the participants included:

the girls listen

the girls are receptive to the information

they are not faking it!

they often ask questions

there has been no negative or abusive reaction

the girls don’t feel alienated by the discussion

the girls seem to expect the discussion

having it incorporated in the recording form helps make ABC practice more
acceptable, the girls know is universal and not a judgment of them in particular
A further demonstration of the receptiveness of the participants to the ABC discussion is
that a substantial number of Quit Cards are being provided to participants. Details relating
to the number of Quit Cards issued are not available, however, analysis of this would be a
useful component of any subsequent review.
Page 17 of 23
11. Preliminary Audit – April 2010
11.1.
Results
A preliminary audit of ABC smokefree practice has been undertaken by the HPV
team during April 2010. This follows the introduction of the recording sticker
(refer Appendix 2) which is affixed to every student’s record and provides for a
simple, tick-box recording of smokefree status and the provision of brief advice
and cessation support.
Data from the preliminary audit are as follows:

1175 student records were reviewed

Smokefree status recorded as screened for 1007 of the 1175 (86%)

Of the 1007 students whose smokefree status had been screened, 741
were recorded as being smokefree (74%) and 266 were recorded as
not being smokefree (26%)

Of the 266 students that were not smokefree, 50 were recorded as
having received brief advice (19%) and 21 received further support
(8%)
11.2.
Comments
The percentage of students whose smokefree status was recorded is relatively
high at 86% suggesting this aspect of the process has been readily adopted by
vaccinators.
The percentage of students recorded as not smokefree is approximately the
same as that reveled in the 2006 census data which showed the prevalence of
smoking among 17 year old girls at just over 25%. It is unclear what the age
composition of the audit sample was and this would be important information to
confirm as if significantly more younger students were involved this would
indicate a higher prevalence that that shown in the Hawke’s Bay 2006 census
statistics1 (which showed smoking prevalence among 15 year old girls at 12%
and among 16 year old girls at 17%).
Page 18 of 23
The percentage of those students that were recorded as receiving brief advice
was relatively low at 19%. It is unclear from the preliminary audit what factors
lie behind this result. It could be that brief advice was not provided in many
instances and, alternatively, it could be that brief advice has indeed been
offered during the vaccination process but that this has not been consistently
recorded. Further investigation is warranted into this aspect in order to identify
how best to address the issue which could involve further training in recording or
further training in delivering brief advice. It could also be that certain features of
the vaccination process are impacting on performance and it would be important
to consider these as well.
The percentage of students that were recorded as receiving cessation support
was also relatively low at 8%. As with screening, further investigation is
warranted to determine the reasons for this. Notwithstanding the relatively low
percentage, it is noteworthy that in the sample of students that were included in
this audit, 26 received further support to become smokefree beyond the
provision of simple brief advice. It is not clear what the nature of this support
was however it is likely to have ranged from more intensive (motivational)
conversations through to the provision of NRT via a Quit Card and referral for
cessation support. That 26 young students have received this kind of advice is
excellent and demonstrates that the opportunity afforded by the HPV
vaccination process can effectively be used to reinforce and support students to
become smokefree.
As above, further investigation would be useful to better understand the nature
of the cessation support provided. It would also be valuable to undertake a
follow up investigation to determine the subsequent impact of that cessation
support.
Indeed an outcome-focused follow up would be highly valuable to determine if
the screening and brief advice has had any impact on the thinking of students
and if the cessation support provided has led to any changes in smoking
behaviour.
Page 19 of 23
12. Appendices
12.1.
APPENDIX 1 - Bookmark Resource
Page 20 of 23
12.2.
APPENDIX 2 - Recording Sticker
Page 21 of 23
12.3.
APPENDIX 3 - Session Outline – 20 minute presentation
20 Minute Introduction For Registered Health Professionals
1. Introduction
a. Introduce the training package, discuss outcomes, intro + E-Learning Tool
b. MOH National Health Targets
c. Duty of care / best practice
d. On completion of the entire training you will be able to provide NRT via the standing
order in hospital or a quit card upon discharge
2. Smokefree language
a. Non-judgemental language reduces resistance
3. NRT Products (Refer to “Quick Reference Card”)
 Long-acting - Patch
 Short-acting – Gum / lozenge / inhaler
 Inhaler is the only of these products not subsidised and ideally used as a short
acting product when patient NBM – important to explain to the patient that this will
not be subsidised on discharge.
 Contraindications
- NBM (gum or lozenge)
- Allergy to sticking plaster (patch)
 Cautions
- Pregnancy/breastfeeding
- Within 2 weeks post severe cardiovascular event/stroke
- Patients admitted into ICU (NRT use in ICU patients is an
Anaesthetist’s decision)
- Theatre – patch needs to be removed for during theatre
4. How to assess nicotine dependency (Refer to “NRT Flowchart”)
5. NRT Standing Order (Resource: HBDHB NRT Standing Order)
 Pre-requisite is E-Learning Tool
 Nicotine patch/gum/lozenge/inhaler
 Documented on medication chart
- Medication Name / Date / Dose / Frequency of administration /
Reference to NRT Standing Order / Name & signature of RN
 Must be countersigned within 24 hours
 All patients receiving NRT require Nicotine withdrawal symptoms assessed twice
daily (BD)
6. Assessing Nicotine Withdrawal (Resource: “Assessing Nicotine Withdrawal Laminated ID
Card”)
 Assessed twice daily for all patients receiving NRT
 Use scale of 0 – 5
 Increase dose or frequency of NRT when patient scores 2 or more
 Document score in Patient Flowchart under Treatment and Observations
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7. Refer for Smokefree Support (Resource: “Hospital Based Smokefree Service Pamphlet”)
 Refer to Hospital Based Smokefree Service ext 2472 for ongoing
support to become smokefree.
 Leave Name, NHI number and a brief message.
8. Where to from here
- How to access E-Learning Tool
- When completed, fax certificate through to L&D ext 2216 (required so that L&D can
update history)
9. Additional information for speciality areas
Doctors; - offer brief advice (robust research backing this)
- sign off on standing orders
- importance of discharge summary relating to smokefree status / NRT commenced (eg
drug interactions)
Maternity and Paediatrics….
Brief advice on becoming smokefree at any stage of wellness is a powerful motivator and a
necessary part of clinical practice.
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