A surgeon led smoking cessation intervention in a head and neck cancer centre

Tang et al. BMC Health Services Research (2014) 14:636 DOI 10.1186/s12913-014-0636-8 RESEARCH ARTICLE Open Access A surgeon led smoking cessation intervention in a head and neck cancer centre Ming Wei Tang1*, Richard Oakley2, Catherine Dale2, Arnie Purushotham3, Henrik Møller4 and Jennifer Elizabeth Gallagher1 Abstract Background: The government has recognised the role of healthcare professionals in smoking cessation interventions with integrated care pathways for identification and referral of at-risk patients who smoke. Referral for suspected cancers has been suggested as a ‘teachable moment’, whereby individuals are motivated and more likely to adopt risk-reducing behaviours. A head and neck cancer referral clinic could therefore provide opportunities for smoking cessation intervention. This study aims to pilot a brief smoking cessation intervention during a consultation visit for patients referred with suspected head and neck cancer and evaluate its acceptability and impact. Methods: A brief script for smoking cessation intervention which included a smoking cessation referral was designed to be delivered to patients attending a rapid access clinic. Patient outcome data was collected by the stop smoking team for patients who accepted the referral. A subset of these patients was also interviewed by telephone; these findings were combined with data provided by the stop smoking services to assess the acceptability and impact of pilot smoking cessation intervention on patients. Results: In total, 473 new patients attended the clinic during the study period, of whom 102 (22%) were smokers. Of these, 80 (78%) accepted a referral to stop smoking services. A total of 75 (74%) patients were approached subsequently in a telephone survey. Of the 80 newly referred patients, 29 (36%) quit smoking at least temporarily. Another eight patients reduced their smoking or set a quit date (10%), so the experience of attending the clinic and the intervention impacted favourably on almost half of the patients (46%). The patient survey found the intervention to be acceptable for 94% (n = 50) of patients. Qualitative analysis of patient responses revealed five elements which support the acceptability of the intervention. Conclusions: The findings of this pilot study suggest that discussion of smoking cessation with patients referred for suspected head and neck cancer may have an impact and facilitate the process towards quitting. A possible diagnosis of cancer appears to present a ‘teachable moment’ to encourage positive health behaviour change. Keywords: Smoking cessation, Stop smoking, Head and neck cancer, Oral cancer, Prevention Background Cancers in the head and neck region account for about 3% of all cancers diagnosed in England [1]. The incidence of head and neck cancer nationally and in south east London is increasing [2]. The majority of head and neck cancers are squamous cell carcinomas and the main risk factors are tobacco * Correspondence: 1 Division of Population and Patient Health, King’s College London Dental Institute at Guy’s, King’s College and St Thomas’ Hospitals, Denmark Hill Campus, London SE5 9RS, UK Full list of author information is available at the end of the article smoking, alcohol consumption, and human papilloma virus infection. In a large international study, tobacco and alcohol together explained 73% of upper aerodigestive tract (UADT) cancer burden, of which almost 29% was due to tobacco alone, less than 1% alcohol alone and 44% by the joint effect of tobacco and alcohol [3]. Smoking was an independent risk factor for head and neck cancer while alcohol consumption in the absence of smoking conferred little or no risk. The joint effect of tobacco and alcohol increased with the number of pack-years and drink-years [4]. Tobacco smoking is © 2014 Tang et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tang et al. BMC Health Services Research (2014) 14:636 the main modifiable risk factor for head and neck cancer and reducing smoking prevalence is one of three key commitments at the heart of the NHS cancer plan [5]. The government has commissioned several white papers [6-9], which provide guidance for tobacco control policy in England. These documents highlight the important role of healthcare professionals in smoking cessation. It is within their capacity to proactively discuss the issue of smoking with patients as it is linked to improved general health. Integrated care pathways must be developed and utilised for identification and referral of at-risk patients who smoke. The NHS stop smoking service plays a key role within this care pathway. Studies have shown that smokers accessing this service are four times more likely to achieve a four-week quit than those without this assistance [10]. Godfrey et al., found NHS smoking cessation services to be a cost-effective lifesaving intervention when compared to many other health-care interventions [11]. Although not ideal, there is evidence that cutting down smoking can be an important part of the process of stopping [12,13]. The importance of making every contact count for health has been emphasised in recent health policy [14]. Patients referred via the two week wait route are perceived by the GP as being at high risk of cancer and early intervention will potentially improve their outcome. With the increasing incidence of head and neck cancer, the initial thrust to pilot a disease prevention program stemmed from the South East London Tumour Working Group. The impact of a smoking cessation intervention is plausibly translatable to patients at risk of other smoking related illnesses. Events such as attending a head and neck cancer diagnosis service have been suggested to be a ‘teachable moment’ whereby individuals may become motivated to adopt risk-reducing behaviours. Several studies have shown high rates of smoking cessation amongst patients with newly diagnosed head and neck cancer [15,16]. This finding may be explained using the health belief model whereby patients perceive a susceptibility to head and neck cancer and its threat, which may be a ‘cue to action’ because the benefit of quitting smoking is evident [17]. A teachable moment in the health care setting may be exploited to encourage smoking cessation in patients with suspected head and neck cancer [18]. The initial diagnostic clinic provides such an opportunity for healthcare professionals to help modify patient behaviour by giving smoking cessation advice and directing patients towards existing smoking cessation (...truncated)