Evaluation of the smoking cessation/nicotine addiction treatment program

Transcription

1 Evaluation of the smoking cessation/nicotine addiction treatment program April 2012 Evaluation and report by Health Promotion Evaluation Unit, School of Sport Science, Exercise and Health & School of Population Health University of Western Australia The Health Promotion Evaluation Unit is an independent academic unit supported by the Western Australian Health Promotion Foundation (Healthway) With contribution from Health Networks Branch Department of Health WA 1

2 Department of Health, State of Western Australia and the University of Western Australia (2012). Copyright to this material produced by the Western Australian Department of Health and the University of Western Australia (UWA) belongs to the State of Western Australia and UWA, under the provisions of the Copyright Act 1968 (C wth Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the Health Networks Branch, Western Australian Department of Health. The Department of Health is under no obligation to grant this permission. Please acknowledge the WA Department of Health and the UWA when reproducing or quoting material from this source. Suggested citation Department of Health, Western Australia and the University of Western Australia. Evaluation of the smoking cessation/nicotine addiction treatment program. Perth: Health Networks Branch, Department of Health, Western Australia; Important Disclaimer: All information and content in this Material is provided in good faith by the WA Department of Health and UWA, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the WA Department of Health and UWA and their respective officers, employees and agents, do not accept legal liability or responsibility for the Material, or any consequences arising from its use. 2

3 Table of contents Executive Summary...6 Introduction...9 Background...9 Program processes...10 Testimonials...12 Methods...14 Data analysis...14 Results Part 1: Combined program results...15 End of NATP smoking status for RKDGP and GEGPN...15 Number of NATP contacts until first quitting smoking...16 Results Part 2: RKDGP Living Well Without Smoking Program...17 Characteristics of clients referred to the RKDGP NATP Smoking status and referral to the RKDGP NATP Source of RKDGP NATP client referral Referrals and participants to the RKDGP NATP program Client engagement with the RKDGP NATP...20 Number of RKDGP NATP contacts Average contact with RKDGP NATP and last recorded client status Number of quit attempts Average quit attempts by Fagerstrom score Impact of RKDGP NATP on Smoking status...22 Change in smoking status Program effectiveness and smoking status Change in smoking status by referral pathway Change in smoking status by initial Fagerstrom classification Type of quit method offered to clients and change in smoking status Change in smoking status by month of RKDGP NATP Results Part 3: GEGPN Butt Out Program...26 Characteristics of client referred to the GEGPN NATP Source of GEGPN NATP client referral Referrals and participants to the GEGPN NATP program Client engagement with the GEGPN NATP...28 Number of GEGPN NATP contacts Average contact with GEGPN NATP and last recorded client status Impact of GEGPN NATP on Smoking status...30 Change in smoking status Program effectiveness and smoking status Change in smoking status by referral pathway Change in smoking status and length of program engagement

4 Conclusions...33 Recommendations...35 Acronyms...36 Appendices...37 Appendix 1: Living Well Without Smoking additional results...37 Client engagement with the RKDGP NATP Impact of RKDGP NATP on Smoking status Appendix 2: GEGPN Butt Out Program additional results...43 Client engagement with the GEGPN NATP Impact of GEGPN NATP on Smoking status List of Tables Table 1: RKDGP NATP client characteristics Table 2: GEGPN NATP client characteristics List of Figures Figure 1: NATP patient smoking status at the end of the program for RKDGP and GEGPN...15 Figure 2: Number of program contacts until first quitting smoking for RKDGP and GEGPN participants who quit smoking...16 *Note: 132 cases has missing smoking status data...18 Figure 3: Smoke status and engagement with the RKDGP NATP...18 Figure 4: Client pathway to the RKDGP NATP program...18 Figure 5: Client referral pathway and engagement with the RKDGP NATP program 19 Figure 6: Number of client engagements with RKDGP NATP...20 Note: the number of contacts was missing for 12 participants...20 Figure 7: Average number of participant contacts with the RKDGP NATP...20 Figure 8: Client quit attempts within the RKDGP NATP...21 Figure 9: Average quit attempts by Fagerstrom score...21 Figure 10: Change in smoking status amongst program participants...22 Figure 11: Change in smoking status and RKDGP NATP engagement...23 Figure 12: Change in smoking status and referral pathway...23 Figure 13: Change in smoking status and Fagerstrom score...24 Figure 14: Change in smoking status and type of quit method offered...25 Figure 15: Number of referrals, clients and clients who quit smoking by month

5 Figure 16: Client pathway to the GEGPN NATP program...27 Figure 17: Client referral pathway and engagement with the GEGPN NATP program...28 Figure 18: Number of client engagements with GEGPN NATP...29 Figure 19: Average number of participant contacts with the GEGPN NATP...29 Figure 20: Change in smoking status amongst program participants and their contacts with the GEGPN NATP program...30 Figure 21: Change in smoking status and GEGPN NATP engagement...31 Figure 22: Change in smoking status and referral pathway GEGPN NATP...31 Figure 23: Change in smoking status and number of program contacts...32 Figure 24: Client engagement by gender...37 Figure 25: Average age of clients engaged in the RKDGP NATP...38 Figure 26: Client smoking status by gender...38 Figure 27: Monthly recruitment and participation of the RKDGP NATP...39 Figure 28: Client RKDGP NATP program status...40 Figure 29: Average client quit attempts by referral pathway...40 Figure 30: Quit attempts by client status...41 Figure 31: Number of quit methods and program engagement...41 Figure 32: Type of quit method offered to clients...42 Figure 33: Change in smoking status and number of quit attempts...42 Figure 34: Change in smoking status and number of quit methods...43 Figure 35: Client engagement by gender...43 Figure 36: Length of program engagement...44 Figure 37: Client GEGPN NATP program status...44 Figure 38: Number of quit methods used by GEGPN NATP participants...45 Figure 39: Average client quit methods by referral pathway...45 Figure 40: Type of quit method offered to clients...46 Figure 41: Change in smoking status and number of quit methods

6 Acknowledgements The following members of the Nicotine Addiction Treatment Project Steering Committee are acknowledged for their contribution to the preparation of this evaluation report. Ms Ann Barblett Ms Nicole Georgiou Clinical Associate Professor Peter Kendall Associate Professor Michael Rosenberg Mr Helen Robinson Mr Kevin Shanks Mr Vishal Sharma Professor Stephen Stick Manager of Health Promotion, South Metropolitan Public Health Unit, South Metropolitan Area Health Service Development Officer, Health Networks Branch, Department of Health WA Clinical Lead, Respiratory Health Network, Head of Respiratory Medicine, Fremantle Hospital and Health Service Health Promotion Evaluation Unit, University of WA Chief Executive Officer, Goldfields Esperance GP Network Deputy Chief Executive Officer, Rockingham Kwinana Division of General Practice Program Coordinator, BUTT OUTT Nicotine Cessation Program and Project Officer Aboriginal Health, Goldfields Esperance GP Network School of Paediatrics and Child Health, University of Western Australia Head of Department, Respiratory Medicine, Princess Margaret Hospital for Children NHMRC Practitioner Fellow Co-Lead Respiratory Health Network 6

7 Executive Summary Nicotine Addiction Treatment Program (NATP) The Rockingham Kwinana Division of General Practice (RKDGP) and the Goldfields Esperance GP Network (GEGPN) were funded to provide the NATP from May 2008 until late December 2010, through the Australian Better Health Initiative (ABHI), via the Western Australian Respiratory Health Network. The NATP is a 12 week, one-on-one comprehensive smoking cessation/ nicotine addiction treatment program where clients are offered either face to face or phone support fortnightly of up to 5 hours Week 1 - an initial assessment on readiness to quit, cessation product information and the collection of baseline data Week 7 - a full healthy lifestyle assessment Week 12 - an hour of relapse information and formally graduated from the program 3 and 6 months post program - follow ups provided to participants Summary of participant characteristics and programs outcomes RKDGP Living Well Without Smoking Program GEGPN Butt Out Program 595 people referred into the program 680 people referred into the program 426 people participated in program (72% of those referred) 269 people participated in program (40% of those referred) 85% of participants were daily smokers 99% of participants were daily smokers Average age (SD) of participants = 46.9 yrs (14.7) Average age (SD) of participants = 42.4 yrs (12) Most common source of referral = 78% GP Most common source of referral = 65% promotions and pit stop activities 74% participation rate from GP referrals 62% participation rate from GP referrals Average number of contacts (SD) clients had with the program = 3.6 (1.4) Varenicline was the most common quit method offered to participants (54% of clients), followed by NRT (48% of clients) 61% of participants reported quitting smoking during the program The highest proportion of clients who quit smoking were referred from the hospital (75%)* Amongst participants who quit smoking: over a half quit for the first time by the 2nd contact over three quarters by the 3rd contact * number of referrals from the hospital were relatively low Average number of contacts (SD) clients had with the program = 7.7 (4.5) Varenicline was the most common quit method offered to participants (80% of clients), followed by NRT (28% of clients) 49% of participants reported quitting smoking during the program The highest proportion of clients who quit smoking were referred from the GP (66%) Amongst participants who quit smoking: more people quit for the first time after their 2nd engagement with the program, with 54% quitting for the first time after 4 contacts Points of interest for the RKDGP NATP Amongst the 25% of participants who remained a smoker at the end of the program, one quarter reduced the amount of cigarettes they regularly smoked. The highest quit smoking rates were amongst those who declined to continue with the program at some point and those who were lost to follow-up. The highest proportion of 7

8 clients who remained a smoker was those who completed the program. This suggests that people opted out of the program once they had quit smoking and remained in the program if they were continuing to attempt to quit. The number of quit attempts was not directly correlated with success in quitting smoking and participants who attempted most times remained smokers. People who quit smoking had a higher Fagerstrom score than those who remained a smoker. Points of interest for the GEGPN NATP Of those referred into the program, less than 2% of people declined to participate. All general practices within the RKDGP catchment area referred clients to the program. When length of program engagement was factored, quit rates were 78% amongst participants with between 6 and 8 program contacts. Quit rates were high for participants who completed the program, with an increasing proportion reducing, rather than quitting smoking at 3 and 6 month follow-up. Conclusions Overall, both programs appeared to achieve their goal of providing a series of opportunities for clients to have a tailored quit smoking program with multiple instances where quit attempts could be made. A collaborative, community approach through key partnerships improved the reach of the program. The RKDGP NATP program achieved a high level of quit attempts amongst participants that resulted in high levels of clients ceasing to smoke cigarettes, or decrease the amount they smoked. THE GEGPN NATP achieved a very high level of quit or reduce smoking outcomes for participants who remained engaged in the program. Recommendations 1. Patient files from the NATP are made available for further examination and analysis. 2. The results of the NATP evaluation are widely promoted to relevant audiences. 3. The following characteristics are recommended for future programs: Ensure all parties involved clearly understand the program objectives have the same expectations for program outcomes Allocate adequate funding and resources to program evaluation (including the development of data collection systems) Allow local variation to ensure program relevance and track variation. Focus promotion of the program on those who may be more willing to participate or are in high risk groups Employ program staff with a clinical background Provide clients with a record of their program progress Adopt a holistic, collaborative approach engaging all relevant agencies and services to maximise referral pathways Medicare Locals should be encouraged to incorporate nicotine addiction services and build on the outcomes of the NATP 4. Develop a statewide skill set for tobacco cessation workers outlining core competencies. 5. Develop educational materials, such as training modules, to ensure primary health care professionals can achieve the competencies outlined by the skill set referred to in Recommendation 4. 8

9 Introduction Through the Australian Better Health Initiative (ABHI), via the Western Australian Respiratory Health Network, the Rockingham Kwinana Division of General Practice (RKDGP) and the Goldfields Esperance GP Network (GEGPN) were funded from May 2008 until late December 2010 to provide a comprehensive smoking cessation/ nicotine addiction treatment program (NATP). The NATP aimed to develop a clinical pathway for nicotine addiction across the continuum of primary, secondary and tertiary prevention. The main focus of the service was to work with the patient to understand their addiction; support the management of nicotine withdrawal and promote motivational behavioural change. The rationale for the program was that the current options for the treatment of nicotine addiction are limited to ad-hoc delivery of: Brief intervention counselling Referral to Quitline Referral to Fresh Start Community Groups (where available); and Nicotine Replacement Therapy via community pharmacy and GP Background Tobacco smoking contributes to the development of all major chronic diseases. The causes of most conditions are multi-factorial, with tobacco being one of the biggest modifiable risk factors in Western Australia, second only to high body mass. Specifically, tobacco was responsible for 6.5% of the total burden of disease and injury in Western Australia in For those who do smoke, the fact remains that smoking will cause the death of 1 in 2 smokers 2 and causes more mortality than high body mass. In 2006, tobacco smoking was estimated to have caused around 1300 deaths in Western Australia and is responsible for 82% of all drug-caused deaths 3. According to the WA Health and Wellbeing Surveillance System, in 2010, 11.5% of Western Australians aged 16 years and above are daily smokers 4. This falls below the Australian average smoking prevalence of 15.1% for persons aged 14 years and over 5. For Western Australian males, daily smoking increased from 15.1% in 2007 to 17.9% in 2010 whilst there was a decrease for females from 14.5% to 11.7% 4,6. People who smoked across Australia in 2010 were more likely to be of low socioeconomic status (24.6%) compared to those of high status (12.5%) 5. 1 Hoad V, Somerford P, Katzenellenbogen J. The burden of disease and injury attributed to preventable risks to health in Western Australia 2006: Department of Health Western Australia; Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in Relation to Smoking: 40 Years' Observations on Male British Doctors. BMJ 1994;309(6959): English D, Holman C, Milne E, et al. The quantification of drug caused morbidity and mortality in Australia. Canberra: Commonwealth Department of Human Services and Health; Davis P, Joyce S. Health and wellbeing of adults in Western Australia 2010: Overview and trends. Perth: Department of Health, Western Australia; Australian Institute of Health and Welfare National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW. 6 Kalic R, Gunnell AS, Griffiths P, McGregor C. National Drug Strategy Survey 2007: Summary Tables WA Households, DAO Surveillance Report Number 01. Perth, Western Australia: Drug and Alcohol Office;

10 In 2010, 37.6% of the adult Aboriginal and Torres Strait Islander (ATSI) population in Australia were current smokers, 7 making smoking 2.2 times as likely when compared to the non-atsi population. Smoking is not a personal lifestyle choice and to view it as such ignores: the superficial nature of smokers understanding of health risks the reality of addiction the fact that the majority of users start and become dependent on nicotine delivered via smoking before they are adults 8. Not withstanding the ability of some individuals who quit without support (self quitters), in recent times there has been a significant shift to focus on nicotine addiction as a medical condition that requires treatment of both the psychosocial and physiological symptoms. This is in part due to the developments in and the role of pharmacotherapies. Despite the addictive nature of smoking and the availability of a range of evidence based methods and products, there are still improvements to be made in WA including: Building the capacity of health professionals to better identify, assess and manage patients with nicotine addiction Enhancing and modifying systems to optimise patient recall, case identification and performance monitoring Developing referral pathways to access treatment and support services The recognition of smoking as an addiction is the fundamental principle of the NATP. The locations chosen to implement the programs were Rockingham/Kwinana and Kalgoorlie/Esperance. Both these locations have well established Divisions of General Practice and Area Health Services with Population/Public Health Units who have demonstrated commitment to reducing the prevalence of smoking in the community. Furthermore, these areas have a significant Aboriginal and low socio-economic population. The WA Health & Wellbeing Surveillance System states that the reported smoking prevalence for persons aged 16 and over for current smokers in the South Metropolitan Area Health Service was males 17.2% and females 15.4% which is slightly higher overall than the North Metropolitan Area Health Service population. The WA Health & Wellbeing Surveillance System states that the smoking prevalence for persons aged 16 and over in the Goldfields South East region for current smokers was males 28.3% and females 21.3%. This region ranks 4 th highest for prevalence of current smokers of the seven WA Country Health Service regions. In the Goldfields region, clinics were conducted in Kalgoorlie-Boulder, Esperance, Norseman, Kambalda and Wiluna. Program processes The NATP is a comprehensive smoking cessation/ nicotine addiction treatment program. It comprises a twelve week, one-on-one, program developed based on current best practice in treatment and management for nicotine addiction. Clients were offered either face to face or phone support fortnightly of up to 5 hours over a 12 week period. This also included an initial assessment on readiness to quit, cessation product information and the collection of baseline data. At week 7 they were invited to have a full healthy lifestyle assessment which gives tips and information around exercise, nutrition and healthy 7 Australian Institute of Health and Welfare National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW. 8 Ministerial Council on Drug Strategy. National Tobacco Strategy Canberra: Commonwealth of Australia;

11 lifestyle goal setting. This service was offered so clients concerned with weight gain, as a result of smoking cessation, achieve an incentive to continue in the program. It was also seen as an opportunity to evaluate the clients risk of chronic disease and provide referral into appropriate services. At week 12 the client was given an hour session of relapse information and formally graduated from the program. Follow ups were provided to participants who remained engaged with the program by phone at both 3 and 6 months. Techniques used by program staff to assist participants in achieving smoking cessation include monitoring carbon monoxide (CO) levels using a smokerlyzer, education and model display use and the Shifman withdrawal questionnaire. A collaborative approach was adopted throughout the NATP. At the onset of the NATP, a Steering Committee was convened with representation from the Department of Health Respiratory Health Network, WAGP Network and the Divisions of General Practice and Area Health Service representatives. The WAGP Network accommodated and supported the Project Manager in the development phase of the project. This arrangement promoted integration across and between primary care and the State health system. The role of the South Metropolitan Public Health Unit (SMPHU) in the NATP helped to establish smoking cessation support services streamlined to meet the needs of specific target populations e.g. Aboriginal people. Through the Kwinana Rockingham Aboriginal and Torres Strait Smoking Cessation Project, numerous government and non-government organisations were consulted (e.g. Heart Foundation WA, Cancer Council WA, Aboriginal Health Council of WA, Asthma Foundation WA, Community Health, Medina Aboriginal Cultural Centre, Red Cross, South Coastal Women s Health Services, South Metropolitan Community Drug Services, Canning Division of General Practice) and culturally appropriate smoking cessation resources were developed. The consultation involved face to face interviews and focus groups with service providers and also a survey of the Aboriginal community. The results indicated that only half of participating service providers obtained smoking status and few provided smoking cessation advice. Service providers supported the need for a pictorial brief motivational tool which the SMPHU later developed. Recommendations from the project include: Provide smoking cessation training to support service providers focusing on broader spiritual, physical and social issues which impact upon Aboriginal health. Promote Quitline and the new Rockingham Kwinana Division of General Practice Aboriginal service to the Aboriginal community in Rockingham and Kwinana Implement additional educational and environmental strategies to support Aboriginal people to quit smoking (e.g. introduce smoke free policies). Formal linkages between the tertiary and primary care settings were created through the Rockingham General Hospital (RGH) Tobacco Management and Discharge Planning Project. This partnership with public health was a beneficial aspect of the NATP. Taking a bottom-up approach with a focus on community capacity building was another aspect of the program process which led to positive outcomes. The RKDGP promoted the NATP through local pharmacies, in newspapers, community events, conferences, forums, dental surgeries, fitness and healthy lifestyle organisations and various other agencies including a father s day Bunnings promotion. Educating the community of the smoking cessation support available ensures those who are thinking about making a quit attempt are informed of their options. The RKDGP were also successful in securing group smoking cessation sessions with local mental health and industry sectors, with these relationships continuing to grow throughout the program. 11

12 Testimonials Doctor case study 1 Dr A was interviewed in order to find out why she refers into the program. Dr A deals with mainstream clients and also clients who are pregnant. Dr A states that the accessing the program is convenient for local clients and Doctors to refer into the program. Clients have always spoken highly of the program with regards to treatment measures. The feedback that they get suggests the program is an integral part of the patients care plan. Dr A prefers the treatment and behavioural measures that the program uses along with taking into account a patient s health issues and whatever existing treatment they may be on. Dr A has recommended and promoted the program among various individuals and GP s in the locality and continues to refer into the program. Patient case study 1 Patient B joined the Butt Outt Nicotine Addiction Treatment program following referral from her GP, she was a pack a day smoker. The referral was initiated when B approached her GP with regards to help with quitting smoking. The patient was pregnant at the time so special consideration was given with regards to the treatment plan that she would be put on. In the first consultation the patient was assessed for her dependency which came out on a high range with a reading of 46 parts per million (ppm) on the Carbon Monoxide (CO) Monitor. The patient was put on Nicotine Replacement Therapy (NRT) with 21mg patches and lozenges in the first week and twice weekly consultations were organised for 4 weeks. The ppm reading on the second session dropped down to 23 which indicated a mid range addiction and the patient was smoking 10 cigarettes a day. The patient was asked to put on another 21mg patch to increase her nicotine intake. The patient stopped smoking completely by week two session one however, due to having a partner who smoked, behavioural issues were to be addressed. The patient was not having any withdrawals or side effects but having recovery symptoms such as vivid dreams. Patient B s partner, Patient C, self referred into the program to give up smoking on week two session two and he was put on NRT. Sessions were held biweekly during weeks three and four. Patient C stopped smoking week four session one and Patient B was asked to remove a patch and discontinue lozenges in the same session. In week four session two, Patient B was comfortable with a single patch and had no withdrawals. 12

13 Patient case study 2 Patient Y was referred to Living Well Without Smoking Program by his Occupational Health Nurse. He had tried many forms of smoking cessation pharmacotherapies, including Zyban, patches and gum, with no long lasting effect. His motivation to quit was mainly because his wife was keen for him to give up. His work pattern only enabled him to attend appointments at the After Hours GP clinic. We talked about getting a script for Champix and provided counselling with regards to effects and confidence to give up for himself. He was reviewed 2 weeks later and, as he had no regular GP, had been unable to get a script for the Champix. Subsequently he was booked into the After Hours GP clinic and given his first script by a GP there. He commenced the Champix having no adverse effects apart from some vivid dreams which was disturbing his sleep pattern. At our 4th consult he had stopped smoking for 3 days and was very confident to stay stopped. His initial Carbon Monoxide (CO) reading was 29 parts per million (ppm) and reduced to 2 ppm. He saw the GP at the clinic again that night for a second Champix script. At the 5 th session, Patient Y remained smoke free, his sleep pattern was getting better and he gave positive feedback. His health assessment was completed at the clinic and he had gained 1kg which was not an issue to him and only took his BMI up to He exercises regularly in work as he has to walk long distances every day but also enjoys long distance bike riding. He was impressed with the program and had asked for leaflets to give to a colleague. He is keen to be reviewed at later stages and feels very confident to stay quit. It was explained to him that he may be able to extend the course of Champix for another 2 months if he felt he needed the support and we will review this in the future. Patient case study 3 Patient Z joined the Living Well Without Smoking Program following referral from his GP. The referral was initiated when Z approached his GP in regard to help with quitting smoking. He was motivated to try and quit and was also addressing issues relating to alcohol consumption and use of marijuana. On his initial consultation he had a full explanation in regard to receptors and the use of products in assisting him to quit and made a further appointment with his GP to get a script for Champix. He received ongoing support and counselling on a 2 weekly basis and after 3 weeks of taking Champix he added in Nicobate Minis to assist him in quitting. This enabled him to stop smoking completely and he then very quickly was able to discontinue the Minis and just remained on the Champix. His CO reading reduced from 28ppm to 2ppm and provided him with encouragement as he was able to see the progress he was making. At his final consultation (16 weeks following commencement) he was smoke free and also controlling the alcohol consumption despite having encountered some recent stress and anxiety in his life. He spoke highly of the program believing that the support and education in combination with the medication had enabled him to quit as he had tried several times before but never managed to quit. He has since recommended the program to a friend who is thinking about quitting. 13

14 Methods Data were recorded by NATP program staff for each client throughout their engagement with the program. Even though referrals were received from a variety of sources including self referral engagement with general practice particularly GPs was seen as a critical component of the program particularly those patients who identified as heavy smokers of habitual smokers. These patients often have only considered quitting due to GP involvement and or been advised of a serious health issue relating to their continued smoking. Upon initial consultation clients were provided a one hour assessment either through visits to the Division, or as part of a Fresh Start course. On first referral, client demographic information was recorded, as well as their smoking status and Fagerstrom score. Information on their referral pathway was also collected as part of the referral process. At each subsequent contact with the program information on smoking status and treatment method were recorded. Clients who declined to engage with the program, continue participation in the program, or were unable to be contacted as part of the program were recorded as part of the database. The client data were recorded and transcribed into databases maintained by the RKDGP and GEGPN. This report is based upon the extracted data between May 2009 and January 2011 for RKDGP and extracted data between June 2009 and July 2011 for GEGPN. Data analysis Client information was analysed across individual engagement with the program. The NATP program engagement differed for each participant and therefore one client may have many data points relating to their interaction with the program, whereas another client may only have one or two contact points. For each contact, the recorded status of client engagement and their self-reported smoking status was used to determine their exposure to the program. An overall intention to treat model was used to assess the impact of the program amongst clients engaged at all levels. 14

15 Results Part 1: Combined program results End of NATP smoking status for RKDGP and GEGPN Figure 1 shows the proportion or participants who quit smoking as a result of the NATP program for RKDGP and GEGPN, as well as the proportion of participants who continued to smoke. RKDGP participants may have entered the program as a non smoker and remained as such (9%), while 5% of participants started smoking again during the program. Amongst GEGPN participants, 14% indicating reducing the amount of cigarettes they smoked Figure 1: NATP patient smoking status at the end of the program for RKDGP and GEGPN 15

16 Number of NATP contacts until first quitting smoking Figure 2 shows that enroling in the RKDGP NATP program was motivation enough for 11% of smokers to quit for the first time. Amongst participants who quit smoking at some point during the RKDGP NATP, over a half quit for the first time by the 2nd contact and over three quarters by the 3rd contact. The data masks the number of times participants may have cycled from being a smoker to non smoker throughout the program, with 61% of participants quitting during the program. In contrast, participants of the GEGPN NATP who quit smoking during the program more frequently quit for the first time after their second engagement with the program, with slightly more than half quitting for the first time after 4 program contacts. % Enrolment First Second Third Fourth Fifth Sixth Number of NATP contacts RKDGP GEGPN Figure 2: Number of program contacts until first quitting smoking for RKDGP and GEGPN participants who quit smoking 16

17 Results Part 2: RKDGP Living Well Without Smoking Program Characteristics of clients referred to the RKDGP NATP A total of 595 people were referred to the RKDGP NATP program, with 72% (n=426) of these clients participating in the program. A further 27% (n=161) of clients who were referred, declined to participate in the program and 1% (n=8) were not contactable following their referral to the program. Table 1 shows the characteristics of participants, clients who declined to participate and those who could not be contacted following referral to the program. Table 1: RKDGP NATP client characteristics Participants Declined (n=426) (n=161) No contact (n=8) Age (Mean ± SD 46.9 ± ± ± 10.0 range) (17 86) (15 67) (26-54) Gender Male Female Smoking Status Daily smoker Occasional smoker Non smoker Fagerstrom Low/Moderate Moderate/High

18 Smoking status and referral to the RKDGP NATP Figure 3 shows the proportion of daily, occasional and non-smokers amongst participants, people who declined participation and people who could not be contacted. Overall, 84% of people engaged in the program were daily cigarette smokers. *Note: 132 cases has missing smoking status data Figure 3: Smoke status and engagement with the RKDGP NATP Source of RKDGP NATP client referral The large majority of clients referred to the RKDGP NATP originated from general practitioners (78%). A range of other pathways (quit line, self-referral or advertisement) represented 10% of referrals, with community health practitioners and hospital referral pathways contributing 6% and 7% of clients respectively. Figure 4: Client pathway to the RKDGP NATP program 18

19 Points to consider The results in Figure 4 highlight the importance of the role of primary care practitioners in identifying patients who smoke and offering them support to quit. All general practices within the Rockingham Kwinana Division of General Practice catchment area referred clients in to the program. There were even a few practices outside of the area who also referred clients in. The lower number of referrals from the tertiary setting may be indicative of the delay in the commencement of the Rockingham General Hospital (RGH) Tobacco Management and Discharge Planning Project. Referrals and participants to the RKDGP NATP program Amongst clients referred to the RKDGP NATP program through their general practitioner (77%), almost three quarters (74%) participated in the program. A slightly lower proportion (70%) of clients referred through community health practitioners chose to participate in the program. The large majority of clients (79%) referred through other sources participated in the RKDGP NATP. Figure 5 shows that approximately one third (32%) of clients referred from the hospital system agreed to participate in the RKDGP NATP program. Figure 5: Client referral pathway and engagement with the RKDGP NATP program 19

20 Client engagement with the RKDGP NATP Number of RKDGP NATP contacts A total of 426 clients had an average (SD) of 3.6 (1.4) contacts with the program. Figure 6, shows the proportion of participants who had multiple contacts with the RKDGP NATP. All participants had at least two contacts with the program. Figure 6: Number of client engagements with RKDGP NATP Average contact with RKDGP NATP and last recorded client status Figure 7 shows the average number of client contacts and last recorded client status. It shows that clients who had completed the program had on average 4.4 contacts, participants who had lost contact with the program did so after 2.8 contacts with the program and participants who chose to drop-out had on average 3.5 contacts with the program. Note: the number of contacts was missing for 12 participants Figure 7: Average number of participant contacts with the RKDGP NATP 20

21 Number of quit attempts Amongst RKDGP NATP participants, almost one half recorded one quit attempt, with almost one quarter (24%) reporting two quit attempts. Thirteen percent of participants reported no quit attempts as part of the RKDGP NATP program. Figure 8: Client quit attempts within the RKDGP NATP Points to consider The number of quit attempts was not directly correlated with success in quitting smoking and participants who attempted most times remained smokers. Average quit attempts by Fagerstrom score The average number of quit attempts was higher amongst participants with a higher Fagerstrom score (Mean = 1.8 quit attempts), compared with participants with a low/moderate Fagerstrom score (mean = 1.3 quit attempts) within the RKDGP NATP program (Figure 9). Figure 9: Average quit attempts by Fagerstrom score 21

22 Impact of RKDGP NATP on Smoking status Change in smoking status Overall, 61% of participants reported quitting smoking during the RKDGP NATP program. One quarter of participants continued to smoke during the RKDGP NATP program. Nine percent of clients remained a non smoker throughout the program, with 5% starting to smoke during the program. Amongst clients who continued to smoke throughout the program, 25% (n=26) reporting becoming an occasional smoker from being a daily smoker (Figure 10). Figure 10: Change in smoking status amongst program participants Program effectiveness and smoking status Three quarters of clients who declined to complete the RKDGP NATP reporting quitting smoking on their previous program engagement (Figure 11). A similar proportion of clients who lost contact with the program reported their quit smoking status. A significantly smaller proportion of clients who completed the program reported they had quit smoking at the time. Over one half of clients who completed the program, remained smoking, with 25% of this group reducing their smoking from daily to occasional. Approximately one in five (21%) clients, who lost contact with the program, reported they had started smoking again. 22

23 Figure 11: Change in smoking status and RKDGP NATP engagement Points to consider The highest quit smoking rates were amongst those who declined to continue with the program at some point and those who were lost to follow-up. The highest proportion of clients who remained a smoker was those who completed the program. This suggests that people opted out of the program once they had quit smoking and remained in the program if they were continuing to attempt to quit. Change in smoking status by referral pathway Figure 12 shows the proportion of clients from different referral pathways and their change in smoking status throughout the program. The highest proportion of clients who quit smoking were referred from the hospital, with the proportion of clients referred from community health practitioner from the hospital setting who quit smoking was the lowest. Figure 12: Change in smoking status and referral pathway 23

24 Points to consider The highest proportion of clients who quit smoking were referred from hospital, indicating a need to improve rates of referral to community smoking cessation support programs for patients at discharge to take advantage of this target group. The results may also be indicative of the fact that those who have recently been admitted to hospital are likely to have experienced an acute or severe health scare, providing motivation to quit. Although it should be noted that the number of referrals from the hospital were relatively low. Change in smoking status by initial Fagerstrom classification As evidenced in Figure 13, the proportion of clients who quit smoking was highest amongst those with a moderate/high Fagerstrom at baseline. Figure 13: Change in smoking status and Fagerstrom score Type of quit method offered to clients and change in smoking status Figure 14, shows the proportion of clients offered different methods during the RKDGP NATP and their change in smoking status. Amongst clients who quit smoking, over one half (54%) were offered NRT whilst almost one half (46%) were offered Varenicline. Amongst clients attending Fresh Start, 31% quit smoking, with 10% of clients who quit smoking being offered acupuncture. Amongst clients who remained a non-smoker throughout the RKDGP NATP, 62% were offered Varenicline as a treatment method, with 39% offered NRT. The large majority of clients who continued smoking during the RKDGP NATP program, were offered Varenicline, with 55% also offered NRT and 46% the Fresh Start program. Amongst clients who started smoking again during the RKDGP NATP program, 39% were offered NRT treatment. 24

25 Figure 14: Change in smoking status and type of quit method offered Change in smoking status by month of RKDGP NATP Figure 15 shows the number of referrals, participants and clients who quit smoking for each month of the RKDGP NATP between May 2009 and December It shows a similar number of clients who participated in the RKDGP NATP quitting smoking across the span of the program. Figure 15: Number of referrals, clients and clients who quit smoking by month Points to consider The decline towards the end of 2010 can be explained by a lack of promotion and limited acceptance of new clients into the program due to the uncertainty of future program funding at that time. 25

26 Results Part 3: GEGPN Butt Out Program Characteristics of client referred to the GEGPN NATP A total of 680 people were referred to the GEGPN NATP program, with 40% (n=269) of these clients participating in the program. A further 2% (n=12) of clients who were referred, declined to participate in the program, with 59% (n=399) not contactable, or on hold following their referral to the program. 59% (n=399) were referred through promotions and pit stop activities. No data is available on places of residents for the 321 Mining Expo participants). Table 2 shows the characteristics of participants, people who declined to participate and those who could not be contacted or were on hold following referral to the program (where data was available). Table 2: GEGPN NATP client characteristics Participants Declined (n=269) (n=12) No contact/ on hold (n=399) Total (680) Age (Mean ± SD Range) 42.4 ± 12.0 (17-75) Gender Male Female Unknown Smoking Status Daily smoker 99 Occasional smoker 0 Non smoker 0 Unknown 1 Points to consider Of those referred into the program, less than 2% of people declined to participate. 321 people of those in the unknown referral category were identified during the biannual mining expo which attracts approximately 5000 overseas and interstate attendees. Therefore the majority of those identified during this promotion were not able to enter the Butt Out program. 26

27 Source of GEGPN NATP client referral The large majority of clients referred to the GEGPN NATP were of unknown (promotions and pit stop activities) origin (65%). Patients referred through general practice represented 29% of referrals, with a small proportion referred through community health practitioner, self-referred or referred through other sources (Figure 16). Explanatory note: The unknown referral category refers to those who signed up to the program during promotions and pit stop activities. Figure 16: Client pathway to the GEGPN NATP program 27

28 Referrals and participants to the GEGPN NATP program Amongst clients referred to the GEGPN NATP program through their general practitioner, 62% participated in the program. A lower proportion (27%) of clients referred through unknown sources (promotions and pit stop activities) chose to participate in the program. The large majority of clients (73%) referred through unknown sources (promotions and pit stop activities) were on hold, or had no contact to begin participation in the GEGPN NATP. Figure 17: Client referral pathway and engagement with the GEGPN NATP program Points to consider The results in Figure 17 are consistent with evidence that suggests advice from a health professional can influence people s decision to give up 9,10 which may explain why a large proportion of those who were referred by general practice decided to participate in the program. From the 21 practices within the GEGPN region, 16 are within the catchment of this program. 11 of these practices referred clients into the Butt Out program. Client engagement with the GEGPN NATP Number of GEGPN NATP contacts A total of 269 clients had on average (SD) 7.7 (4.5) contacts with the program. Figure 18, shows the proportion of participants who had multiple contacts with the GEGPN NATP. One fifth of respondents had one contact with the program, while 60% had 11 recorded contacts with the program. 9 Chapman S. The role of doctors in promoting smoking cessation. BMJ 1993;307: Stead L, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2008(2). 28

29 Explanatory note: No contact/on hold refers to clients referred into the program but not yet participating. This can be for a range of reasons e.g. transient nature of the region (left region, unable to locate/contact, predominate fly in fly out mining industry, holidays, etc) Figure 18: Number of client engagements with GEGPN NATP Average contact with GEGPN NATP and last recorded client status Figure 19 shows the average number of client contacts and last recorded client status. It shows that clients who had completed the program had on average 12.2 contacts, participants who were currently engaged with the program had 1.9 contacts, with patients engaging with the program 13 times to attain a 3 month follow-up. Average program contacts Currently in program (n=187) Completed (n=170) 3 month follow up (n=140) 12 6 month follow up (n=2) Figure 19: Average number of participant contacts with the GEGPN NATP 29

30 Impact of GEGPN NATP on Smoking status Change in smoking status Overall, 49% of participants reported quitting smoking during the GEGPN NATP program. Amongst participants who had between 6 and 8 contacts with the GEGPN NATP program, 78% had quit smoking, while no participants who had between 1 and 5 contacts had quit smoking. This compared with 99% of participants who had between 1 and 5 program contacts with the GEGPN NATP program remaining current smokers (Figure 20). Figure 20: Change in smoking status amongst program participants and their contacts with the GEGPN NATP program Points to consider It should be noted that participants were offered twice weekly contact to assist in smoking cessation. This report lists each of these contacts and not the weeks enrolled. Thus by week four, 47% of the enrolled participants had quit. By week 6 a further 31% had quit. The GEGPN Butt Out program increased its contact with clients but remained focused on the weeks of the program not the number of contacts (this relates to adjusting treatments and support for clients). Program effectiveness and smoking status Quit rates were high for participants who completed the program, with increasing proportion of participants reducing, rather than quitting smoking at 3 and 6 month follow-up (Figure 21). Almost all participants who were currently enrolled in the GEGPN NATP program remained current smokers. 30

31 Proportion Currently in program (n=187) Completed (n=170) 3 month follow up (n=140) 6 month follow up (n=2) Continued smoking reduce smoking quit smoking Figure 21: Change in smoking status and GEGPN NATP engagement Change in smoking status by referral pathway Figure 22 shows the proportion of clients from different referral pathways and their change in smoking status throughout the program. The highest proportion of clients who reduced or quit smoking were referred from General Practice, with the proportion of clients referred from unknown sources the highest proportion of participants who continue to smoke. Figure 22: Change in smoking status and referral pathway GEGPN NATP 31

32 Change in smoking status and length of program engagement Figure 23 shows the number of program contacts and participant s change in smoking status. The figure shows a higher proportion of clients who engaged in more program contacts had either reduced or quit smoking. Figure 23: Change in smoking status and number of program contacts Points to consider Data relating to each participant s Fagerstrom score is not available for analysis as the database was set up to record scores according to the 10 Fagerstrom Quiz Questions. However, the Fagerstrom test used by the program staff involved one question only: When does the individual have their first cigarette? Within or after 30 minutes of waking up. 32