Public Submission by Health Care Consumer's Association Incorporated - Draft National Tobacco Strategy 2010 - 2018
Health Care Consumer's Association Inc
100 Maitland Street
Hackett ACT 2602
Phone: 02 6230 7800
Fax: 02 6230 7833
ABN: 59 698 548 902
HCCA Submission on the Draft National Tobacco Strategy 2012-201826 June, 2012
Contact: Darlene Cox
BackgroundThe Health Care Consumers’ Association (HCCA) of the ACT was formed over 30 years ago to provide a voice for consumers on local health issues and now provides opportunities for health care consumers in the ACT to participate in all levels of health service planning, policy development and decision making.
HCCA involves consumers through:
- consumer representation
- training in health rights and navigating the health system
- community forums
- information sessions about health services
- advocating for issues of concern to consumers
The HCCA is dedicated to the promotion of consumer-centred health care, which we believe can be successfully achieved through the application of five key principles:
2. Choice and empowerment
3. Consumer involvement in health policy
4. Access and support
HCCA welcomes the opportunity to provide input into the Draft National Tobacco Strategy 2012-2018. We strongly support the initiative to reduce tobacco related harm throughout Australia and congratulate the National Drug Strategy on the progress that has already been made.
There are a number of key issues that the HCCA would like to see addressed in the NTS. While many of these issues are touched on in the draft NTS, it is important to ensure that sufficient measures are taken to fully address these significant areas.
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Key IssuesWe believe it is imperative that strategy should incorporate ways to address the following key issues:
1. Support for smokers to quit no matter where they live in Australia - in cities or in rural or isolated communities.
2. Provision of programs, access and support to enable the poorest and most disadvantaged in our community to quit smoking.
3. Provision of a “Wrap Around” family strategy for both parents and grandparents of babies and young children to quit smoking together.
4. Individual support for people who wants to quit smoking.
5. Develop strategies to allow, or encourage, health professionals to:
- develop their professional skills, in order to offer consumers evidence-based support to quit
- correctly and regularly assess levels of smoking and prescribe the correct NRT product for individual smokers
- will refer to QUIT programs and offer QUIT packs to consumers advised to give up smoking.
- Treat consumers in a non-judgemental, supportive and sensitive manner, and seek opportunities to engage them conversations about quitting.
This submission focuses on the need to develop strategies to provide more effective support to quit smoking for consumers in primary health care settings, especially pregnant women. Our case study, “Maria & Baby Jake”, illustrates how opportunities are missed, lost or ineffectively offered to assist a consumer to quit smoking. This case study has been included as an attachment with our submission. It is essential that supporting pregnant women to be able to quit smoking is conducted in an opportunistic, supportive, caring & non judgemental way. Addressing smoking rates amongst pregnant women is particularly important, as their smoking will affect not only their own health, but also their unborn child, their other children and family.
The cost to the health system for training staff in effective strategies to support quitting is small compared to the costs to the health system associated with smoking related emergencies during pregnancy and extensive stays in neonatal intensive care for premature babies of pregnant smokers.
Through consultation with our membership, HCCA has collected a number of case studies and anecdotal evidence indicating that this is a serious issue in the ACT. This is primarily due to a lack of ongoing professional development to support health professionals to build skills and confidence to enable them to provide adequate support for consumers to quit in a primary health care setting.
This issue relates to the health care consumer’s right to access timely and effective health care and to have open channels of communication with their health care providers, as outlined in the Australian Charter of Health Care Rights.
These recommendations relate to a number of key objectives and priority areas listed in the draft NTS, these include:
- to eliminate harmful exposure to tobacco smoke among non-smokers;
- to reduce harm associated with continuing use of tobacco and nicotine products;
5.4 Priority Areas4. strengthen efforts to reduce smoking among people in disadvantaged populations with high smoking prevalence
7. reduce exceptions to smoke-free workplaces, public places and other settings; and
8. provide greater access to a range of evidence-based cessation services to support smokers to quit.
Smoking During PregnancyCurrently, 15.3% of women in the ACT smoke during pregnancy, with 6% smoking 10 or more cigarettes per day (1). The risks associated with smoking during pregnancy are well known throughout the medical profession, and include ante partum haemorrhage, premature rupture of membranes and threatened premature labour (2,3). It is advised that women who smoke more than 10 cigarettes a day would be likely to benefit from the use of nicotine replacement therapy (NRT) (4). However, some doctors believe NRTs may be unsafe for use by pregnant women and are often reluctant to prescribe them. It is also common for health professionals to select an inappropriate dosage or type of NRT, as tobacco withdrawal symptoms are not accurately assessed.
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HCCA strongly urges that the NTS considers providing all pregnant women, their smoking partners and family members with specialist support to quit smoking by better training health professionals to assess and administer effective NRT. This would be in accordance with the Smoking Cessation Guidelines for Health Professionals (5)
HCCA has developed a case study entitled “Maria & Baby Jake”, which outlines the lack of support provided to Maria to quit smoking during her pregnancy. This was despite 17 identified missed opportunities to provide Maria with support or conduct an effective intervention. At 16 weeks gestation, a midwife recorded Maria’s status as a smoker, in accordance with best practice. However, there were no additional assessments conducted regarding her level of nicotine dependence, nor was she given any form of referral to QUIT services or cessation aid. Although Maria was told that she should attempt to quit, the lack of support provided to her meant that the likelihood of her doing so was very low.
Maria was admitted to the antenatal ward with threatened premature labour and an antepartum haemorrhage, both of which are smoking related conditions. Yet, Maria was only prescribed a 7mg nicotine replacement patch, which was too small a dose to be effective. During this time, the midwives displayed frustration at Maria’s continued smoking, failing to recognise that Maria was not receiving an adequate dose of NRT.
Baby Jake was born prematurely at 34 weeks gestation. He required breathing support and spent three weeks in the neonatal intensive care unit. It is likely that he will become an irritable baby who finds it difficult to settle. Baby Jake will continue to have health difficulties throughout his life if he continues to be subjected to environmental tobacco smoke.
The case study clearly illustrates the lost opportunities and failure to implement existing ACT Health Policy as well as international best practice. This is primarily the result of a lack of guidelines or a clear systematic approach to supporting pregnant women to quit smoking. When pregnant women present to health care services for the first time, their status as a smoker needs to be thoroughly assessed and strategies put in place to provide them with as much support as is necessary. In addition, the advice that is given to these women during and after pregnancy needs to be appropriate and accurate. In Maria’s case, her midwives informed her that she should not smoke during breastfeeding, but offered no further advice. As a result of this, Maria discontinued breastfeeding rather than attempting to quit.
When pregnant women who smoke are admitted to an antenatal ward, it is essential that they are assessed accurately in terms of their withdrawal symptoms and provided with the most effective form of NRT. This needs to be carefully tailored to the individual woman. In order to facilitate this, health professionals need to be provided with training and education regarding the most appropriate NRT to use for women during pregnancy. Lack of confidence in this area has been identified as a major barrier to supporting consumers to quit smoking (5). This could be achieved by supporting QUIT to provide educators to train health professionals.
At present, QUIT training programs in the ACT only focus on supporting people to quit in the context of the workplace. QUIT Packs or fax referrals to QUITLINE are not made available in hospitals to every consumer advised to quit smoking.
There is also a strong need to identify the social and interpersonal barriers to quitting that exist within the health system, as social support also plays an important role in the cessation of smoking (ref). When Maria was unable to quit during her time in the antenatal ward, the staff displayed a distinct lack of understanding, interpreting her irritability as a negative personality trait rather than a withdrawal symptom.
Service providers need to ensure that they are sensitive to the social determinants of health and the stress involved in attempting to quit smoking. Through empathy and effective communication, health care providers will be better able to support consumers to quit.
Additional NotesHCCA notes that the draft NTS lists unassisted cessation as the most effective means of quitting. While ‘cold turkey’ may be the most commonly reported means through which people have given up smoking, it is also important to consider relapse rates, and whether quitting ‘cold turkey’ would be appropriate for people in primary care settings. Moreover, it could be the case that most people are attempting to quit without cessation aids because they are not being provided with the opportunity to do so. There is evidence to suggest that the success rate for quitting smoking increases with every appropriate intervention made available to the smoker in a timely way.
We would also like to point out that the Quitline phone service still incurs a cost if it is accessed by a mobile phone. Our information indicates that the majority of consumers in low socio-economic groups have mobiles as opposed to landlines, meaning that the cost associated with Quitline would act as a barrier to access for these disadvantaged consumers. We believe the system should include a call-back system to allow these consumers to access a free service from mobile phones.
Monitoring ProgressIn light of these recommendations, a number of progress indicators could be used to assess the extent to which the NTS has addressed the need to support health consumers to QUIT smoking. These include a number of indicators already included in the draft NTS, as well as a few additional ones.
Relevant existing indicators:
- fewer infants exposed to tobacco in utero and after birth;
- fewer children exposed to smoke at home, in cars, public places, play areas and child-care facilities;
- fewer adults smoking regularly;
- more adult smokers attempting to quit;
- fewer quitters relapsing.
- fewer women smoking during pregnancy; and
- reduced smoking rates for consumers in in-patient care settings.
References1. Maternal and Perinatal Health in the ACT 2000-2004. Health Series N0. 44.
2. Tikkanen, M. Nuutila, M., Hiilesmaa, V. et al (2010). Clinical presentation and risk factors of placental abruption. Acta Obstetrica et Gynaecologica Scandinavica. 85(6) 700-705.
3. Wong, P. & Bauman, A (1997). How well does epidemiological evidence hold for the relationship between smoking and adverse obstetric outcomes in New South Wales? Australian and New Zealand Journal of Obstetrics and Gynaecology. 37 (2): 168-73.
4. Ashwin, C., & Watts, K. (2010). Women’s use of nicotine replacement therapy in pregnancy: a structured review of the literature. Midwifery. 26(3) 304-310.
5. The Royal Australian College of General Practitioners (2011). Supporting Smoking Cessation: A Guide for Health Professionals.
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