Impact of hospitalisation on patient smoking: current practice and potential for nurse-provided smoking cessation care

Research Doctorate - Doctor of Philosophy (PhD)Tobacco smoking is currently responsible for the deaths of 50 Australians every day. We have known for a long time that these deaths are preventable, however, the difficulty lies in helping people to overcome their addiction to nicotine, and in preventing young people from taking up the behaviour. The hospital setting has been described in the literature as a "window of opportunity" and a "teachable moment" for providing smokers with encouragement, support and skills to quit smoking while they are in hospital. Nurses have been described as an "under-utilised resource" in efforts to control the tobacco epidemic. The nature of the hospital setting differs markedly from that of the general practice setting, where extensive research effort has been focused over the last two decades. The public health research literature offers very little in the way of information about the potential of the hospital setting, or of nurses as providers of smoking cessation care. Therefore this thesis aims to determine the potential of the hospital setting and of nurses as providers of smoking cessation advice, and to inform the development, and appropriate targeting of hospital based smoking cessation interventions in the future. The approach taken follows the steps identified in research models designed to guide the development of health behaviour change research. These models identify the need to have accurate measures of the target behaviour, knowledge of the prevalence of the targeted behaviour, an understanding of the perceptions of the target group towards health behaviour change, including knowledge of risk, attitudes to change and barriers to receiving help. They also stress the need for knowledge of the perceived appropriateness of the intended provider group, their knowledge, attitudes, barriers and skills in providing the health behaviour intervention, and data on the current levels of health intervention, being provided to the target population by these providers. Four decades have passed since the landmark article in The Journal of American Medical Association (JAMA) in 1950, linking smoking as an aetiological factor in lung cancer. However, during the 1980s American hospitals were still selling cigarettes. This paradox between research literature and public health policy deserves investigation. Hence Chapter 1 of the thesis summarises the history and nature of tobacco control in relation to hospitals, health policy and health professionals (particularly nurses). This literature review provides an understanding of some of the factors which will impact on the introduction of change to the health sector. Following this, the thesis discusses a series of studies providing the data necessary to develop, introduce and appropriately target smoking cessation care. Data from the studies discussed in this thesis were collected during one data collection period during 1991. The patient studies in Chapters 2-4 involved a cross-sectional survey of all consenting and eligible inpatients in the 6 largest hospitals of the Hunter Area, on randomly selected data collection days. Immunology, Paediatrics, Intensive Care and the Delivery Suites were excluded from the study, as all patients in these wards would have been ineligible to participate. There was a total of 1552 patients in hospital during data collection and of these 744 (48%) were ineligible (mentally, physically or emotionally incapable of providing informed consent). Of eligible patients, 711 (88%) consented to participate in a study, which they were told would involve a brief bedside interview, possibly a saliva sample taken for analysis of tobacco products, and a self-completed questionnaire. The studies reported in Chapters 5-6 involved a cross-sectional survey of all day shift nursing staff on the wards, on the same randomly selected data collection days. There were 399 nurses on the day shifts in the 52 wards, and of these 388 (97%) were eligible, and 382 (98%) participated in the study. Nurses received a brief ward-based interview and completed a questionnaire (88% returned)