The day the ash-tray finally tipped me over
I still remember the gentleman on ward 2B. He’d just had a COPD flare so bad we nearly intubated him. When I asked if he’d thought about stopping smoking, he shrugged: “I dunno! How can you help me?”
That was 2009. I walked back to the nurses’ station, stared at the NICE guideline print-out gathering coffee-cup rings and thought: We’re the doctors – if we don't push about quitting, who on earth will?
Two years later, with the help of the marvellous stop-smoking nurses in St Helens and Knowsley, we ran a little experiment. The results surprised us, annoyed us, and ultimately taught us a lesson I still wheel out when mentoring junior docs today.
Why we did it (and what we already knew)
NICE had – and still has – a beautifully simple rule: every smoker gets advice + referral to a specialist cessation service.
In 2010 my colleague and I audited 200 in-patient notes. We found that 74 % of smokers left hospital without even a whiff of a referral. We called these “missed opportunities”; the patients probably called it “another day of buying fags on the way out.”
Something had to change. Education looked like the cheapest, safest lever we could pull.
The plan: teach the troops, count the numbers
Between January and March 2011 we delivered a short, punchy teaching package to anyone in scrubs or scruffy shoes:
- 30-minute lunch-time talk from the hospital Stop-Smoking Service
- A one-page flow-chart: Ask – Advise – Act
- Tiny pocket cards with the referral phone number (because, amazingly, half the ward staff didn’t know it)
- A promise of chocolate biscuits (evidence-based bribery)
We then re-surveyed staff attitudes and compared referral rates to the same quarter the previous year. Ethics gave us the nod, the finance director gave us the biscuits, and off we went.
What the questionnaires told us (the tea-room gossip version)
We handed out 65 anonymous forms; 58 came back (89 % – not bad for voluntary paperwork). Here are the headline numbers in plain English:
| Question | Before teaching | After teaching |
|---|---|---|
| Knew we had local guidelines | 45 % | 58 % |
| Had any cessation training in last 12 m | 50 % | 71 % |
| Thought hospital admission was a cracking time to quit | 79 % | 84 % |
| Actually referred smokers to SCS | 54 % | 64 % |
Translation: teaching moved the needle, but only about one centimetre.
Now for the bits that made me tug my beard:
- 24 % flat-out said they “didn’t want more training”.
- 12 % believed referring wasn’t part of their job (I still can’t write that without wincing).
- The commonest reasons for not referring stayed identical before and after education: “No time,” “Patient not interested,” “I forgot” – the unholy trinity of hospital inertia.
What the data whispered while no-one was listening
Here’s the thing most conference posters don’t say out loud: education increased awareness, but attitudes are stickier than tar.
We’d given people knowledge; we hadn’t given them a SYSTEM. It’s like handing someone a map but no car. Unless the referral is baked into the admission checklist, the discharge letter template, and the pharmacy automatic-stop order, it falls off the radar at 2 a.m. when the ward is heaving.
The small 10-percentage-point bump in referrals was nice, but the p-value was friendly rather than furious (p = 0.21). We presented it in Amsterdam, clapped each other on the back, then went home to wrestle the same old paperwork.
So did we just waste our breath? Far from it.
- We proved the obvious: knowledge ≠behaviour. That alone stopped us throwing good money after bad on endless lecture tours.
- We found the 12 % who disengage. Target interventions elsewhere (pharmacists, physios, HCAs) and you gain traction without a shouting match.
- We collected the baseline that got us funding for the truly game-changing stuff that followed:
- Electronic referral tick-box in the e-discharge (referrals trebled within six months).
- Nicotine-replacement protocol started by ward clerks (yes, clerks!).
- Carbon-monoxide monitors on every respiratory ward – nothing focuses the mind like blowing into a machine that turns red.
Practical bits you can steal for your own hospital
- Make the default the right thing: embed SCS referral in the electronic admission bundle. People can still opt out, but laziness now works for you.
- Use teachable moments, not lectures. A five-minute demo at the bedside beats a 60-slide deck after a 12-hour shift.
- Champion by profession: doctors aren’t the only gate-keepers. Our smoking-cessation pharmacists achieved a referral rate double that of the medics.
- Celebrate small wins loudly. We started emailing “Referrer of the Week” and stuck a gold star on the ward notice board. Juvenile? Maybe. Effective? Absolutely.
- Measure, feed back, repeat. Monthly run-charts on the staffroom wall kept the issue alive far better than my occasional stomping around with a stethoscope.
The patient voice that still echoes
Six months after the study, I bumped into the same gentleman from 2B – now 127 days smoke-free, sporting a bright-yellow “I quit!” badge from the community SCS. He grabbed my hand and said, “One of those young nurses told me you’d phone them for me while I was half-asleep. Best phone call I ever took.”
That single story still pays the emotional mortgage on all the statistical headaches.
Bottom line (because I know you’re skimming on your phone)
Education is the starter motor, not the engine. It wakes people up, but systems, routine and culture keep the car on the road.
If you’re trying to boost smoking-cessation referrals, by all means teach – just don’t stop there. Redesign the pathway until doing the right thing is the easiest thing. Your future patients’ lungs will thank you, preferably without another admission.
Light-hearted postscript
Since 2011 I’ve quit three things: adding extra salt to my curry, apologising for my terrible golf swing, and believing a PowerPoint alone can change the world.
I’ve yet to quit my morning coffee. If anyone starts a cessation service for that, sign me up—after my espresso.
Until next time, keep breathing easy.