An observational study of system-level changes to improve the recording of very brief advice for smoking cessation in an inpatient mental health setting

Smoking prevalence among people with psychosis remains high. Providing Very Brief Advice (VBA) comprising: i) ASK, identifying a patient’s smoking status ii) ADVISE, advising on the best way to stop and iii) ACT (OFFER), offering a referral to specialist smoking cessation support, increases quit attempts in the general population. We assessed whether system-level changes in a UK mental health organisation improved the recording of the provision of ASK, ADVISE, ACT (OFFER) and consent to referral to specialist smoking cessation support (ACT (CONSENT)).

We conducted a study using a regression discontinuity design in four psychiatric hospitals with patients who received treatment from an inpatient psychosis service over 52 months (May 2012–September 2016). The system-level changes to facilitate the provision of VBA comprised: A) financially incentivising recording smoking status and offer of support (ASK and ACT (OFFER)); B) introduction of a comprehensive smoke-free policy; C) enhancements to the patient electronic healthcare record (EHCR) which included C1) a temporary form to record the financial incentivisation of ASK and ACT (OFFER) C2) amendments to how VBA was recorded in the EHCR and C3) the integration of a new electronic national referral system in the EHCR. The recording of ASK, ADVISE, ACT (OFFER/CONSENT) were extracted using a de-identified psychiatric case register.

There were 8976 admissions of 5434 unique individuals during the study period. Following A) financial incentive, the odds of recording ASK increased (OR: 1.56, 95%CI: 1.24–1.95). Following B) comprehensive smoke-free policy, the odds of recording ADVICE increased (OR: 3.36, 95%CI: 1.39–8.13). Following C1) temporary recording form, the odds of recording ASK (OR:1.99, 95%CI:1.59–2.48) and recording ACT (OFFER) increased (OR: 4.22, 95%CI: 2.51–7.12). Following C3) electronic referral system, the odds of recording ASK (OR:1.79, 95%CI: 1.31–2.43) and ACT (OFFER; OR: 1.09, 95%CI: 0.59–1.99) increased. There was no change in recording VBA outcomes following C2) amendments to VBA recording.

Financial incentives and the recording of incentivised outcomes, the comprehensive smoke-free policy, and the electronic referral system, were associated with increases in recording individual VBA elements, but other changes to the EHCR were not. System-level changes may facilitate staff recording of VBA provision in mental health settings.