National Heart Foundation Hospital & Research InstituteDept. of Epidemiology and Research

ProgramsTobacco cessation counselling by nurses

Nurses want to help patients quit. Few are equipped to.

This study assessed what nurses at Bangladesh's primary health care facilities know about tobacco cessation counselling and what they actually do. Despite moderate exposure to training, the gap between knowledge and practice persists: the barriers are limited training, time and workforce shortages.

A completed study, April to November 2023, by the Department of Epidemiology and Research with the Bangladesh Center for Communication Programs, supported by the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health.

328
Nurses interviewed, all trained in NCD care
55
Upazila health complexes, in all eight divisions
11.9%
Had adequate knowledge of cessation counselling
20.7%
Practised counselling following the 5A approach

01Why nurses

The front line of cessation is the NCD corner

Tobacco use is a leading cause of cardiovascular disease, cancer and respiratory illness in Bangladesh, in both smoked and smokeless forms. As a signatory to the WHO Framework Convention on Tobacco Control, the country has committed under Article 14 to offer help to people who want to quit. In practice that help is mostly limited to brief counselling at primary health care facilities.

Those facilities have NCD corners staffed by nurses who screen and counsel patients for risk factors, tobacco among them. With more than 50,000 registered nurses in the health system, and frequent, trusted contact with patients, nurses are the people best placed to turn a routine visit into a quit attempt.

Yet, although WHO protocols and NCD training exist, nobody had measured how well nurses know them or whether they use them. This study set out to do that, and to identify what stands in the way.

02How the study was done

Three ways of looking at the same corner

  1. 01

    Survey

    Face-to-face structured interviews with 328 registered nurses trained in NCD care, working at 55 upazila health complexes selected across the eight divisions. The questionnaire covered personal details, knowledge of tobacco-related disease, knowledge of cessation, counselling practice, and the 5A protocol.

  2. 02

    Key informant interviews

    Ten interviews with policy experts, upazila health and family planning officers and nursing supervisors, on the challenges nurses face and why the knowledge-practice gap persists among trained staff.

  3. 03

    Observation

    Visits to selected facilities during peak hours to watch counselling as it happens, using a standard checklist, so that reported practice could be checked against real practice.

03What the nurses told us

Willing, partly trained, rarely following the protocol

Nearly nine in ten nurses were women, with an average age of 34. Almost all had never used tobacco themselves. Three quarters held a nursing diploma.

  1. 73.8%

    of the nurses had received training in tobacco cessation, and 68.6% had been trained on the WHO 5A approach (ask, advise, assess, assist, arrange).

  2. 98.2%

    said they were willing to help patients who wanted to quit, and 80.8% reported counselling such patients themselves.

  3. 87.1%

    used brief advice and counselling to motivate patients to quit. Just under two in five (39%) said they applied the 5A approach.

  4. 11.9%

    had adequate knowledge when scored on tobacco-related disease, cessation theory and the 5A protocol.

  5. 20.7%

    actually practised counselling that followed the 5A approach. The gap between what nurses know and what they do was the study's central finding.

  6. Advise and arrange

    were the steps most nurses managed. Cessation advice was usually folded into hypertension visits rather than given as a dedicated session.

What gets in the way

  • Too little time and heavy workloads at NCD corners
  • A shortage of skilled staff and of nurses overall
  • No dedicated training programme on cessation counselling
  • Almost no cessation content in undergraduate nursing curricula and training materials
  • Few resources and no protected space for counselling

What it means

Knowledge alone does not produce counselling. Nurses who had been trained still tended to give advice in passing, during hypertension follow-up, and to stop at the easiest steps of the protocol. The key informants were clear that without dedicated time, staff and locally adapted materials that teach behaviour change as well as facts, the pattern will not shift.

Request the full report from the department

04What should change

Six recommendations, and one policy ask

Bangladesh already has the commitment, under FCTC Article 14, and the workforce. The study's recommendations are about turning both into routine practice.

  1. 01

    Revise medical education curricula and refine training materials so health providers gain proficiency in cessation counselling.

  2. 02

    Include tobacco dependence treatment in the nursing education curriculum.

  3. 03

    Build nurses' confidence through specialised training focused on cessation counselling.

  4. 04

    Develop NCD-oriented training materials that integrate cessation with NCD management counselling, and consider dedicated cessation nurses or counsellors at upazila health complexes.

  5. 05

    Enrich training materials with health education and behaviour change content.

  6. 06

    Formulate national guidelines for tobacco cessation counselling, giving every facility a standard framework.

Policy implication

Bring every health facility under a government policy that mandates brief cessation counselling for each patient who seeks care, backed by a national guideline on tobacco cessation counselling for health providers and by education modules and training materials built for the purpose.

05Study team

Who did the work

Dr. Ahmad Khairul Abrar
Co-Investigator, Department of Epidemiology and Research
H.M. Miraz Mamudh
Partner team, Bangladesh Center for Communication Programs

06Related

Part of the department's tobacco work.

The study fed directly into the department's next step: piloting Bangladesh's first tobacco quitline, so that nurses at NCD corners have somewhere to refer patients who want to quit.

The quitline pilot Tobacco Control Program Study record Contact the department