Effectiveness of an on-call counselor at increasing smoking treatment

Strategies to improve smoking cessation rates in primary care

BACKGROUND

Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials).

OBJECTIVES

To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.

Closed-Loop Electronic Referral From Primary Care Clinics to a State Tobacco Cessation Quitline: Effects Using Real-World Implementation Training

INTRODUCTION

Patients who use tobacco are too rarely connected with tobacco use treatment during healthcare visits. Electronic health record enhancements may increase such referrals in primary care settings. This project used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to assess the implementation of a healthcare system change carried out in an externally valid manner (executed by the healthcare system).

METHODS

The healthcare system used their standard, computer-based training approach to implement the electronic health record and clinic workflow changes for electronic referral in 30 primary care clinics that previously used faxed quitline referral. Electronic health record data captured rates of assessment of readiness to quit and quitline referral 4 months before implementation and 8 months (May-December 2017) after implementation. Data, analyzed from October 2018 to June 2019, also reflected intervention reach, adoption, and maintenance.

RESULTS

For reach and effectiveness, from before to after implementation for electronic referral, among adult patients who smoked, assessment of readiness to quit increased from 24.8% (2,126 of 8,569) to 93.2% (11,163 of 11,977), quitline referrals increased from 1.7% (143 of 8,569) to 11.3% (1,351 of 11,977), and 3.6% were connected with the quitline after implementation. For representativeness of reach, electronic referral rates were especially high for women, African Americans, and Medicaid patients. For adoption, 52.6% of staff who roomed at least 1 patient who smoked referred to the quitline. For maintenance, electronic referral rates fell by approximately 60% over 8 months but remained higher than pre-implementation rates.

CONCLUSIONS

Real-world implementation of an electronic health record-based electronic referral system markedly increased readiness to quit assessment and quitline referral rates in primary care patients. Future research should focus on implementation methods that produce more consistent implementation and better maintenance of electronic referral.

Individual behavioural counselling for smoking cessation

BACKGROUND

Individual counselling from a smoking cessation specialist may help smokers to make a successful attempt to stop smoking.

OBJECTIVES

The review addresses the following hypotheses:1. Individual counselling is more effective than no treatment or brief advice in promoting smoking cessation.2. Individual counselling is more effective than self-help materials in promoting smoking cessation.3. A more intensive counselling intervention is more effective than a less intensive intervention.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register for studies with counsel* in any field in May 2016.

SELECTION CRITERIA

Randomized or quasi-randomized trials with at least one treatment arm consisting of face-to-face individual counselling from a healthcare worker not involved in routine clinical care. The outcome was smoking cessation at follow-up at least six months after the start of counselling.

DATA COLLECTION AND ANALYSIS

Both authors extracted data in duplicate. We recorded characteristics of the intervention and the target population, method of randomization and completeness of follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. In analysis, we assumed that participants lost to follow-up continued to smoke. We expressed effects as a risk ratio (RR) for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study using the Cochrane 'Risk of bias' tool and the GRADE approach.

MAIN RESULTS

We identified 49 trials with around 19,000 participants. Thirty-three trials compared individual counselling to a minimal behavioural intervention. There was high-quality evidence that individual counselling was more effective than a minimal contact control (brief advice, usual care, or provision of self-help materials) when pharmacotherapy was not offered to any participants (RR 1.57, 95% confidence interval (CI) 1.40 to 1.77; 27 studies, 11,100 participants; I2 = 50%). There was moderate-quality evidence (downgraded due to imprecision) of a benefit of counselling when all participants received pharmacotherapy (nicotine replacement therapy) (RR 1.24, 95% CI 1.01 to 1.51; 6 studies, 2662 participants; I2 = 0%). There was moderate-quality evidence (downgraded due to imprecision) for a small benefit of more intensive counselling compared to brief counselling (RR 1.29, 95% CI 1.09 to 1.53; 11 studies, 2920 participants; I2 = 48%). None of the five other trials that compared different counselling models of similar intensity detected significant differences.

AUTHORS' CONCLUSIONS

There is high-quality evidence that individually-delivered smoking cessation counselling can assist smokers to quit. There is moderate-quality evidence of a smaller relative benefit when counselling is used in addition to pharmacotherapy, and of more intensive counselling compared to a brief counselling intervention.

Telephone care co-ordination for tobacco cessation: randomised trials testing proactive versus reactive models

OBJECTIVES

We conducted two parallel studies evaluating the effectiveness of proactive and reactive engagement approaches to telephone treatment for smoking cessation.

METHODS

Patients who smoked and were interested in quitting were referred to this study and were eligible if they were current smokers and had an address and a telephone number. The data were collected at 35 Department of Veterans Affairs (VA) sites, part of four VA medical centres in both California and Nevada. In study 1, participants received multisession counselling from the California Smokers' Helpline (quitline). In study 2, they received self-help materials only. Patients were randomly assigned by week to either proactive or reactive engagement, and primary care staff were blind to this assignment. Providers gave brief advice and referred them via the electronic health record to a tobacco co-ordinator. All patients were offered cessation medications.

OUTCOME

Using complete case analysis, in study 1 (quitline), patients in the proactive condition were more likely than those in the reactive condition to report abstinence at 6 months (21.0% vs 16.4%, p=0.03). No difference was found between conditions in study 2 (self-help) (16.9% vs 16.5%, p=0.88). Proactive outreach resulted in increased use of cessation medications in both the quitline (70.1% vs 57.6%, p<0.0001) and the self-help studies (74.5% vs 48.2%, p<0.0001).

CONCLUSION

Proactive outreach with quitline intervention was associated with greater long-term abstinence. Both studies resulted in high rates of medication use. Sites should use a proactive outreach approach and provide counselling whenever possible.

TRIAL REGISTRATION NUMBER

NCT00123682.

Integrating tobacco treatment into thoracic oncology settings: Lessons learned

Clinical practice guidelines recommend tobacco treatment for all cancer patients. However, little is known about how to integrate tobacco treatment into cancer care. The results of our pilot study of an evidence-based tobacco treatment integrated into a thoracic oncology clinic demonstrated good feasibility and efficacy, providing an opportunity to inform future tobacco treatment integration efforts. Here, we describe the process of intervention development, clinic integration, patient identification, and patient enrollment. We report on the intervention content and delivery, patterns of quitting for participants in the tobacco treatment group, and changes in smoking-related psychosocial variables. Clinical implications and suggestions for future research are discussed.

Recruiting and engaging smokers in treatment in a primary care setting: developing a chronic care model implemented through a modified electronic health record

Almost 35 million U.S. smokers visit primary care clinics annually, creating a need and opportunity to identify such smokers and engage them in evidence-based smoking treatment. The purpose of this study is to examine the feasibility and effectiveness of a chronic care model of treating tobacco dependence when it is integrated into primary care systems using electronic health records (EHRs). The EHR prompted primary care clinic staff to invite patients who smoked to participate in a tobacco treatment program. Patients who accepted and were eligible were offered smoking reduction or cessation treatment. More than 65 % of smokers were invited to participate, and 12.4 % of all smokers enrolled in treatment-30 % in smoking reduction and 70 % in cessation treatment. The chronic care model developed for treating tobacco dependence, integrated into the primary care system through the EHR, has the potential to engage up to 4.3 million smokers in treatment a year.

Effectiveness of telephone-based follow-up support delivered in combination with a multi-component smoking cessation intervention in family practice: a cluster-randomized trial

OBJECTIVE

To determine whether telephone-based smoking cessation follow-up counseling (FC), when delivered as part of a multi-component intervention program is associated with increased rates of follow-up support and smoking abstinence.

METHODS

A cluster randomized controlled-trial was conducted within family medicine practices in Ontario, Canada. Consecutive adult patients who smoked were enrolled at two time points, the baseline period (2009) and the post-intervention period (2009-2011). Smoking abstinence was determined by telephone interview 4 months following enrollment. Both groups implemented a multi-component intervention program. Practices randomized to the FC group could also refer patients to a follow-up support program which involved 5 telephone contacts over a 2-month period.

RESULTS

Eight practices, 130 providers, and 928 eligible patients participated in the study. No statistically significant difference in 7-day point-prevalence abstinence was observed between intervention groups. There was a significant increase in referral to follow-up in both intervention groups. Significantly higher rates of smoking abstinence [25.7% vs. 11.3%; adjusted OR 3.1 (95% CI: 1.1, 8.6), p<0.05] were documented among the twenty-nine percent of FC participants who were referred to the follow-up support program compared to the MC group.

CONCLUSION

Access to external follow-up support did not increase rates at which follow-up support was delivered.

Interventions for recruiting smokers into cessation programmes

BACKGROUND

Tobacco control is a top public health priority around the globe due to the high prevalence of cigarette smoking and its associated morbidity and mortality. Much effort has been focused on establishing the effectiveness of different smoking cessation strategies. This review, however, aims to address the initial challenge faced by smoking cessation programmes: recruitment of smokers.

OBJECTIVES

The primary objective of this review was to determine the effectiveness of different strategies for recruiting smokers into cessation programmes. The secondary objective was to determine the impact that these strategies had on smoking cessation rates at least six months after enrolment into a cessation programme.

SEARCH METHODS

We searched the specialised register of the Cochrane Tobacco Addiction Group using a search strategy which included the terms ('recruit$', 'invit$', 'enter', 'entry', 'enrolment') combined with ('smok$', 'cigarette', 'smoking cessation', 'tobacco') in the title, abstract or keyword fields. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and registers of current and ongoing trials. We also searched the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials and cluster randomised controlled trials that compared at least two different methods of recruiting current smokers into a smoking cessation programme. We also included those studies which focused on the effectiveness of a smoking cessation programme as long as the study involved multiple recruitment methods and reported results of the recruitment phase.

DATA COLLECTION AND ANALYSIS

From each included study, we extracted data on the type of participants, type of recruitment strategies (i.e., setting, mode of communication used, intensity and duration) and comparisons, and on randomisation, allocation concealment, and blinding procedures.Our primary outcome was the proportion of smokers successfully recruited to each cessation programme compared to alternative modalities of recruitment. Our secondary outcome was smoking cessation for at least six months. Given the substantial heterogeneity across recruitment interventions and participants, we adopted a narrative synthesis approach for summarising results.

MAIN RESULTS

This review includes 19 studies with a total of 14,890 participants. We categorised the included studies according to the modes used to deliver the recruitment strategy: head to head comparison of individual recruitment strategies; comparison of the same delivery mode but with different content or intensity; and the addition of another mode to an existing recruitment method.We identified three studies that made head-to-head comparisons of different types of recruitment strategies. Of these, only one study detected a significant effect, finding that a personal phone call was more effective than a generic invitation letter (RR 40.73, 95% CI 2.53 to 654.74). Five studies compared interventions using the same delivery modes but different content. Results showed that tailored messages through an interactive voice response system resulted in a higher recruitment rate than assessment of smoking status alone using the same system (RR 8.64, 95% CI 4.41 to 16.93), and that text messages indicating scarcity of places available were more effective than generic text message reminders (RR 1.45, 95% CI 1.07 to 1.96). One study compared interventions using the same delivery mode but different intensity and found that allowing for more phone call attempts to reach potential participants can result in better recruitment (RR 1.87, 95% CI 1.61 to 2.18). Finally, 10 studies investigated the effect of adding a recruitment mode to existing recruitment strategies. Findings showed that: adding a text message reminder or real quotes from participants to a personal phone call improved recruitment of participants (RR 3.38, 95% CI 1.26 to 9.08 and RR 29.07, 95% CI 1.74 to 485.70, respectively); that adding a personal phone call to an existing newsletter can also increase recruitment rates (RR 65.12, 95% CI 4.06 to 1045.4]); that a reactive-proactive recruitment phase is more effective than a proactive phase alone (63.8% versus 47.5%, RR not available); and that active recruitment at schools is more effective than passive recruitment (p < 0.001, denominator not available for calculation of RR). Additionally, a number of studies in this category showed that providing incentives can effectively increase the number of participants recruited into smoking cessation programmes.Out of the 19 included studies, only four reported on the effect of recruitment strategy on smoking cessation at six months or longer. Three of these studies compared strategies that used the same delivery mode with different content. Their results were non-significant. The remaining three studies evaluated adding an additional mode to an existing recruitment intervention. Only one of them showed a significant difference in the levels of smoking cessation that favoured the enhanced recruitment strategy, but this may have reflected the offer of incentives once in the programme rather than the recruitment strategy itself (RR at 15 or 18 months 2.60, 95% CI 1.48 to 4.56).

AUTHORS' CONCLUSIONS

The substantial heterogeneity across the included studies restricts our ability to draw firm conclusions about the effectiveness of different recruitment strategies in relation to recruitment of participants into smoking cessation programmes or levels of smoking cessation. The limited evidence, however, suggests that the following elements may improve the recruitment of smokers into cessation programmes: personal, tailored interventions; recruitment methods that are proactive in nature; and more intensive recruitment strategies (i.e., those strategies that require increased contact with potential participants).

Effectiveness of smoking-cessation interventions for urban hospital patients: study protocol for a randomized controlled trial

BACKGROUND

Hospitalization may be a particularly important time to promote smoking cessation, especially in the immediate post-discharge period. However, there are few studies to date that shed light on the most effective or cost-effective methods to provide post-discharge cessation treatment, especially among low-income populations and those with a heavy burden of mental illness and substance use disorders.

METHODS/DESIGN

This randomized trial will compare the effectiveness and cost-effectiveness of two approaches to smoking cessation treatment among patients discharged from two urban public hospitals in New York City. During hospitalization, staff will be prompted to ask about smoking and to offer nicotine replacement therapy (NRT) on admission and at discharge. Subjects will be randomized on discharge to one of two arms: one arm will be proactive multi-session telephone counseling with motivational enhancement delivered by study staff, and the other will be a faxed or online referral to the New York State Quitline. The primary outcome is 30-day point-prevalence abstinence from smoking at 6-month follow-up post-discharge. We will also examine cost-effectiveness from a societal and a payer perspective, as well as explore subgroup analyses related to patient location of hospitalization, race/ethnicity, immigrant status, and inpatient diagnosis.

DISCUSSION

This study will explore issues of implementation feasibility in a post-hospitalization patient population, as well as add information about the effectiveness and cost-effectiveness of different strategies for designing smoking cessation programs for hospitalized patients.

TRIAL REGISTRATION

Clinicaltrials.gov ID# NCT01363245.

Strategies to increase the delivery of smoking cessation treatments in primary care settings: a systematic review and meta-analysis

OBJECTIVES

A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics.

METHODS

The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for "5As" (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies.

RESULTS

Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing "5As" delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6-2.1] for "ask", 1.6 [95% CI 1.4-1.8] for "advice", 9.3 [95% CI 6.8-12.8] for "assist" (quit date) and 3.5 [95% CI 2.8-4.2] for "assist" (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5-2.0] and multi-component interventions [OR 2.2; 95% CI 1.7-2.8] were found to significantly increase smoking abstinence.

CONCLUSION

Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.

Targeting primary care referrals to smoking cessation clinics does not improve quit rates: implementing evidence-based interventions into practice

OBJECTIVE

To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice.

DATA SOURCES/STUDY SETTING

We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states.

STUDY DESIGN

In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care.

DATA COLLECTION

To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns.

PRINCIPAL FINDINGS

Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation.

CONCLUSIONS

EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

Individual behavioural counselling for smoking cessation

BACKGROUND

Individual counselling from a smoking cessation specialist may help smokers to make a successful attempt to stop smoking.

OBJECTIVES

The objective of the review is to determine the effects of individual counselling.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register for studies with counsel* in any field. Date of the most recent search: December 2004.

SELECTION CRITERIA

Randomized or quasi-randomized trials with at least one treatment arm consisting of face-to-face individual counselling from a healthcare worker not involved in routine clinical care. The outcome was smoking cessation at follow up at least six months after the start of counselling.

DATA COLLECTION AND ANALYSIS

Both authors extracted data. The intervention and population, method of randomization and completeness of follow up were recorded.

MAIN RESULTS

We identified 21 trials with over 7000 participants. Eighteen trials compared individual counselling to a minimal behavioural intervention, four compared different types or intensities of counselling. Individual counselling was more effective than control. The odds ratio for successful smoking cessation was 1.56 (95% confidence interval 1.32 to 1.84). In a subgroup of three trials where all participants received nicotine replacement therapy the point estimate of effect was smaller and did not reach significance (odds ratio 1.34, 95% confidence interval 0.98 to 1.83). We failed to detect a greater effect of intensive counselling compared to brief counselling (odds ratio 0.98, 95% confidence interval 0.61 to 1.56).

AUTHORS' CONCLUSIONS

Smoking cessation counselling can assist smokers to quit.