Smoking cessation treatment by primary care physicians: An update and call for training

Healthcare Providers' Knowledge of Evidence-Based Treatment for Tobacco Dependence, DocStyles 2020

PURPOSE

Although smoking cessation reduces the risk of all-cause mortality, evidence-based cessation treatments are underused. This study examined healthcare provider knowledge of evidence-based cessation treatments and associations between knowledge and clinical practice characteristics.

DESIGN

Cross-sectional survey.

SETTING

2020 DocStyles.

SUBJECTS

1480 U.S. healthcare providers.

MEASURES

Provider knowledge of availability of tobacco use disorder diagnostic criteria, clinical practice guideline availability, treatment efficacy, evidence-based counseling modalities, and medications approved by the U.S. Food and Drug Administration (FDA).

ANALYSIS

Adjusted odds ratios (aORs), adjusted for personal and clinical practice characteristics.

RESULTS

Less than half of respondents demonstrated high knowledge of availability of diagnostic criteria (36.8%), cessation treatment efficacy (33.2%), evidence-based counseling modalities (5.6%), and FDA-approved medications (40.1%). Significant differences were found between specialties: compared to internists, family physicians were less likely to have low knowledge of medications (aOR = .69, 95% CI = .53, .90) and obstetricians/gynecologists were more likely to have low knowledge of medications (aOR = 2.62, 95% CI = 1.82, 3.76). Overall, few associations between knowledge and clinical practice characteristics were identified.

CONCLUSION

Most providers had low knowledge of the topics of interest, with little variation across clinical practice characteristics, indicating room for improvement. Efforts to improve provider knowledge of evidence-based treatments are an important component of a comprehensive approach to improving delivery and use of cessation interventions and increasing tobacco cessation.

Rationale, design, and protocol for a hybrid type 1 effectiveness-implementation trial of a proactive smoking cessation electronic visit for scalable delivery via primary care: the E-STOP trial

BACKGROUND

Cigarette smoking remains the leading cause of preventable disease and death in the United States. Primary care offers an ideal setting to reach adults who smoke cigarettes and improve uptake of evidence-based cessation treatment. Although U.S. Preventive Services Task Force Guidelines recommend the 5As model (Ask, Advise, Assess, Assist, Arrange) in primary care, there are many barriers to its implementation. Automated, comprehensive, and proactive tools are needed to overcome barriers. Our team developed and preliminarily evaluated a proactive electronic visit (e-visit) delivered via the Electronic Health Record patient portal to facilitate evidence-based smoking cessation treatment uptake in primary care, with promising initial feasibility and efficacy. This paper describes the rationale, design, and protocol for an ongoing Hybrid Type I effectiveness-implementation trial that will simultaneously assess effectiveness of the e-visit intervention for smoking cessation as well as implementation potential across diverse primary care settings.

METHODS

The primary aim of this remote five-year study is to examine the effectiveness of the e-visit intervention vs. treatment as usual (TAU) for smoking cessation via a clinic-randomized clinical trial. Adults who smoke cigarettes are recruited across 18 primary care clinics. Clinics are stratified based on their number of primary care providers and randomized 2:1 to either e-visit or TAU. An initial baseline e-visit gathers information about patient smoking history and motivation to quit, and a clinical decision support algorithm determines the best evidence-based cessation treatment to prescribe. E-visit recommendations are evaluated by a patient's own provider, and a one-month follow-up e-visit assesses cessation progress. Main outcomes include: (1) cessation treatment utilization (medication, psychosocial cessation counseling), (2) reduction in cigarettes per day, and (3) biochemically verified 7-day point prevalence abstinence (PPA) at six-months. We hypothesize that patients randomized to the e-visit condition will have better cessation outcomes (vs. TAU). A secondary aim evaluates e-visit implementation potential at patient, provider, and organizational levels using a mixed-methods approach. Implementation outcomes include acceptability, adoption, fidelity, implementation cost, penetration, and sustainability.

DISCUSSION

This asynchronous, proactive e-visit intervention could provide substantial benefits for patients, providers, and primary care practices and has potential to widely improve reach of evidence-based cessation treatment.

TRIAL REGISTRATION

NCT05493254.

Good practice regarding smoking cessation management in Spain: Challenges and opportunities for primary care physicians and nurses

INTRODUCTION

We analyze the activities carried out by primary care (PC) physicians and nurses with respect to smoking cessation and evaluate their self-reported training, knowledge, and behavior.

METHODS

A cross-sectional study was conducted including 1514 PC physicians and nurses from June 2016 to March 2017, in Spain. The main variable was Good Practice (GP) in attention to smokers. To identify associated factors, a multilevel logistic regression model was used adjusted for sex, age, type of center, contract, years of employment, tobacco consumption, and self-reported training/knowledge.

RESULTS

Of the 792 physicians and 722 nurses, 48.6% referred to GP in smoking cessation management. The finding related to: being a non-smoker (OR=1.8; 95% CI: 1.2–2.5) or ex-smoker (OR=1.4; 95% CI: 1.02–2.1), having a good level of knowledge (OR=1.8; 95% CI: 1.3–2.4) and training (OR=2.4; 95% CI: 1.8–3.2), and, to a lesser extent, being female (OR=1.3; 95% CI: 1.03–1.7), and work experience >10 years (OR=1.4; 95% CI: 1.03–1.9). The main GP barriers were: lack of time (45.5%), organizational problems (48.4%), and 35.4% lack of training.

CONCLUSIONS

The GP of PC physicians and nurses regarding smoking cessation management is related to being non-smokers or ex-smokers, and having sufficient training and knowledge. Lack of time and organizational problems were considered to be the main barriers. The promotion of training activities in the Spanish National Health Service with the support of scientific societies is required.

Evaluation of a Proactive Smoking Cessation Electronic Visit to Extend the Reach of Evidence-Based Cessation Treatment via Primary Care

Background: Best practice guidelines for smoking cessation treatment through primary care advise the 5As model. However, compliance with these guidelines is poor, leaving many smokers untreated. The purpose of this study was to develop and preliminarily evaluate an asynchronous smoking cessation electronic visit (e-visit) that could be delivered proactively through the electronic health record (EHR) to adult smokers treated within primary care. The goal of the e-visit is to automate 5As delivery to ensure that all smokers receive evidence-based cessation treatment. As such, the aims of this study were twofold: (1) to examine acceptability, feasibility, and treatment metrics associated with e-visit utilization and (2) to preliminarily examine efficacy relative to treatment as usual (TAU) within primary care. Methods: Participants (n = 51) were recruited from primary care practices between November 2018 and October 2019 and randomized 2:1 to receive either the smoking cessation e-visit or TAU. Participants completed assessments of cessation outcomes 1-month and 3-months postenrollment and e-visit analytics data were gathered from the EHR. Results: Self-report feedback from e-visit participants indicated satisfaction with the intervention and interest in using e-visits again in the future. Nearly all e-visits resulted in prescription of a U.S. Food and Drug Administration (FDA)-approved smoking cessation medication. In general, smoking cessation outcomes favored the e-visit condition at both 1 (odds ratios [ORs]: 2.10-5.39) and 3 months (ORs: 1.31-4.67). Conclusions: These results preliminarily indicate the feasibility, acceptability, and efficacy of this smoking cessation e-visit within primary care. Future studies should focus on larger scale examination of effectiveness and implementation across settings. The clinicaltrials.gov registration number for this trial is NCT04316260.

The effects of a short-term physician training on smoking cessation in a university pulmonary department

Objective: The objective was to evaluate the effect of a short physician training in smoking cessation on the physicians' performance of smoking cessation interventions. The effects on patients' cessation rates were analyzed as well. A further aim was to identify barriers for providing cessation interventions. The study was conducted in an acute care pulmonology department of a German university hospital. Methods: 24 physicians of the pulmonology department of a German university hospital received a two-hour training in smoking cessation. 109 pre- and 89 post-training group patients were compared with regard to the frequencies of received smoking cessation interventions (Ask, Advise, Assist) and three- and six-month abstinence rates. Physicians estimated their intervention frequencies and gave reasons for not providing cessation interventions. Results: In a multivariable analysis (p<0.05), the physicians' application of "Ask" (OR 3.28, 95% CI 1.13-9.53) and the six-month abstinence rates (OR 2.70, 95% CI 1.24-5.84) were significantly higher in the post-training group. The univariate analysis also showed a significant effect on "Assist" (OR 2.05, 95% CI 1.09-3.87). No significant effect was seen on "Advise to quit". Physicians overestimated their intervention frequencies and reported the patients' low motivation to stop, an oncological disease and palliative care situation as barriers to performing smoking cessation. Conclusion: A short physician training in a hospital department of pulmonology increases the use of guideline-based cessation strategies and may improve cessation rates. The findings show that hospital-based strategies such as physician trainings could be useful in the improvement of smoking cessation. Strategies for overcoming barriers for providing smoking cessation interventions are needed.

Enhancing smoking cessation in Mexico using an e-Health tool in primary healthcare

OBJECTIVE

To evaluate an e-Health tool designed to enhance smoking cessation in Mexico in primary healthcare.

MATERIALS AND METHODS

Smokers 18 years of age and older were recruited in the waiting room of two primary healthcare clinics in Mexico City. Participants used an eHealth smoking cessation tool that included smoking-related assessments, education on pharmacotherapy, and motivational videos. A follow-up assessment was conducted at 12 weeks week on smoking status. Logistic regression models were performed to identify factors associated with smoking cessation or consumption reduction.

RESULTS

A total of 132 smokers were enrolled in the study. At follow-up, 23.5% of participants self-reported smoking cessation. Among those who did not quit smoking, 65.0% decreased the number of cigarettes. Factors associated significantly with smoking cessation were: being a non-daily smoker, being interested in quitting smoking, having low level of physical dependence, and participating in cessation treatment.

CONCLUSIONS

The e-Health tool produced a high rate of smoking cessation. Better outcomes are obtained when this tool is used with conventional cessation programs.

Nicotine replacement therapy sampling via primary care: Methods from a pragmatic cluster randomized clinical trial

BACKGROUND

Primary care is the most important point of healthcare contact for smokers. Brief physician advice to quit, based on the 5As/AAR model, offers some efficacy but is inconsistently administered and has limited population impact. Nicotine replacement therapy (NRT) sampling, defined as provision of a brief NRT starter kit, when added to the 5As/AAR, is well-suited to primary care because it is simple, brief, and can be provided to all smokers. This article describes the design and methods of an ongoing comparative effectiveness trial testing standard care vs. standard care + NRT sampling within primary care.

METHODS

Smokers were recruited directly from primary care practices between July 2014 and December 2017 within an established network of South Carolina clinics. Interventions were delivered randomly by clinic personnel, and phone-based follow-ups were centrally coordinated by research staff to track outcomes through six months post-intervention. Primary study aims are to examine the impact of NRT sampling on smoking, inclusive of cessation, quit attempts, and uptake of evidence-based treatment.

RESULTS

Twenty-two clinics were recruited. Across clinics, patient census ranged from 985 to 10,957 and number of providers ranged from 1 to 63. Average patient age across clinics was 52.9 years and smoking prevalence across ranged from 10.6% to 28.5%.

CONCLUSION

Improving the effectiveness and reach of brief interventions within primary care could have a considerable impact on population quit rates. We consider the advantages and disadvantages of key methodological decisions relevant to the design of future primary care-based cessation trials.

The TOBg Tobacco Treatment Guidelines for Adolescents: A real-world pilot study

INTRODUCTION

We conducted a pilot study to: 1) obtain feedback from prevention practitioners in terms of their satisfaction, knowledge, and self-efficacy following exposure to the Tobacco Treatment Guidelines for Adolescents (TOBg Guidelines); and 2) examine the effectiveness of a school-based intervention based on the TOBg Guidelines on quit rates among a sample of adolescent tobacco users.

METHODS

Two parallel studies were conducted. In Study 1, prevention practitioners were exposed to a 1-day training in the TOBg Guidelines with assessment occurring before, immediately after, and at 6 months following the training. In Study 2, participating adolescent smokers were exposed to a 3-session group-based smoking cessation intervention that drew on the TOBg Guidelines and was delivered by practitioners trained in Study 1. The primary outcome measure was self-reported smoking status assessed at 1 month and at 6 months following baseline.

RESULTS

A total of 18 prevention practitioners and 65 adolescent tobacco users participated in the pilot study. The majority of practitioners reported high rates of satisfaction with the TOBg Guidelines and indicated that the guidelines positively influenced the manner in which they addressed tobacco use with adolescents. Prevention practitioners’ self-efficacy for intervening with adolescent smokers was also significantly increased following exposure to the TOBg Guidelines and training. Among adolescents exposed to the school-based intervention, 62.5% and 23.1% had reduced smoking by 50% or more at 1 month and at 6 months follow-up, respectively. No significant change in smoking abstinence was documented.

CONCLUSIONS

The TOBg Guidelines for adolescent smokers were well received by prevention practitioners and were feasible to implement in a real-world school setting.

Is There an Association Between Smoking Status and Prosthetic Joint Infection After Primary Total Joint Arthroplasty?

BACKGROUND

Recent reports highlighted the association between smoking and higher risk of postsurgical infections. The aim was to compare the incidence of prosthetic joint infection after primary total joint arthroplasty (TJA) according to smoking status.

METHODS

A prospective hospital registry-based cohort study was performed including all primary knee and hip TJAs performed between March 1996 and December 2013. Smoking status preoperatively was classified into never, former, and current smoker. Incidence rates and hazard ratios (HRs) for prosthetic joint infection according to smoking status were assessed within the first year and beyond.

RESULTS

We included 8559 primary TJAs (mean age 69.5 years), and median follow-up was 67 months. There were 5722 never, 1315 former, and 1522 current smokers. Incidence rates of infection within the first year for never, former, and current smokers were, respectively, 4.7, 10.1, and 10.9 cases/1000 person-years, comparing ever vs never smokers, crude and adjusted HRs were 2.35 (95% confidence interval [CI] 1.39-3.98) and 1.8 (95% CI 1.04-3.2). Beyond the first year, crude and adjusted HRs were 1.37 (95% CI 0.78-2.39) and 1.12 (95% CI 0.61-2.04).

CONCLUSION

Smoking increased the infection risk about 1.8 times after primary hip or knee TJA in both current and former smokers. Beyond the first year, the infection risk was similar to never smokers.

Factors associated with rates of tobacco treatment delivery by General Practitioners in Greece: Missed opportunities for prevention?

INTRODUCTION

This study investigates the clinic-, provider- and patient-level factors associated with delivery of 4 (Ask, Advise, Assist, Arrange) elements of the 5As approach to smoking cessation in general practice in Greece.

METHODS

We conducted a secondary analysis of data derived from a quasi-experimental study (The TiTAN Crete study) among general practitioners (GPs) in Crete, Greece in 2015–2016. Twenty-four GPs and a cross-sectional sample of 1301 smokers from their practices were surveyed. This paper reports on the results of the multi-level modelling conducted to examine predictors of 4As delivery.

RESULTS

Our analysis found clinic characteristics, including the presence of an electronic medical record, being located in a rural setting, and being in private practice were significantly associated with increased rates of tobacco treatment delivery. Female GPs were more likely than males to arrange follow-up (AOR 3.38, 95%CI 1.11, 10.35). Our analysis found a variety of patient-level factors were positively associated with tobacco treatment delivery, including: longer smoking history; presence of a smoking related illness; readiness to quit smoking; and symptoms or a diagnosis of anxiety, depression or other mental health illness. Other patient-level factors were negatively associated with tobacco treatment delivery, including level of education and reason for visit. Patients seen in clinic for episodic care were less likely to be ‘asked’ (AOR 0.22, 95%CI 0.12, 0.39), ‘advised’ (AOR 0.22, 95%CI 0.13, 0.38), and receive ‘assistance’ (AOR 0.36, 95%CI 0.19, 0.66) compared to patients seen in clinic for a medical examination.

CONCLUSIONS

Providers are significantly more frequently delivering tobacco treatment to a sub-group of high-risk patients compared to other tobacco users in their clinical practice. This results in missed opportunities for early intervention and disease prevention.

Impact of the Tobacco Treatment Guidelines for High Risk Groups (TOB.g): A pilot study among physicians specializing in CVD, Diabetes and COPD

INTRODUCTION

The 2017 Tobacco Cessation Guidelines for High-risk Groups (TOB-G) is a comprehensive document on best practices for smoking cessation in clinical practice. The purpose of this pilot study was to assess physician satisfaction and changes in tobacco-related knowledge, self-efficacy and attitudes following exposure to training in the TOB-G guidelines for patients with cardiovascular disease (CVD), chronic obstructive pulmonary disease (COPD), or diabetes.

METHODS

A pre-post pilot study was conducted. All participating physicians received an electronic or printed copy of the TOB-G guidelines for patients with CVD, COPD or diabetes. Physicians were also exposed to a one-day training focused on the key clinical practice recommendations from the TOB.g guidelines. Outcome measurement occurred via survey before, immediately following and 6 months after exposure to the training.

RESULTS

Fifty physicians participated in the TOB.g training session. High rates of participant satisfaction were documented (exceeded expectations 47.7%; met expectations to a great extent 52.3%). Significant increases in physician knowledge and self-efficacy were documented immediately following and 6 months after exposure to the guideline training session. Exposure to the training was associated with positive changes in some but not all tobacco-related treatment attitudes, however these were no longer significant at the 6-month follow-up. Lower knowledge, confidence and unfavourable attitudes were documented for aspects of treatment related to pharmacotherapy.

CONCLUSIONS

Positive changes in previously reported barriers to the delivery of tobacco treatment among physicians were documented following exposure to the TOB.g guidelines and training for patients with CVD, COPD or diabetes.

Impact of large-scale distribution and subsequent use of free nicotine patches on primary care physician interaction

BACKGROUND

Large-scale distribution efforts of free nicotine replacement therapy (NRT) have been documented to be cost-effective interventions for increasing smoking quit rates. However, despite nearly a dozen studies evaluating their effectiveness, none have examined whether free NRT provision promotes further primary care help-seeking and the impact that it may have on cessation efforts.

METHODS

In the context of a randomized controlled trial, a secondary analysis was conducted on 1000 adult regular smokers randomized to be mailed a 5-week supply of nicotine patches or to a no intervention control group. Recipients and users of free nicotine patches at an 8 week follow-up were successfully case matched to controls based on age, gender, baseline level of nicotine dependence and intent to quit (n = 201 per group). Differences in physician interaction between the two groups were evaluated at both 8 week and 6 month follow-ups. The impact of physician interaction on self-reported smoking abstinence at each follow-up was also examined.

RESULTS

Although no differences in physician interaction were noted between groups at the 8 week follow-up, at the 6 month follow-up, nicotine patch users reported greater frequency of discussing smoking with their physician (43.9%), as compared to the control group (30.3%) (p = 0.011). Across both groups, over 90% of those that discussed smoking with a physician were encouraged to quit and approximately 70% were provided with additional support. Separate ANOVAs revealed no significant impact of physician interaction on cessation (p > 0.05), regardless of group or follow-up period, however, at the 6 month follow-up, nicotine patch users who discussed cessation with a physician had made serious quit attempts at significantly greater rates (72.6%), compared to controls (49.1%) (p = 0.007).

CONCLUSIONS

Irrespective of group, the majority of smokers in the present study did not discuss cessation with their physician. Recipients and users of nicotine patches however, were more likely to discuss smoking with their physician, suggesting that the provision of free NRT particularly to those who are likely to use it may facilitate opportunities for benefits beyond the direct pharmacological effects of the medication.

TRIAL REGISTRATION

clinicaltrials.gov , NCT01429129 . Registered: 2 September 2011.

Smoking behavior and beliefs about the impact of smoking on anti-tuberculosis treatment among health care workers

SETTING

Tuberculosis (TB) health care facilities throughout Georgia.

OBJECTIVE

To describe smoking behaviors among health care workers (HCWs) at TB facilities and determine HCWs' knowledge and beliefs regarding the impact of tobacco use on anti-tuberculosis treatment.

DESIGN

Cross-sectional survey from May to December 2014 in Georgia. Adult HCWs (age 18 years) at TB facilities were eligible. We administered a 60-question anonymous survey about tobacco use and knowledge of the effect of smoking on anti-tuberculosis treatment.

RESULTS

Of the 431 HCWs at TB facilities who participated, 377 (87.5%) were female; the median age was 50 years (range 20-77). Overall, 59 (13.7%) HCWs were current smokers and 35 (8.1%) were past smokers. Prevalence of current smoking was more common among physicians than among nurses (18.6% vs. 7.9%, P < 0.0001). Among HCWs, 115 (26.7%) believed smoking does not impact anti-tuberculosis treatment, and only 25.3% of physicians/nurses received formal training in smoking cessation approaches. Physicians who smoked were significantly more likely to believe that smoking does not impact anti-tuberculosis treatment than non-smoking physicians (aOR 5.11, 95%CI 1.46-17.90).

CONCLUSION

Additional education about the effect of smoking on TB treatment outcomes is needed for staff of TB health care facilities in Georgia. Nurses and physicians need more training about smoking cessation approaches for patients with TB.

Implementation of tobacco cessation brief intervention in complementary and alternative medicine practice: qualitative evaluation

Background

This article presents findings from qualitative interviews conducted as part of a research study that trained Acupuncture, Massage, and Chiropractic practitioners’ in Arizona, US, to implement evidence-based tobacco cessation brief interventions (BI) in their routine practice. The qualitative phase of the overall study aimed to assess: the impact of tailored training in evidence-based tobacco cessation BI on complementary and alternative medicine (CAM) practitioners’ knowledge and willingness to implement BIs in their routine practice; and their patients’ responses to cessation intervention in CAM context.

Methods

To evaluate the implementation of skills learned from a tailored training program, we conducted semi-structured qualitative interviews with 54 CAM practitioners in Southern Arizona and 38 of their patients. Interview questions focused on reactions to the implementation of tobacco cessation BIs in CAM practice.

Results

After participating in a tailored BI training, CAM practitioners reported increased confidence, knowledge, and motivation to address tobacco in their routine practice. Patients were open to being approached by CAM practitioners about tobacco use and viewed BIs as an expected part of wellness care.

Conclusions

Tailored training motivated CAM practitioners in this study to implement evidence-based tobacco cessation BIs in their routine practice. Results suggest that CAM practitioners can be a valuable point of contact and should be included in tobacco cessation efforts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-017-1836-7) contains supplementary material, which is available to authorized users.

Disparities in receipt of 5As for smoking cessation in diverse primary care and HIV clinics

Clinical practice guidelines recommend that clinicians implement the 5As (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation at every clinical encounter. We sought to examine the prevalence of patient- and clinician-reported 5As in two primary care and one HIV care clinics in San Francisco, California between August 2013 and March 2014 (n = 462 patients and n = 61 clinicians). We used multivariable logistic regression analysis to identify factors associated with receipt of the 5As, adjusting for patient demographics, patient insurance, clinic site, patient tobacco use, and patient comorbidities. The patient-reported prevalence of 5As receipt was as follows: Ask, 49.9%; Advise, 47.2%; Assess, 40.6%; any Assist, 44.9%; and Arrange, 22.4%. In multivariable analysis, receipt of Advise, Assess, and Assist were associated with older patient age. Whereas patients with HIV had a lower odds of reporting being advised (AOR 0.5, 95% CI 0.3–0.8) or assessed for readiness to quit (AOR 0.6, 95% CI 0.4–0.9), patients with pulmonary diseases had higher odds of reporting being assisted (AOR 1.6, 95% 1.0–2.6) than patients without these diagnoses. Although the majority of clinicians reported asking (91.8%), advising (91.8%), and assessing (93.4%) tobacco use ‘most of the time’ or ‘always’ during a clinical encounter, fewer reported assisting (65.7%) or arranging (19.7%) follow-up. Only half of patients reported being screened for tobacco use and fewer reported receipt of the other 5As, with significant disparities in receipt of the 5As among patients with HIV. Our findings confirm the need for interventions to increase clinician-delivered cessation treatment in primary and HIV care.

•

Clinical practice guidelines recommend the use of 5As for smoking cessation.

•

Patient reports of Assist and Arrange were low in primary care and HIV care.

•

There were significant disparities in the receipt of 5As among patients with HIV.

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Digital interventions could facilitate clinician-delivered 5As for patients.

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.

A Systematic Literature Review of Self-Reported Smoking Cessation Counseling by Primary Care Physicians

Tobacco consumption is a risk factor for chronic diseases and worldwide around six million people die from long-term exposure to first- or second-hand smoke annually. One effective approach to tobacco control is smoking cessation counseling by primary care physicians. However, research suggests that smoking cessation counseling is not sufficiently implemented in primary care. In order to understand and address the discrepancy between evidence and practice, an overview of counseling practices is needed. Therefore, the aim of this systematic literature review is to assess the frequency of smoking cessation counseling in primary care. Self-reported counseling behavior by physicians is categorized according to the 5A’s strategy (ask, advise, assess, assist, arrange). An electronic database search was performed in Embase, Medline, PsycINFO, CINAHL and the Cochrane Library and overall, 3491 records were identified. After duplicates were removed, the title and abstracts of 2468 articles were screened for eligibility according to inclusion/exclusion criteria. The remaining 97 full-text articles reporting smoking cessation counseling by primary care physicians were assessed for eligibility. Eligible studies were those that measured physicians’ self-reported smoking cessation counseling activities via questionnaire. Thirty-five articles were included in the final review (1 intervention and 34 cross-sectional studies). On average, behavior corresponding to the 5A’s was reported by 65% of physicians for “Ask”, 63% for “Advise”, 36% for “Assess”, 44% for “Assist”, and 22% of physicians for “Arrange”, although the measurement and reporting of each of these counseling practices varied across studies. Overall, the results indicate that the first strategies (ask, advise) were more frequently reported than the subsequent strategies (assess, assist, arrange). Moreover, there was considerable variation in the items used to assess counseling behaviour and developing a standardized instrument to assess the counseling strategies implemented in primary care would help to identify and address current gaps in practice.

Use of Smoking Cessation Interventions by Physicians in Argentina

BACKGROUND

Physician-implemented interventions for smoking cessation are effective but infrequently used. We evaluated smoking cessation practices among physicians in Argentina.

METHODS

A self-administered survey of physicians from six clinical systems asked about smoking cessation counselling practices, barriers to tobacco use counselling and perceived quality of training received in smoking cessation practices.

RESULTS

Of 254 physicians, 52.3% were women, 11.8% were current smokers and 52% never smoked. Perceived quality of training in tobacco cessation counselling was rated as very good or good by 41.8% and as poor/very poor by 58.2%. Most physicians (90%) reported asking and recording smoking status, 89% advised patients to quit smoking but only 37% asked them to set a quit date and 44% prescribed medications. Multivariate analyses showed that Physicians' perceived quality of their training in smoking cessation methods was associated with greater use of evidence-based cessation interventions. (OR = 6.5; 95% CI = 2.2-19.1); motivating patients to quit (OR: 7.9 CI 3.44-18.5), assisting patients to quit (OR = 9.9; 95% CI = 4.0-24.2) prescribing medications (OR = 9.6; 95% CI = 3.5-26.7), and setting up follow-up (OR = 13.0; 95% CI = 4.4-38.5).

CONCLUSIONS

Perceived quality of training in smoking cessation was associated with using evidence-based interventions and among physicians from Argentina. Medical training programs should enhance the quality of this curriculum.

Change of government's subsidization policy improves smoking cessation services: a cross-sectional study from the perspectives of physicians

Background

The Taiwanese government increased financial subsidies for smoking cessation services in 2012. We aimed to evaluate the effects of this new policy on smoking cessation services from the physician’s perspective.

Methods

This was a cross-sectional nationwide survey. Physicians who provided smoking cessation services for more than ten patient encounters in the preceding year of the new policy (February 2011 to March 2012) were recruited. The questionnaire was developed by two experts and was validated by a committee consisting of 11 delegates.

Results

We sent a total of 1,319 questionnaires. The response rate was 45.9 %. The majority of respondents were male (88.4 %), middle-aged (65.3 %), and worked as family physicians (56.1 %). Most physicians agreed that the new policy had increased the number of patients seeking smoking cessation, increased patients’ willingness to adopt pharmacotherapy, helped physicians to prescribe medications, improved patients’ adherence to medications, and improved quality of care. These changes were most prominent in medical centers. Changes in the practice of the 5As (ask, advise, assess, assist, arrange) were moderate. Among different medical settings, the most significant change was an increase in the expenditure on smoking cessation medications.

Conclusions

The new subsidization policy in Taiwan has improved smoking cessation services. Overall, physicians reported positive effects of the new policy. Further study is warranted to evaluate the long-term influence of the policy.

Identifying effective behavioural components of Intervention and Comparison group support provided in SMOKing cEssation (IC-SMOKE) interventions: a systematic review protocol

BACKGROUND

Systematic reviews of behaviour change interventions for smoking cessation vary in scope, quality, and applicability. The current review aims to generate more accurate and useful findings by (1) a detailed analysis of intervention elements that change behaviour (i.e. behaviour change techniques (BCTs)) and potential moderators of behaviour change (i.e. other intervention and sample characteristics) and (2) assessing and controlling for variability in support provided to comparison groups in smoking cessation trials.

METHODS

A systematic review will be conducted of randomized controlled trials of behaviour change interventions for smoking cessation in adults (with or without pharmacological support), with a minimum follow-up of 6 months, published after 1995. Eligible articles will be identified through the Cochrane Tobacco Addiction Group Specialized Register. Study authors will be asked for detailed descriptions of smoking cessation support provided to intervention and comparison groups. All data will be independently coded by two researchers. The BCT taxonomy v1 (tailored to smoking cessation interventions) and template for intervention description and replication criteria will be used to code intervention characteristics. Data collection will further include sample and trial characteristics and outcome data (smoking cessation rates). Multilevel mixed-effects meta-regression models will be used to examine which BCTs and/or BCT clusters delivered to intervention and comparison groups explain smoking cessation rates in treatment arms (and effect sizes) and what key moderators of behaviour change are. Predicted effect sizes of each intervention will be computed assuming all interventions are compared against comparison groups receiving the same levels of behavioural support (i.e. low, medium, and high levels). Multi-disciplinary advisory board members (policymakers, health care providers, and (ex-)smokers) will provide strategic input throughout the project to ensure the review's applicability to policy and practice.

DISCUSSION

By capturing BCTs in intervention and comparison groups, this systematic review will provide more accurate estimates of the effectiveness of smoking cessation interventions, the most promising BCTs and/or BCT clusters associated with smoking cessation rates in intervention and comparison arms, and important moderators of behaviour change. The results could set new standards for conducting meta-analyses of behaviour change interventions and improve research, service delivery, and training in the area of smoking cessation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015025251.

Hospital doctors' smoking behavior and attitude towards smoking cessation interventions for patients: a survey in an Italian Comprehensive Cancer Centre

PURPOSE

Tobacco control guidelines recommend all healthcare professionals to ask patients about their smoking status and to offer them at least minimal cessation advice. However, few data are available about the daily practice of hospital clinicians who work with smoking cancer patients. This study assesses, in a comprehensive cancer center, the physicians' smoking habit, their clinical practice in offering a smoking cessation intervention to patients who smoke, and the training they received in this field.

METHODS

A Web-based survey was sent to 285 physicians.

RESULTS

The survey response rate was 75%. Sixty-two percent, 24%, and 14% of responders were never, former, and current smokers, respectively. Six percent of all responding physicians have already participated in smoking cessation training and 43% of them declared their willingness to be trained. Eighty-six percent of all responding physicians asked about the patients' smoking status, 50% routinely advised patients to quit smoking, and 32% assessed their motivation to do so. Smoking cessation guidelines were not followed mostly for lack of time, fear to increase patients' stress, and lack of smoking cessation training. Ninety-four percent of responding physicians knew the smoking cessation service for outpatients and 65% referred at least one patient, 66% of responding physicians knew the service for inpatients, and 36% of them asked for at least one intervention in the ward.

CONCLUSIONS

This study pointed out partial adherence of the physicians working in a leading cancer center to the smoking cessation guidelines. The clinicians' smoking habits did not influence the training and the clinical practice in offering patients smoking cessation interventions.

The Efficacy of Three Modalities of Internet-Based Psychotherapy for Non-Treatment-Seeking Online Problem Gamblers: A Randomized Controlled Trial

Background

Internet-based interventions targeted at the most at-risk gamblers could reduce the treatment gap for addictive disorders. Currently, no clinical trial has included non–treatment-seeking patients who have been recruited directly in their gambling environment. This study was the first exclusively Internet-based randomized controlled trial among non–help-seeking problem gamblers with naturalistic recruitment in their gambling environment.

Objective

The aim of this study was to assess the efficacy of three modalities of Internet-based psychotherapies with or without guidance, compared to a control condition, among problem gamblers who play online poker.

Methods

All active poker gamblers on the Winamax website were systematically offered screening. All problem poker gamblers identified with a Problem Gambling Severity Index (PGSI) score of ≥5 were eligible to be included in the trial. Problem gamblers were randomized into four groups: (1) waiting list (control group), (2) personalized normalized feedback on their gambling status by email, (3) an email containing a self-help book to be downloaded with a Cognitive Behavioral Therapy (CBT) program without guidance, and (4) the same CBT program emailed weekly by a trained psychologist with personalized guidance. Efficacy was assessed based on the change in PGSI between baseline and 6 weeks (end of treatment) or 12 weeks (maintenance) and supported by player account-based gambling data automatically collected at the three time points.

Results

All groups met high attrition rates (83%), but the group with guidance had a significantly higher dropout rate than the other three groups, including the control group. Although all groups showed some improvement, with a mean decrease of 1.35 on the PGSI, no significant difference in efficacy between the groups was observed. One-third of the problem gamblers fell below the problem gambling threshold at 6 weeks.

Conclusions

Guidance could have aversively affected problem gamblers who had not sought help. Despite the lack of significant difference in efficacy between groups, this naturalistic trial provides a basis for the development of future Internet-based trials in individuals with gambling disorders. Comorbidities, natural course of illness, and intrinsic motivation seem to be critical issues to consider in future designs.

Trial Registration

ANSM 2013-A00794-41

Primary Care Provider-Delivered Smoking Cessation Interventions and Smoking Cessation Among Participants in the National Lung Screening Trial

IMPORTANCE

The National Lung Screening Trial (NLST) found a reduction in lung cancer mortality among participants screened with low-dose computed tomography vs chest radiography. In February 2015, Medicare announced its decision to cover annual lung screening for patients with a significant smoking history. These guidelines promote smoking cessation treatment as an adjunct to screening, but the frequency and effectiveness of clinician-delivered smoking cessation interventions delivered after lung screening are unknown.

OBJECTIVE

To determine the association between the reported clinician-delivered 5As (ask, advise, assess, assist [talk about quitting or recommend stop-smoking medications or recommend counseling], and arrange follow-up) after lung screening and smoking behavior changes.

DESIGN, SETTING, AND PARTICIPANTS

A matched case-control study (cases were quitters and controls were continued smokers) of 3336 NLST participants who were smokers at enrollment examined participants' rates and patterns of 5A delivery after a lung screen and reported smoking cessation behaviors.

MAIN OUTCOMES AND MEASURES

Prevalence of the clinician-delivered 5As and associated smoking cessation after lung screening.

RESULTS

Delivery of the 5As 1 year after screening were as follows: ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%. Receipt of ask, advise, and assess was not significantly associated with quitting in multivariate models that adjusted for sociodemographic characteristics, medical history, screening results, nicotine dependence, and motivation to quit. Assist was associated with a 40% increase in the odds of quitting (odds ratio, 1.40; 95% CI, 1.21-1.63), and arrange was associated with a 46% increase in the odds of quitting (odds ratio, 1.46; 95% CI, 1.19-1.79).

CONCLUSIONS AND RELEVANCE

Assist and arrange follow-up delivered by primary care providers to smokers who were participating in the NLST were associated with increased quitting; less intensive interventions (ask, advise, and assess) were not. However, rates of assist and arrange follow-up were relatively low. Our findings confirm the need for and benefit of clinicians taking more active intervention steps in helping patients who undergo screening to quit smoking.

Factors Influencing Smoking Cessation Counselling: A Qualitative Study of Medical Residents

Introduction: Physicians in training must be able to counsel their patients on smoking cessation, however, little is known about the barriers that they face to counselling their patients.

Aims: The study sought to identify barriers to smoking cessation counselling specific to physicians in training.

Methods: Qualitative interviews in the form of focus groups were conducted with 30 medical residents. Focus groups were audio taped, transcribed verbatim and coded by two independent reviewers. Similar codes were grouped to form categories and then aggregated to form themes.

Results: Seven themes emerged describing resident barriers to provision of smoking cessation counselling : (1) Lack of self-efficacy for providing counselling; (2) their perception that patients are not willing to change; (3) a lack of available resources/information for providers and patients; (4) differences in supervising physician's recommendations; (5) perceived lack of time; (6) a perception of lack of continuous care; and (7) a lack of practical skills in counselling.

Conclusions: This study highlighted residents’ perceived barriers to providing smoking cessation counselling. These barriers are similar to those encountered by other providers. Additional barriers specific to residency exist and more training is necessary.

Practice Implications: The barriers that physicians encounter to smoking cessation counselling must be addressed early on in residency training.

State-of-the-art office-based interventions to eliminate youth tobacco use: the past decade

Tobacco use and tobacco smoke exposure are among the most important preventable causes of premature disease, disability, and death and therefore constitute a major pediatric health concern. The pediatric primary care setting offers excellent opportunities to prevent tobacco use in youth and to deliver cessation-related treatment to youth and parents who use tobacco. This report updates a "state-of-the-art" article published a decade ago on office-based interventions to address these issues. Since then there has been marked progress in understanding the nature, onset, and trajectories of tobacco use and nicotine addiction in youth with implications for clinical practice. In addition, clinicians need to remain abreast of emerging nicotine delivery systems, such as electronic cigarettes, that may influence uptake or continuation of smoking. Although evidence-based practice guidelines for treating nicotine addiction in youth are not yet available, research continues to build the evidence base toward that goal. In the interim, practical guidelines are available to assist clinicians in addressing nicotine addiction in the pediatric clinical setting. This article reports current practices in addressing tobacco in pediatric primary care settings. It reviews our increasing understanding of youth nicotine addiction, summarizes research efforts on intervention in the past decade and additional research needed going forward, and provides practical guidelines for pediatric health care providers to integrate tobacco use prevention and treatment into their clinical practice. Pediatric providers can and should play an important role in addressing tobacco use and dependence, both in the youth they care for and in parents who use tobacco.

Population-Level Quality Measures for Behavioral Screening and Intervention

Delivered routinely in general health care settings, smoking, alcohol, depression, and obesity screening and intervention (behavioral screening and intervention [BSI]) could substantially improve population health and reduce health care costs. Yet BSI is seldom delivered in an evidence-based manner. This article assesses the adequacy of quality measures for BSI. Online searches of the National Quality Forum's Quality Positioning System and the National Clearinghouse for Quality Measures databases were conducted using the keywords smoking, tobacco, alcohol, depression, and obesity The types and focuses of each measure were classified, and differences between the metrics and evidence-based practice were identified. Most measures indicate whether BSI components are delivered, not how well. Clinicians can perform well on most metrics without delivering evidence-based services. More rigorous quality measures are needed. A new kind of measure is proposed, whereby separate terms representing the reach and effectiveness of key BSI components are multiplied to produce a single indicator of population-level impact for each behavioral topic.

Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students

OBJECTIVE

Physicians play a critical role in addressing tobacco dependence, yet report limited training. Tobacco dependence treatment curricula for medical students could improve performance in this area. This study identified student and medical school tobacco treatment curricula characteristics associated with intentions and use of the 5As for tobacco treatment among 3rd year U.S. medical students.

METHODS

Third year medical students (N=1065, 49.3% male) from 10 U.S. medical schools completed a survey in 2009-2010 assessing student characteristics, including demographics, tobacco treatment knowledge, and self-efficacy. Tobacco curricula characteristics assessed included amount and type of classroom instruction, frequency of tobacco treatment observation, instruction, and perception of preceptors as role models.

RESULTS

Greater tobacco treatment knowledge, self-efficacy, and curriculum-specific variables were associated with 5A intentions, while younger age, tobacco treatment self-efficacy, intentions, and each curriculum-specific variable were associated with greater 5A behaviors. When controlling for important student variables, greater frequency of receiving 5A instruction (OR=1.07; 95%CI 1.01-1.12) and perception of preceptors as excellent role models in tobacco treatment (OR=1.35; 95%CI 1.04-1.75) were significant curriculum predictors of 5A intentions. Greater 5A instruction (B=.06 (.03); p<.05) and observation of tobacco treatment (B=.35 (.02); p<.001) were significant curriculum predictors of greater 5A behaviors.

CONCLUSIONS

Greater exposure to tobacco treatment teaching during medical school is associated with both greater intentions to use and practice tobacco 5As. Clerkship preceptors, or those physicians who provide training to medical students, may be particularly influential when they personally model and instruct students in tobacco dependence treatment.

Assessing Medical Students' Tobacco Dependence Treatment Skills Using a Detailed Behavioral Checklist

CONSTRUCT: This article describes the development and implementation of an assessment intended to provide objective scores that would be valid indications of medical students' abilities to counsel patients about tobacco dependence.

BACKGROUND

Assessing medical students' advanced communication skills, particularly in the context of providing tobacco-dependence treatment, consistently and accurately is challenging; doing so across multiple medical schools is even more difficult.

APPROACH

Ten medical schools implemented a tobacco-dependence treatment case as part of an Objective Structured Clinical Examination for 3rd-year medical students. A 33-item checklist with detailed criteria and examples was developed for scoring students' performances. Trained coders viewed and coded 660 videotaped encounters; approximately 10% also were coded by the coding supervisor to check accuracy.

RESULTS

Average time required to code an encounter was approximately 31 minutes; accuracy (i.e., agreement with the gold standard coder) was excellent. Overall, students performed an average of 1 in 4 of the 33 behaviors included on the checklist, and only 1 in 10 discussed setting a quit date. Most students (almost 9 in 10) asked how much the patient smoked in a day, and just over 7 in 10 informed the patient that the cough was due to smoking.

CONCLUSIONS

The authors developed and implemented a rigorous assessment that will be used to evaluate medical students' tobacco-dependence treatment skills. Operationalizing the specific counseling behaviors, training coders to accurately capture students' performances using a structured checklist, and conducting the coding all required substantial time commitments but will provide confidence in the objectivity of the assessment results. In addition, this assessment can be used to provide formative information on medical students' tobacco-dependence treatment skills and to tailor ongoing training for medical students in this area.

What's in a setting?: Influence of organizational culture on provider adherence to clinical guidelines for treating tobacco use

BACKGROUND

Organizational culture is an important but underinvestigated feature of the work environment that can impact provider behavior, including adherence to clinical practice guidelines. There is substantial evidence that physician assistance to smokers can produce significant reductions in tobacco use. However, this evidence has not been well translated into practice, as only a small proportion of smokers receive recommended treatment during medical visits.

PURPOSE

This study examines organizational culture as a contextual feature of primary care clinics and its impact on adherence to evidence-based guidelines for treating tobacco use.

METHODOLOGY

Cross-sectional survey data were collected from 500 primary care providers in 60 community clinics located in New York City. Relationships between provider adherence to "5A" clinical guidelines, as recommended by the U.S. Public Health Service, and both provider and organizational covariates were described. We used hierarchical linear modeling to examine the associations between clinic culture and provider treatment patterns.

FINDINGS

Providers in clinics with stronger "group/clan," "hierarchical," and "rational" culture types, as compared with a "developmental" culture, reported greater adherence to 5A guidelines (p < .05). System-level structures and care processes were positively associated (p < .01), whereas number of ongoing quality initiatives was negatively associated with 5A delivery (p < .05). Provider familiarity with guidelines (p < .01), confidence with cessation counseling (p < .05), and perceived effectiveness in helping smokers quit were associated with more frequent 5A intervention (p < .01).

PRACTICE IMPLICATIONS

Findings suggest that organizational culture can influence provider adherence to cessation treatment guidelines, even when controlling for other factors known to affect practice patterns. Specifically, cultures that emphasize human resources and performance standards are conducive to integrating 5A guidelines into routine practice. Understanding the role of organizational culture enables healthcare managers and practitioners to be strategic when implementing, and also sustaining, use of evidence-based guidelines.

Response to a mobile health decision-support system for screening and management of tobacco use

PURPOSE/OBJECTIVES

To describe the predictors of nurse actions in response to a mobile health decision-support system (mHealth DSS) for guideline-based screening and management of tobacco use.

DESIGN

Observational design focused on an experimental arm of a randomized, controlled trial.

SETTING

Acute and ambulatory care settings in the New York City metropolitan area.

SAMPLE

14,115 patient encounters in which 185 RNs enrolled in advanced practice nurse (APN) training were prompted by an mHealth DSS to screen for tobacco use and select guideline-based treatment recommendations.

METHODS

Data were entered and stored during nurse documentation in the mHealth DSS and subsequently stored in the study database where they were retrieved for analysis using descriptive statistics and logistic regressions.

MAIN RESEARCH VARIABLES

Predictor variables included patient gender, patient race or ethnicity, patient payer source, APN specialty, and predominant payer source in clinical site. Dependent variables included the number of patient encounters in which the nurse screened for tobacco use, provided smoking cessation teaching and counseling, or referred patients for smoking cessation for patients who indicated a willingness to quit.

FINDINGS

Screening was more likely to occur in encounters where patients were female, African American, and received care from a nurse in the adult nurse practitioner specialty or in a clinical site in which the predominant payer source was Medicare, Medicaid, or State Children's Health Insurance Program. In encounters where the patient payer source was other, nurses were less likely to provide tobacco cessation teaching and counseling.

CONCLUSIONS

mHealth DSS has the potential to affect nurse provision of guideline-based care. However, patient, nurse, and setting factors influence nurse actions in response to an mHealth DSS for tobacco cessation.

IMPLICATIONS FOR NURSING

The combination of a reminder to screen and integration of guideline-based recommendations into the mHealth DSS may reduce racial or ethnic disparities to screening, as well as clinician barriers related to time, training, and familiarity with resources.

Physicians' attitudes and use of e-cigarettes as cessation devices, North Carolina, 2013

INTRODUCTION

Electronic cigarettes (e-cigarettes) are not currently approved or recommended by the Food and Drug Administration (FDA) or various medical organizations; yet, they appear to play a substantial role in tobacco users' cessation attempts. This study reports on a physician survey that measured beliefs, attitudes, and behavior related to e-cigarettes and smoking cessation. To our knowledge this is the first study to measure attitudes toward e-cigarettes among physicians treating adult smokers.

METHODS

Using a direct marketing company, a random sample of 787 North Carolina physicians were contacted in 2013 through email, with 413 opening the email and 128 responding (response rate = 31%). Physicians' attitudes towards e-cigarettes were measured through a series of close-ended questions. Recommending e-cigarettes to patients served as the outcome variable for a logistic regression analysis.

RESULTS

Two thirds (67%) of the surveyed physicians indicated e-cigarettes are a helpful aid for smoking cessation, and 35% recommended them to their patients. Physicians were more likely to recommend e-cigarettes when their patients asked about them or when the physician believed e-cigarettes were safer than smoking standard cigarettes.

CONCLUSIONS

Many North Carolina physicians are having conversations about e-cigarettes with their patients, and some are recommending them. Future FDA regulation of e-cigarettes may help provide evidence-based guidance to physicians about e-cigarettes and will help ensure that patients receive evidence-based recommendations about the safety and efficacy of e-cigarettes in tobacco cessation.

Challenges of implementing routine health behavior change support in a children's hospital setting

OBJECTIVE

Evidence indicates that health behavior change initiatives are often not implemented successfully. This qualitative study aims to understand the barriers and facilitators to implementation of health behavior change brief advice into routine practice in an acute children's hospital setting.

METHODS

Semi-structured interviews were conducted with health professionals working at a UK children's hospital (n=33). Participants were purposively sampled to incorporate a range of specialties, job roles and training.

RESULTS

An inductive thematic framework analysis identified two emergent themes. These capture the challenges of implementing routine health behavior change support in a children's hospital setting: (1) 'health professional knowledge, beliefs and behaviors' and (2) 'patient and family related challenges'.

CONCLUSION

This study enhances findings from previous research by outlining the challenges pediatric health professionals face in relation to supporting health behavior change. Challenges include failure to assume responsibility, low confidence, prioritization of the health provider relationship with patients and families, health provider and patient knowledge, and low patient and family motivation.

PRACTICE IMPLICATIONS

Skills-based behavior change training is needed for pediatric health professionals to effectively support health behavior change.

Use of provider-based complementary and alternative medicine by adult smokers in the United States: Comparison from the 2002 and 2007 NHIS survey

PURPOSE

To provide a snapshot of provider-based complementary and alternative medicine (pbCAM) use among adult smokers and assess the opportunity for these providers to deliver tobacco cessation interventions.

DESIGN

Cross-sectional analysis of data from the 2002 and 2007 National Health Interview Surveys.

SETTING

Nationally representative sample.

SUBJECTS

A total of 54,437 (31,044 from 2002; 23,393 from 2007) adults 18 years and older.

MEASURES

The analysis focuses on 10 types of pbCAM, including acupuncture, Ayurveda, biofeedback, chelation therapy, chiropractic care, energy therapy, folk medicine, hypnosis, massage, and naturopathy.

ANALYSIS

The proportions of current smokers using any pbCAM as well as specific types of pbCAM in 2002 and 2007 are compared using SAS SURVEYLOGISTIC.

RESULTS

Between 2002 and 2007, the percentage of recent users of any pbCAM therapy increased from 12.5% to 15.4% (p = .001). The largest increases occurred in massage, chiropractic, and acupuncture. Despite a decrease in the national average of current smokers (22.0% to 19.4%; p = .001), proportions of smokers within specific pbCAM disciplines remained consistent.

CONCLUSION

Complementary and alternative medicine (CAM) practitioners, particularly those in chiropractic, acupuncture, and massage, represent new cohorts in the health care community to promote tobacco cessation. There is an opportunity to provide brief tobacco intervention training to CAM practitioners and engage them in public health efforts to reduce the burden of tobacco use in the United States.

Absence de conseils hygiéno-diététiques donnés aux hypertendus et caractéristiques des patients et de leur médecin généraliste

Le médecin généraliste est essentiel dans la prise en charge des patients hypertendus, qui comprend la dispensation de conseils hygiéno-diététiques. Notre objectif était d’analyser les caractéristiques des patients et de leur généraliste associées au fait que le praticien n’ait pas donné ces conseils. Cinquante-neuf généralistes franciliens ont répondu à des questionnaires à l’aide de leurs dossiers, et leurs 1192 patients hypertendus traités, de 25 à 79 ans, ont été interrogés par téléphone. Les analyses, utilisant des modèles mixtes à intercept aléatoire, ont porté sur « ne pas avoir donné de conseils » concernant le sel, la perte de poids, la diminution de la consommation d’alcool et l’exercice physique. Les médecins dispensaient moins de conseils aux hypertendus ayant un faible risque cardiovasculaire et un suivi récent avec peu de consultations dans l’année. Au contraire, une organisation de la pratique avec des consultations longues, au tarif de l’assurance maladie, et la participation à la formation médicale continue étaient associées à plus de conseil, ainsi que le fait que le médecin soit lui-même hypertendu. En ciblant de manière privilégiée les patients qui reçoivent moins de conseils, le développement de programmes d’éducation thérapeutique pourrait améliorer cette situation.

The delivery of preventive care to clients of community health services

Background

Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; and acceptability of care. This will assist in informing interventions that facilitate adoption of opportunistic preventive care delivery to all clients.

Methods

In 2009 and 2010 a telephone survey was undertaken of 1284 clients across a network of 56 public community health facilities in one health district in New South Wales, Australia. The survey assessed receipt of preventive care (assessment, brief advice, and referral/follow-up) regarding smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, and physical inactivity; and acceptability of care.

Results

Care was most frequently reported for smoking (assessment: 59.9%, brief advice: 61.7%, and offer of referral to a telephone service: 4.5%) and least frequently for inadequate fruit or vegetable consumption (27.0%, 20.0% and 0.9% respectively). Sixteen percent reported assessment for all risks, 16.2% received brief advice for all risks, and 0.6% were offered a specific referral for all risks. The following were associated with increased care: diabetes services, number of appointments, being male, Aboriginal, unemployed, and socio-economically disadvantaged. Acceptability of preventive care was high (76.0%-95.3%).

Conclusions

Despite strong client support, preventive care was not provided opportunistically to all, and was preferentially provided to select groups. This suggests a need for practice change strategies to enhance preventive care provision to achieve adherence to clinical guidelines.

The impact of a team-based intervention on the lifestyle risk factor management practices of community nurses: outcomes of the community nursing SNAP trial

BACKGROUND

Lifestyle risk factors like smoking, nutrition, alcohol consumption, and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care is an appropriate setting to address these risk factors in individuals. Generalist community health nurses (GCHNs) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time. The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practices of GCHNs.

METHODS

The trial used a quasi-experimental design involving four generalist community nursing services in NSW, Australia. The services were randomly allocated to either an intervention group or control group. Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessments and interventions. The control group provided usual care. A sample of 129 GCHNs completed surveys at baseline, 6 and 12 months to examine changes in their practices and levels of confidence related to the management of SNAP risk factors. Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice.

RESULTS

Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers. Nurses in the intervention group reported assessing physical activity, weight and nutrition more frequently, as well as providing more brief interventions for physical activity, weight management and smoking cessation. There was little change in referral rates except for an improvement in weight management related referrals. Nurses' perception of the importance of 'client and system-related' barriers to risk factor management diminished over time.

CONCLUSIONS

This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practices of GCHNs. Barriers to referral remained. The service model needs to be adapted to sustain these changes and enhance referral.

TRIAL REGISTRATION

ACTRN12609001081202.

Talking about smoking in primary care medical practice--results of experimental studies from the US, UK and Germany

OBJECTIVE

To analyse effects of patient and physician characteristics on questions and advice about smoking in primary care practice and to examine country differences.

METHODS

We conducted a factorial experiment, employing filmed scenarios in which actors played the role of patients with symptoms of coronary heart disease (CHD) or type 2 diabetes. Versions were filmed with patient-actors of different gender, age, race, and socioeconomic status. The videotapes were presented to primary care physicians in the US, UK and Germany. Physicians were asked whether they would ask questions about smoking or give cessation advice.

RESULTS

Female and older CHD patients are less likely to be asked or get advice about smoking in all three countries. Effects of physician attributes are weak and inconsistent. Compared to physicians in the US and the UK, German doctors are least likely to ask questions or give advice.

CONCLUSIONS

Although all physicians viewed the same cases their questioning and advice giving differed according to patient attributes and country. Due to the experimental design external validity of the study may be limited.

PRACTICE IMPLICATIONS

Findings have implications for medical education and professional training of physicians as well as for the organization and financing of health care.

Health policymakers' knowledge and opinions of physicians smoking and tobacco policy control in Lao PDR

BACKGROUND

In 2007, a regulation on smoke-free health facilities and institutions was adopted by the Lao government. Little is known about health policymakers' knowledge and opinions regarding tobacco policy control, including physicians' behaviour. This paper aims to describe the knowledge of Lao health policymakers and their opinions regarding physicians tobacco use and national smoking policy control.

METHODS

In 2007, we made a qualitative explorative study with data from a purposive sample of 18 key informants through semi-structured, face-to-face interviews. The key informants, who were heads of departments, directors of hospitals and directors of centres, mainly worked at the national level, and some provincial levels. Content analysis was used.

RESULTS

Policymakers perceived the inadequate implementation of a smoke-free regulation and policy as being a barrier and that the general public may not accept physicians smoking, since they are regarded as role models. Most of the respondents mentioned that regulations or laws related to control of smoking in health institutions are available in Laos, but they lacked detailed knowledge of them probably because regulations as well as the smoke-free policy documents were not widely disseminated. The respondents agreed that anti-smoking education should be integrated in the training curricula, especially in the medical schools, and that the provision of counselling on health consequences from smoking and methods of smoking cessation was important.

CONCLUSION

This study contributes to tobacco policy evidence and to knowledge regarding factors related to the uptake of evidence into policymaking. Dissemination and implementation of a tobacco control policy nationally, and integration of tobacco cessation training programs in the curricula were found to be productive approaches for improvement.

Quality of cardiovascular disease care in Ontario, Canada: missed opportunities for prevention - a cross sectional study

Background

Primary care plays a key role in the prevention and management of cardiovascular disease (CVD). We examined primary care practice adherence to recommended care guidelines associated with the prevention and management of CVD for high risk patients.

Methods

We conducted a secondary analysis of cross-sectional baseline data collected from 84 primary care practices participating in a large quality improvement initiative in Eastern Ontario from 2008 to 2010. We collected medical chart data from 4,931 patients who either had, or were at high risk of developing CVD to study adherence rates to recommended guidelines for CVD care and to examine the proportion of patients at target for clinical markers such as blood pressure, lipid levels and hemoglobin A1c.

Results

Adherence to preventive care recommendations was poor. Less than 10% of high risk patients received a waistline measurement, half of the smokers received cessation advice, and 7.7% were referred to a smoking cessation program. Gaps in care exist for diabetes and kidney disease as 54.9% of patients with diabetes received recommended hemoglobin-A1c screenings, and only 55.8% received an albumin excretion test. Adherence rates to recommended guidelines for coronary artery disease, hypertension, and dyslipidemia were high (>75%); however <50% of patients were at target for blood pressure or LDL-cholesterol levels (37.1% and 49.7% respectively), and only 59.3% of patients with diabetes were at target for hemoglobin-A1c.

Conclusions

There remain significant opportunities for primary care providers to engage high risk patients in prevention activities such as weight management and smoking cessation. Despite high adherence rates for hypertension, dyslipidemia, and coronary artery disease, a significant proportion of patients failed to meet treatment targets, highlighting the complexity of caring for people with multiple chronic conditions.

Trial Registration

NCT00574808

Physician advice on avoiding secondhand smoke exposure and referrals for smoking cessation services

Background

Secondhand smoke (SHS) exposure causes premature death and disease. Eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from SHS exposure, and also contributes to helping smokers quit smoking. Primary health care providers can play an important role in advising nonsmoking patients to avoid SHS exposure, cautioning current smokers against exposing others to SHS, and referring tobacco users to cessation programs.

Methods

The purpose of this paper is to examine primary care provider (obstetricians/gynecologists, pediatricians, and general practitioners) advice regarding SHS exposure and referral to cessation programs. Using data from the 2008 DocStyles survey (n = 1,454), we calculated the prevalence and adjusted odds ratios for offering patients advice regarding SHS exposure and referring adults who smoked or used other tobacco products to a cessation program.

Results

The current study found that among a convenience sample of primary care providers, 94.9% encouraged parents to take steps to protect children from SHS exposure, 86.1% encouraged smokers to make their homes and cars smoke-free, and 77.4% encouraged nonsmokers to avoid SHS exposure. Approximately 44.0% of primary care providers usually or always referred patients who smoked or used tobacco products to cessation programs such as a quitline, a group cessation class, or one-on-one counseling.

Conclusion

Findings from a convenience sample of primary care providers who participated in a web-based survey, suggests that many primary care providers are advising parents to protect children from SHS exposure, encouraging patients who smoke to maintain smoke-free homes and cars, and advising smokers on ways to avoid exposing others to SHS. Healthcare providers are encouraged to advise patients to avoid SHS exposure and to refer patients who use tobacco products to cessation services.

A national survey of training and smoking cessation services provided in community pharmacies in Thailand

Over the past few years, several training programs have been run in support of smoking cessation services within community pharmacy circles in Thailand. These have included a comprehensive training program offered by the Thai Pharmacy Network for Tobacco Control (TPNTC) and brief training programs run by other agencies. This study provides an estimate of the scale of smoking cessation activities among Thai pharmacies, and examines the impact of both the brief and comprehensive training programs on the provision of smoking cessation services. A self-administered questionnaire was mailed to 3,600 Thai community pharmacists. A total of 1,001 questionnaires were returned (response rate: 27.8%). Smoking cessation services were provided by 71.1% of the respondents, and 47.4% of such services gave only brief advice. Comprehensive services (defined by the 5A's: ask, advise, assess, assist, and arrange follow-up) accounted for 15.3% of the respondents. Only 293 pharmacists (29.6%) said they had received cessation training; 62.5% of whom had received such training from TPNTC. The receipt of brief and comprehensive training was associated with a higher rate of the provision of brief advice, when compared with no training, showing adjusted odds ratios (ORs) of 2.93 (95% CI, 1.66-5.18) and 5.93 (95% CI, 3.18-10.17) respectively, while evidence of differences between these training programs was not observed, having an adjusted OR of 1.94 (95% CI, .89-4.21). TPNTC trained pharmacists were 4.98 times (95% CI, 2.24-11.05) more likely than those who received other brief training to provided the 5A's cessation services. All types of training program help to promote the provision of brief counseling by pharmacists. Comprehensive training is associated with the increased provision of both 4A's and 5A's cessation services.

Smoking cessation assistance for patients with bladder cancer: a national survey of American urologists

PURPOSE

Cigarette smoking is a known risk factor for bladder cancer. How urologists address smoking cessation among patients with bladder cancer is not well-known. We assessed the practice patterns of American urologists regarding smoking cessation assistance for patients with bladder cancer.

MATERIALS AND METHODS

A questionnaire regarding smoking cessation practice patterns was sent to 1,821 American urologists in the 2008 American Urological Association membership directory. Responses were summarized with frequency and percent. Statistical comparison was made using chi-square tests. Multiple logistic regression was used to detect significant predictors of providing smoking cessation assistance.

RESULTS

Responses were received from 601 urologists who collectively treated an estimated 14,713 patients with bladder cancer in the last year. More than half (55.6%) of urologists never discuss smoking cessation while only 19.8% always discuss smoking cessation with patients with bladder cancer. Of urologists who never discuss smoking cessation 40.7% believe that smoking cessation may not alter the course or outcome of the disease and 37.7% do not feel qualified giving smoking cessation counseling. Most urologists (93.7%) have never had formal smoking cessation training. Urologists with smoking cessation training were more likely to always provide smoking cessation assistance compared to those without training (20.6% vs 6.0%, p = 0.0011). Number of patients with bladder cancer treated (OR 3.96) and formal smoking cessation training (OR 13.49) were significant predictors of providing smoking cessation assistance.

CONCLUSIONS

American urologists demonstrate a low rate of providing smoking cessation assistance to patients with bladder cancer. Urologists who are trained in smoking cessation most commonly provide smoking cessation assistance. We recommend integrating formal smoking cessation instruction into courses that address bladder cancer and strongly encourage the American Urological Association to adopt practice pattern guidelines.

Health improvement and prevention study (HIPS) - evaluation of an intervention to prevent vascular disease in general practice

Background

The Health Improvement and Prevention Study (HIPS) study aims to evaluate the capacity of general practice to identify patients at high risk for developing vascular disease and to reduce their risk of vascular disease and diabetes through behavioural interventions delivered in general practice and by the local primary care organization.

Methods/Design

HIPS is a stratified randomized controlled trial involving 30 general practices in NSW, Australia. Practices are randomly allocated to an 'intervention' or 'control' group. General practitioners (GPs) and practice nurses (PNs) are offered training in lifestyle counselling and motivational interviewing as well as practice visits and patient educational resources. Patients enrolled in the trial present for a health check in which the GP and PN provide brief lifestyle counselling based on the 5As model (ask, assess, advise, assist, and arrange) and refer high risk patients to a diet education and physical activity program. The program consists of two individual visits with a dietician or exercise physiologist and four group sessions, after which patients are followed up by the GP or PN. In each practice 160 eligible patients aged between 40 and 64 years are invited to participate in the study, with the expectation that 40 will be eligible and willing to participate. Evaluation data collection consists of (1) a practice questionnaire, (2) GP and PN questionnaires to assess preventive care attitudes and practices, (3) patient questionnaire to assess self-reported lifestyle behaviours and readiness to change, (4) physical assessment including weight, height, body mass index (BMI), waist circumference and blood pressure, (5) a fasting blood test for glucose and lipids, (6) a clinical record audit, and (7) qualitative data collection. All measures are collected at baseline and 12 months except the patient questionnaire which is also collected at 6 months. Study outcomes before and after the intervention is compared between intervention and control groups after adjusting for baseline differences and clustering at the level of the practice.

Discussion

This study will provide evidence of the effectiveness of a primary care intervention to reduce the risk of cardiovascular disease and diabetes in general practice patients. It will inform current policies and programs designed to prevent these conditions in Australian primary health care.

Trial Registration

ACTRN12607000423415

Faculty development in tobacco cessation: training health professionals and promoting tobacco control in developing countries

ISSUES

Cessation programs are essential components of comprehensive tobacco control. Health-care providers, especially physicians, have major responsibility for role modeling and promoting cessation. For successful, sustainable cessation training programs, countries need health-care professionals with knowledge and skills to deliver and teach tobacco cessation.

APPROACH

Review literature relevant to faculty development in tobacco cessation and discuss its strategic potential in tobacco control.

KEY FINDINGS

Faculty development is essential for sustainable tobacco cessation training programs, and a potentially powerful strategy to shift professional and societal norms towards cessation and support of comprehensive tobacco control in countries with normative tobacco use and underdeveloped tobacco control programs.

IMPLICATIONS

Medical faculty are in a key position to influence tobacco cessation and control programs because of their roles as educators and researchers, receptivity to innovation and, influence on competencies and standards for medical education and practice. Faculty development programs must consider the number and type of faculty, and tobacco cessation curricula needed. Faculty development fosters the ability to institutionalise cessation education for students and community practitioners. Academic faculty are often leaders in their professional disciplines, influential in establishing clinical practice standards, and technical experts for government and other key health organisations.

CONCLUSION

Training health-care professional faculty to become knowledgeable and committed to tobacco cessation opens opportunities to promote cessation and shift professional and societal norms away from tobacco use.

Increasing consumer demand for tobacco treatments: Ten design recommendations for clinicians and healthcare systems

Health professionals play an important role in addressing patient tobacco use in clinical settings. While there is clear evidence that identifying tobacco use and assisting smokers in quitting affects outcomes, challenges to improve routine, clinician-delivered tobacco intervention persist. The Consumer Demand Initiative has identified simple design principles to increase consumers' use of proven tobacco treatments. Applying these design strategies to activities across the healthcare system, we articulate ten recommendations that can be implemented in the context of most clinical systems where most clinicians work. The recommendations are: (1) reframe the definition of success, (2) portray proven treatments as the best care, (3) redesign the 5A's of tobacco intervention, (4) be ready to deliver the right treatment at the right time, (5) move tobacco from the social history to the problem list, (6) use words as therapy and language that makes sense, (7) fit tobacco treatment into clinical team workflows, (8) embed tobacco treatment into health information technology, (9) make every encounter an opportunity to intervene, and (10) end social disparities for tobacco users. Clinical systems need to change to improve tobacco treatment implementation. The consumer- and clinician-centered recommendations provide a roadmap that focuses on increasing clinician performance through greater understanding of the clinician's role in helping tobacco users, highlighting the value of evidence-based tobacco treatments, employing shared decision-making skills, and integrating routine tobacco treatment into clinical system routines.

The evaluation of a Taiwanese training program in smoking cessation and the trainees' adherence to a practice guideline

Background

The Taiwanese government began reimbursement for smoking cessation in 2002. Certification from a training program was required for physicians who wanted reimbursement. The program certified 6,009 physicians till 2007. The objective of this study is to evaluate the short- and long term efficacy of the training program.

Methods

For short term evaluation, all trainees in 2007 were recruited. For long term evaluation, computer randomly selected 2,000 trainees who received training from 2002 to 2006 were recruited. Course satisfaction, knowledge, confidence in providing smoking cessation services and the adherence to a practice guideline were evaluated by questionnaires.

Results

Trainees reported high satisfaction with the training program. There was significant difference between pre- and post-test scores in knowledge. Confidence in providing services was lower in the long term evaluation compared to short term evaluation. For adherence to a practice guideline, 86% asked the status of smoking, 88% advised the smokers to quit, 76% assessed the smoker's willingness to quit, 59% assisted the smokers to quit, and 60% arranged follow-up visits for smokers. The incentive of reimbursement was the most significant factor affecting confidence and adherence.

Conclusions

The training program was satisfactory and effective. Adherence to a practice guideline in our study was better than studies without physician training in other countries.

Promoting smoking cessation in pregnancy with Video Doctor plus provider cueing: a randomized trial

OBJECTIVE

This study examined the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy.

DESIGN

A randomized clinical trial was conducted from 2006 to 2008.

SETTING

Five community prenatal clinics in the San Francisco Bay Area of the United States.

PARTICIPANTS

A total of 410 pregnant patients completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (n = 42) were randomized regardless of their intention to quit smoking.

METHODS

Participants were assigned to either usual care or intervention. Intervention participants received 15-minute Video Doctor sessions plus provider cueing, at baseline and one month, prior to their routine prenatal visit. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants, and a cueing sheet for providers.

MAIN OUTCOME MEASURES

Receipt of advice from the provider and 30-day smoking abstinence, both by self-report.

RESULTS

Intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (60.9 vs. 15.8%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. The 30-day abstinence rate at two months post baseline was 2.5 times greater in the intervention group; the difference was not significant (26.1 vs. 10.5%, p = 0.12).

CONCLUSIONS

The Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers.