Smoking cessation in primary care: a clinical effectiveness trial of two simple interventions

Strategies to improve the implementation of preventive care in primary care: a systematic review and meta-analysis

BACKGROUND

Action on smoking, obesity, excess alcohol, and physical inactivity in primary care is effective and cost-effective, but implementation is low. The aim was to examine the effectiveness of strategies to increase the implementation of preventive healthcare in primary care.

METHODS

CINAHL, CENTRAL, The Cochrane Database of Systematic Reviews, Dissertations & Theses - Global, Embase, Europe PMC, MEDLINE and PsycINFO were searched from inception through 5 October 2023 with no date of publication or language limits. Randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies comparing implementation strategies (team changes; changes to the electronic patient registry; facilitated relay of information; continuous quality improvement; clinician education; clinical reminders; financial incentives or multicomponent interventions) to usual care were included. Two reviewers screened studies, extracted data, and assessed bias with an adapted Cochrane risk of bias tool for Effective Practice and Organisation of Care reviews. Meta-analysis was conducted with random-effects models. Narrative synthesis was conducted where meta-analysis was not possible. Outcome measures included process and behavioural outcomes at the closest point to 12 months for each implementation strategy.

RESULTS

Eighty-five studies were included comprising of 4,210,946 participants from 3713 clusters in 71 cluster trials, 6748 participants in 5 randomised trials, 5,966,552 participants in 8 interrupted time series, and 176,061 participants in 1 controlled before after study. There was evidence that clinical reminders (OR 3.46; 95% CI 1.72-6.96; I2 = 89.4%), clinician education (OR 1.89; 95% CI 1.46-2.46; I2 = 80.6%), facilitated relay of information (OR 1.95, 95% CI 1.10-3.46, I2 = 88.2%), and multicomponent interventions (OR 3.10; 95% CI 1.60-5.99, I2 = 96.1%) increased processes of care. Multicomponent intervention results were robust to sensitivity analysis. There was no evidence that other implementation strategies affected processes of care or that any of the implementation strategies improved behavioural outcomes. No studies reported on interventions specifically designed for remote consultations. Limitations included high statistical heterogeneity and many studies did not account for clustering.

CONCLUSIONS

Multicomponent interventions may be the most effective implementation strategy. There was no evidence that implementation interventions improved behavioural outcomes.

TRIAL REGISTRATION

PROSPERO CRD42022350912.

An electronic health record-based interoperable eReferral system to enhance smoking Quitline treatment in primary care

OBJECTIVE

The study sought to determine whether interoperable, electronic health record-based referral (eReferral) produces higher rates of referral and connection to a state tobacco quitline than does fax-based referral, thus addressing low rates of smoking treatment delivery in health care.

MATERIALS AND METHODS

Twenty-three primary care clinics from 2 healthcare systems (A and B) in Wisconsin were randomized, unblinded, over 2016-2017, to 2 smoking treatment referral methods: paper-based fax-to-quit (system A =6, system B = 6) or electronic (eReferral; system A = 5, system B = 6). Both methods referred adult patients who smoked to the Wisconsin Tobacco Quitline. A total of 14 636 smokers were seen in the 2 systems (system A: 54.5% women, mean age 48.2 years; system B: 53.8% women, mean age 50.2 years).

RESULTS

Clinics with eReferral, vs fax-to-quit, referred a higher percentage of adult smokers to the quitline: system A clinic referral rate = 17.9% (95% confidence interval [CI], 17.2%-18.5%) vs 3.8% (95% CI, 3.5%-4.2%) (P < .001); system B clinic referral rate = 18.9% (95% CI, 18.3%-19.6%) vs 5.2% (95% CI, 4.9%-5.6%) (P < .001). Average rates of quitline connection were higher in eReferral than F2Q clinics: system A = 5.4% (95% CI, 5.0%-5.8%) vs 1.3% (95% CI, 1.1%-1.5%) (P < .001); system B = 5.3% (95% CI, 5.0%-5.7%) vs 2.0% (95% CI, 1.8%-2.2%) (P < .001).

DISCUSSION

Electronic health record-based eReferral provided an effective, closed-loop, interoperable means of referring patients who smoke to telephone quitline services, producing referral rates 3-4 times higher than the current standard of care (fax referral), including especially high rates of referral of underserved individuals.

CONCLUSIONS

eReferral may help address the challenge of providing smokers with treatment for tobacco use during busy primary care visits.ClinicalTrials.gov; No. NCT02735382.

Trends in smoking documentation rates in safety net clinics

OBJECTIVE

To assess the impact of provider incentive policy on smoking status documentation.

DATA SOURCES

Primary data were extracted from structured electronic medical records (EMRs) from 15 community health centers (CHCs).

STUDY DESIGN

This was an observational study of data from 2006 to 2013, assessing changes in documentation of smoking status over time.

DATA EXTRACTION METHODS

We extracted structured EMR data for patients age 18 and older with at least one primary care visit.

PRINCIPAL FINDINGS

Rates of documented smoking status rose from 30 percent in 2006 to 90 percent in 2013; the largest increase occurred from 2011 to 2012 following policy changes (21.3% [95% CI, 8.2%, 34.4%] from the overall trend). Rates varied by clinic and across patient subgroups.

CONCLUSIONS

Documentation of smoking status improved markedly after introduction of new federal standards. Further improvement in documentation is still needed, especially for males, nonwhite patients, those using opioids, and HIV + patients. More research is needed to study whether changes in documentation lead to improvements in counseling, cessation, and patient outcomes.

Continuing conversations about adverse childhood experiences (ACEs) screening: A public health perspective

Currently, in the U.S. and worldwide, childhood trauma is a public health crisis. Childhood adversities, such as abuse, neglect, and related household stressors, are common, interrelated and contribute to multiple adverse social, behavioral and health outcomes throughout the lifespan. The present article provides further discussion regarding adverse childhood experiences (ACEs) screening in healthcare utilizing the etic and emic perspectives. Screening in the healthcare system leans toward the etic view: objective observations of symptoms, which may then lead to intervention delivery. Whereas the emic view provides the subjective perspective as experienced by participants of a system, culture, or common group. Finkelhor's argument about cautions regarding widespread screening is relevant in the current allopathic healthcare system, which utilizes an etic perspective and where evidence-based ACEs interventions within a biomedical-centric model are lacking. Therefore, in healthcare settings, universal ACEs screening may serve the clinicians with a surveillance tool to inform and guide medical practice and policy as they relate to delivering trauma-informed care. The Public Health Code of Ethics and Basis for Action reminds us about the values approach for collecting and using data ethically to protect population health. Practitioners and researchers across the globe are beginning to take community-engaged action, with an emic view of all community members involved.

Screening for adverse childhood experiences (ACEs): Cautions and suggestions

This article argues that it is still premature to start widespread screening for adverse childhood experiences (ACE) in health care settings until we have answers to several important questions: 1) what are the effective interventions and responses we need to have in place to offer to those with positive ACE screening, 2) what are the potential negative outcomes and costs to screening that need to be buffered in any effective screening regime, and 3) what exactly should we be screening for? The article makes suggestions for needed research activities.

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults

PURPOSE

To help clinicians and care systems determine the priority for tobacco counseling in busy clinic schedules, we assessed the lifetime health and economic value of annually counseling youth to discourage smoking initiation and of annually counseling adults to encourage cessation.

METHODS

We conducted a microsimulation analysis to estimate the health impact and cost effectiveness of both types of tobacco counseling in a US birth cohort of 4,000,000. The model used for the analysis was constructed from nationally representative data sets and structured literature reviews.

RESULTS

Compared with no tobacco counseling, the model predicts that annual counseling for youth would reduce the average prevalence of smoking cigarettes during adult years by 2.0 percentage points, whereas annual counseling for adults will reduce prevalence by 3.8 percentage points. Youth counseling would prevent 42,686 smoking-attributable fatalities and increase quality-adjusted life years (QALYs) by 756,601 over the lifetime of the cohort. Adult counseling would prevent 69,901 smoking-attributable fatalities and increase QALYs by 1,044,392. Youth and adult counseling would yield net savings of $225 and $580 per person, respectively. If annual tobacco counseling was provided to the cohort during both youth and adult years, then adult smoking prevalence would be 5.5 percentage points lower compared with no counseling, and there would be 105,917 fewer smoking-attributable fatalities over their lifetimes. Only one-third of the potential health and economic benefits of counseling are being realized at current counseling rates.

CONCLUSIONS

Brief tobacco counseling provides substantial health benefits while producing cost savings. Both youth and adult intervention are high-priority uses of limited clinician time.

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.

Physician and patient concordance of report of tobacco cessation intervention in primary care in India

Background

Tobacco cessation interventions by physicians hold promise in improving quit rates. The 5As intervention (‘Ask’, ‘Advise’, ‘Assess’, ‘Assist’ and ‘Arrange’) is an evidence-based approach for tobacco cessation. However, little is known about adherence with the tobacco cessation interventions in primary care in India. In the present study we assessed physicians’ adherence with the 5As intervention and explored physician and patient concordance on the report of 5As intervention for tobacco cessation.

Methods

We used data from two cross-sectional surveys conducted in 12 districts of Andhra Pradesh and Gujarat in India. The surveys were administered simultaneously to both patients attending, and physicians working in health facilities providing primary care. Health facilities were selected by systematic random sampling and patients were recruited by simple random sampling. Common health facilities where both surveys were performed were identified, and individual patients were matched to their physicians through a unique matching code to obtain the two study samples.

Results

Slight agreement was observed between the physician and patient responses on ‘Ask’ and ‘Arrange’ component of the 5As intervention. The ‘Advise’, ‘Assess’ and ‘Assist’ components showed low agreement. Slightly higher levels of agreement were seen on all components of the 5As, except ‘Advise’, for those patients who had made an attempt to quit.

Conclusions

Our study suggests an urgent need for revising current strategies in order to strengthen the ‘Advise’, ‘Assess’, and ‘Assist’ interventions in tobacco cessation in primary care settings. Patient surveys should be used routinely in assessing fidelity and provider adherence for large scale behavioral health programs.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

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.

Impact of vital signs screening & clinician prompting on alcohol and tobacco screening and intervention rates: a pre-post intervention comparison

Background

Though screening and intervention for alcohol and tobacco misuse are effective, primary care screening and intervention rates remain low. Previous studies have increased intervention rates using vital signs screening for tobacco misuse and clinician prompts for screen-positive patients for both alcohol and tobacco misuse. This pilot study's aims were: (1) To determine the feasibility of combined vital signs screening for tobacco and alcohol misuse, (2) To assess the impact of vital signs screening on alcohol and tobacco screening and intervention rates, and (3) To assess the additional impact of tobacco assessment prompts on intervention rates.

Methods

In five outpatient practices, nurses measuring vital signs were trained to routinely ask a single tobacco question, a prescreening question that identified current drinkers, and the single alcohol screening question for current drinkers. After 4-8 weeks, clinicians were trained in tobacco intervention and nurses were trained to give tobacco abusers a tobacco questionnaire which also served as a clinician intervention prompt. Screening and intervention rates were measured using patient exit interviews (n = 622) at baseline, during the "screening only" period, and during the tobacco prompting phase. Changes in screening and intervention rates were compared using chi square analyses and test of linear trends. Clinic staff were interviewed regarding patient and staff acceptability. Logistic regression was used to evaluate the impact of nurse screening on clinician intervention, the impact of alcohol intervention on concurrent tobacco intervention, and the impact of tobacco intervention on concurrent alcohol intervention.

Results

Alcohol and tobacco screening rates and alcohol intervention rates increased after implementing vital signs screening (p < .05). During the tobacco prompting phase, clinician intervention rates increased significantly for both alcohol (12.4%, p < .001) and tobacco (47.4%, p = .042). Screening by nurses was associated with clinician advice to reduce alcohol use (OR 13.1; 95% CI 6.2-27.6) and tobacco use (OR 2.6; 95% CI 1.3-5.2). Acceptability was high with nurses and patients.

Conclusions

Vital signs screening can be incorporated in primary care and increases alcohol screening and intervention rates. Tobacco assessment prompts increase both alcohol and tobacco interventions. These simple interventions show promise for dissemination in primary care settings.

Clinical psychologists and smoking cessation: treatment practices and perceptions

A random sample of clinical psychologists was surveyed regarding their smoking cessation practices and perceptions. A total of 352 psychologists responded (57%) to the valid and reliable questionnaire. The majority (59.1%) of psychologists did not always identify and document the smoking status of patients. The majority reported high efficacy expectations (66.4%) and low outcome expectations (55.1%) for using the 5A's smoking cessation counseling technique. Counselors that had never smoked were almost two times more likely to have higher efficacy expectations than those that were current smokers or ex-smokers (OR = 1.94, 95% CI 1.18-3.12). The factors that predicted regular use of the 5A's included the number of identified barriers, psychologists' level of self efficacy, and the urbanicity of one's practice location.

Improving access to smoking cessation services for disadvantaged groups: a systematic review

BACKGROUND

Smoking is a main contributor to health inequalities. Identifying strategies to find and support smokers from disadvantaged groups is, therefore, of key importance.

METHODS

A systematic review was carried out of studies identifying and supporting smokers from disadvantaged groups for smoking cessation, and providing and improving their access to smoking-cessation services. A wide range of electronic databases were searched and unpublished reports were identified from the national research register and key experts.

RESULTS

Over 7500 studies were screened and 48 were included. Some papers were of poor quality, most were observational studies and many did not report findings for disadvantaged smokers. Nevertheless, several methods of recruiting smokers, including proactively targeting patients on General Physician's registers, routine screening or other hospital appointments, were identified. Barriers to service use for disadvantaged groups were identified and providing cessation services in different settings appeared to improve access. We found preliminary evidence of the effectiveness of some interventions in increasing quitting behaviour in disadvantaged groups.

CONCLUSIONS

There is limited evidence on effective strategies to increase access to cessation services for disadvantaged smokers. While many studies collected socioeconomic data, very few analysed its contribution to the results. However, some potentially promising interventions were identified which merit further research.

Smoking cessation readiness: are your patients ready to quit?

PURPOSE

To explore the assessment of patient readiness to receive smoking cessation interventions using the transtheoretical model (TTM) and the five stages of change; and to give the primary care provider an evidence-based toolkit to assist in evaluating for readiness and supporting the smoking cessation process.

DATA SOURCES

Evidence-based literature, theoretical framework, and peer-reviewed articles.

CONCLUSIONS

Utilizing the TTM along with proper training and education of the provider and patient increases the probability that smoking cessation will occur. Combinations of pharmaceutical and nonpharmaceutical interventions are the most effective in smoking cessation.

IMPLICATIONS FOR PRACTICE

Providers can be prepared at every patient visit to address the smoking cessation needs of all patients. The toolkit provided in this article will help facilitate evaluation of readiness and support of effective, long-term smoking cessation and reduce eventual smoking-related morbidities.

Integrating screening and interventions for unhealthy behaviors into primary care practices

BACKGROUND

Four unhealthy behaviors (tobacco use, unhealthy diet, physical inactivity, and risky alcohol use) contribute to almost 37% of deaths in the U.S. However, routine screening and interventions targeting these behaviors are not consistently provided in primary care practices.

METHODS

This was an implementation study conducted between October 2005 and May 2007 involving nine practices in three geographic clusters. Each cluster of practices received a multicomponent intervention sequentially addressing the four behaviors in three 6-month cycles (unhealthy diet and physical inactivity were combined). The intervention included baseline and monthly audits with feedback; five training modules (addressing each behavior plus stages of change [motivational interviewing]); practice facilitation; and bimonthly quality-circle meetings. Nurses, medical assistants, or both were taught to do screening and very brief interventions such as referrals and handouts. The clinicians were taught to do brief interventions. Outcomes included practice-level rates of adoption, implementation, and maintenance.

RESULTS

Adoption: Of 30 clinicians invited, nine agreed to participate (30%).

IMPLEMENTATION

Average screening and brief-intervention rates increased 25 and 10.8 percentage points, respectively, for all behaviors. However, the addition of more than two behaviors was generally unsuccessful. Maintenance: Screening increases were maintained across three of the behaviors for up to 12 months. For both unhealthy diet and risky alcohol use, screening rates continued to increase throughout the study period, even during the periods when the practices focused on the other behaviors. The rate of combined interventions returned to baseline for all behaviors 6 and 12 months after the intervention period.

CONCLUSIONS

It appears that the translational strategy resulted in increased screening and interventions. There were limits to the number of interventions that could be added within the time limits of the project. Inflexible electronic medical records, staff turnover, and clinicians' unwillingness to allow greater nurse or medical-assistant involvement in care were common challenges.

Vital signs screening for alcohol misuse in a rural primary care clinic: a feasibility study

CONTEXT

Alcohol misuse is more common in rural areas, and rural problem drinkers are less likely to seek alcohol treatment services. Rural clinics face unique challenges to implementing routine alcohol screening and intervention.

PURPOSE

To assess the feasibility of using the single alcohol screening question (SASQ) during routine nursing vital signs in a rural clinic, and to determine its effect on alcohol screening and intervention rates.

METHODS

Patient exit interviews were used to identify alcohol misuse and to measure changes in screening and intervention rates. Chi-square tests were used to compare rates of screening across study phases, while odds ratios from logistic regression analyses were used to quantify association between nurse screening and clinician intervention.

FINDINGS

Exit interviews were completed by 126 current drinkers (41 before vital signs screening implementation and 85 afterward). Screening rates for alcohol misuse rose from 14.6% at baseline to 20.0% (P = .027) after screening implementation. Clinician intervention rates among alcohol misusers rose from 6.3% to 11.8% (P = .039). Nurse screening increased the odds of clinician intervention (OR 1.47; 95% CI 1.10-1.95).

CONCLUSIONS

Vital signs screening proved to be feasible in this rural clinic and produced modest but significant increases in alcohol screening by nurses and brief interventions by clinicians. Additional studies are needed to define effective strategies for further increasing these rates.

Effect on cessation counseling of documenting smoking status as a routine vital sign: an ACORN study

PURPOSE

Guidelines encourage primary care clinicians to document smoking status when obtaining patients' blood pressure, temperature, and pulse rate (vital signs), but whether this practice promotes cessation counseling is unclear. We examined whether the vital sign intervention influences patient-reported frequency and intensity of tobacco cessation counseling.

METHODS

This study was a cluster-randomized, controlled trial conducted in the Virginia Ambulatory Care Outcomes Research Network (ACORN). At intervention practices, nurses and medical assistants were instructed to assess the tobacco use status of every adult patient and record it with the traditional vital signs. Control practices did not use any systematic tobacco screening or identification system. Outcomes were the proportion of smokers reporting clinician counseling of any kind and the frequency of 2 counseling subcomponents: simple quit advice and more intensive discussion.

RESULTS

A total of 6,729 adult patients (1,149 smokers) at 18 primary care practices completed exit questionnaires during a 6-month comparison period. Among 561 smokers at intervention practices, 61.9% reported receiving any counseling, compared with 53.4% of the 588 smokers at control practices, for a difference of 8.6% (P = .04). The effect was largely restricted to simple advice, which was reported by 59.9% of intervention patients and 51.5% of control patients (P=.04). There was no significant increase in more extensive discussion, with 32.5% and 29.3% of patients at intervention and control practices, respectively, reporting this type of counseling (P=.18).

CONCLUSIONS

The vital sign intervention promotes tobacco counseling at primary care practices through a modest increase in simple advice to quit. When implemented as a stand-alone intervention, it does not appear to increase intensive counseling.

Physician assessment of patient smoking in Indonesia: a public health priority

OBJECTIVE

To explore Indonesian physician's smoking behaviours, their attitudes and clinical practices towards smoking cessation.

DESIGN

Cross-sectional survey.

SETTING

Physicians working in Jogjakarta Province, Indonesia, between October and December 2003.

SUBJECTS

447 of 690 (65%) physicians with clinical responsibilities responded to the survey (236 men, 211 women), of which 15% were medical faculty, 35% residents and 50% community physicians.

RESULTS

22% of male (n = 50) and 1% of female (n = 2) physicians were current smokers. Approximately 72% of physicians did not routinely ask about their patient's smoking status. A majority of physicians (80%) believed that smoking up to 10 cigarettes a day was not harmful for health. The predictors for asking patients about smoking were being male, a non-smoker and a medical resident. The odds of advising patients to quit were significantly greater among physicians who perceived themselves as sufficiently trained in smoking cessation.

CONCLUSIONS

Lack of training in smoking cessation seems to be a major obstacle to physicians actively engaging in smoking cessation activities. Indonesian physicians need to be educated on the importance of routinely asking their patients about their tobacco use and offering practical advice on how to quit smoking.

Impact of a primary care intervention on smoking, drinking, diet, weight, sun exposure, and work risk in families with cancer experience

BACKGROUND

Modifying multiple behavior risks is a promising approach to reduce cancer risk. Primary prevention advices of the European Code against Cancer were included in an educational intervention (EI) using social cognitive theories for motivating families with cancer experiences to adopt six cancer prevention behaviors.

METHODS

A randomized clinical controlled trial recruited 3,031 patients from Primary Care among cancer patients' relatives. The experimental group (EG) received four EI, one EI every six months, focused on tobacco, alcohol, diet, weight, sun and work, and based on social cognitive models. The impact of the first three EI was calculated measuring at baseline and 18 months later: (a) The percentage of people with each risk behavior; (b) The score reached in a Total Cancer Behavioral Risk (TCBR) indicator; (c) The Odds Ratios at the post-test.

RESULTS

Five risk behaviors decreased significantly more (p<0.01) in the EG than in the CG: Smoking (OR=0.662), drinking (OR=0.504), diet (OR=0.542), weight (OR=0.698), and sun (OR=0.389). The TCBR indicator also decreased an average of nearly 5 points (28.42 vs. 23.82), significantly more (p<0.001) in the EG.

CONCLUSION

Families with cancer experiences changed five cancer risk behaviors when approached in Primary Care with interventions based on social cognitive models.

Randomized controlled trial of a computer-based, tailored intervention to increase smoking cessation counseling by primary care physicians

OBJECTIVE

The primary care visit represents an important venue for intervening with a large population of smokers. However, physician adherence to the Smoking Cessation Clinical Guideline (5As) remains low. We evaluated the effectiveness of a computer-tailored intervention designed to increase smoking cessation counseling by primary care physicians.

METHODS

Physicians and their patients were randomized to either intervention or control conditions. In addition to brief smoking cessation training, intervention physicians and patients received a one-page report that characterized the patients' smoking habit and history and offered tailored recommendations. Physician performance of the 5As was assessed via patient exit interviews. Quit rates and smoking behaviors were assessed 6 months postintervention via patient phone interviews. Intervention effects were tested in a sample of 70 physicians and 518 of their patients. Results were analyzed via generalized and mixed linear modeling controlling for clustering.

MEASUREMENTS AND MAIN RESULTS

Intervention physicians exceeded controls on "Assess" (OR 5.06; 95% CI 3.22, 7.95), "Advise" (OR 2.79; 95% CI 1.70, 4.59), "Assist-set goals" (OR 4.31; 95% CI 2.59, 7.16), "Assist-provide written materials" (OR 5.14; 95% CI 2.60, 10.14), "Assist-provide referral" (OR 6.48; 95% CI 3.11, 13.49), "Assist-discuss medication" (OR 4.72;95% CI 2.90, 7.68), and "Arrange" (OR 8.14; 95% CI 3.98, 16.68), all p values being < 0.0001. Intervention patients were 1.77 (CI 0.94, 3.34,p = 0.078) times more likely than controls to be abstinent (12 versus 8%), a difference that approached, but did not reach statistical significance, and surpassed controls on number of days quit (18.4 versus 12.2, p < .05) but not on number of quit attempts.

CONCLUSIONS

The use of a brief computer-tailored report improved physicians' implementation of the 5As and had a modest effect on patients' smoking behaviors 6 months postintervention.

Racial/ethnic disparities in report of physician-provided smoking cessation advice: analysis of the 2000 National Health Interview Survey

OBJECTIVES

We explored racial/ethnic disparities in reports of smoking cessation advice among smokers who had visited a physician in the previous year. Also, we examined the likelihood of receipt of such advice across Hispanic subgroups and levels of English proficiency.

METHODS

We analyzed data from the 2000 National Health Interview Survey.

RESULTS

Nearly half of the 5652 respondents reported receiving smoking cessation advice from their doctor. Compared with Hispanics, and after control for a range of other factors, respondents in the non-Hispanic White (adjusted odds ratio [OR]=1.57, 95% confidence interval [CI]=1.2, 2.0), non-Hispanic Black (adjusted OR=1.44, 95% CI=1.0, 2.0), and other non-Hispanic (adjusted OR=2.19, 95% CI=1.3, 3.6) groups were significantly more likely to report receiving advice. English proficiency was not associated with receipt of physician advice among Hispanic smokers.

CONCLUSIONS

Some 16 million smokers in the United States could not recall receiving advice to quit smoking from their physician in the preceding year. These missed opportunities, compounded by racial/ethnic disparities such as those observed between Hispanics and other groups and between Hispanic subgroups, suggest that considerably greater effort is needed to diminish the toll stemming from smoking and smoking-related diseases.

Measuring provider adherence to tobacco treatment guidelines: A comparison of electronic medical record review, patient survey, and provider survey

An accurate method of measuring primary care providers' tobacco counseling actions is needed for monitoring adherence to clinical practice guidelines. We compared three methods of measuring providers' tobacco counseling practices: electronic medical record (EMR) review, patient survey, and provider survey. We mailed a survey to 1,613 smokers seen by 114 Boston-area primary care providers during a 2-month period to assess what tobacco counseling actions had occurred at the visit (N = 766; 47% response rate). Smokers' reports were compared with the EMR and with their providers' self-reported usual tobacco counseling practices, derived from a provider survey (N = 110; 96% response rate). Patients reported receiving each counseling action more frequently than providers documented it in the EMR. Agreement between the patient survey and the EMR was poor for all 5A steps (kappa statistic = 0.01-0.22). Providers reported that they often or always performed each 5A action at a higher rate than indicated by EMR or patient report. However, providers who said they often or always performed individual 5A steps did not have consistently higher mean rates of EMR documentation or patient report than those who said they performed the 5A's less frequently. Little agreement was found among the three methods of measuring primary care providers' tobacco counseling actions. Implementing an EMR does not necessarily improve providers' documentation of tobacco interventions, but EMR adaptations that would standardize provider documentation of tobacco counseling might make the EMR a more reliable tool for monitoring providers' delivery of tobacco treatment services.