Improving smoking cessation advice in Australian general practice: what do GPs suggest is needed?

Smoking cessation advice from a general practitioner (GP) significantly increases quit rates among patients who smoke. However, smoking is not discussed during most routine consultations with smokers. This study describes GPs' own views about strategies to support their cessation advice. In 1997, a random sample of 311 GPs in NSW (73% response rate) completed a self-administered questionnaire about smoking cessation. Most respondents were 'very confident' about discussing the health effects of smoking (81.7%). Fewer were as confident about negotiating a quit date (21.5%) or using evidence-based smoking cessation techniques (19.3%). The top three preferred strategies to support smoking cessation advice were all resources for patients: subsidised nicotine replacement therapy (rated as 'quite useful' by 60.5%), pamphlets (55.0%) and free access to smoking cessation clinics (50.8%). Skills training (39.7%) was the preferred resource to improve practitioner effectiveness. Interventions combining skills training with patient resources are likely to be well received by GPs.     

Evidence-based practice and research utilisation: perceived research knowledge, attitudes, practices and barriers among Australian paediatric occupational therapists

Background/aim: Evidence‐based practice (EBP) and research utilisation (RU) are promoted as ways for clients to receive the best level of care. However, limited research has evaluated the use of these approaches by occupational therapists. This study investigated the knowledge, attitudes, practices of and barriers to EBP and RU of a group of paediatric occupational therapists from Australia. Methods: Questionnaires were received from 138 participants (response rate 46%) who completed the Research Knowledge, Attitudes and Practices of Research Survey, the Edmonton Research Orientation Survey and the Barriers to Research Utilisation Scale. Results: The participants held positive attitudes towards research, and were willing to access new information to guide practice approaches. However, participants were less confident in their research knowledge and practices and implemented research findings into clinical practice. Multiple barriers to RU were perceived, particularly associated with the presentation and accessibility of research. Participants reported limited engagement in conducting research studies, although the majority of the participants reported implementing the findings of research into their clinical practice to some extent. Conclusion: Additional research education and support within organisations would be beneficial to ensure that children and families are receiving occupational therapy services that are based on sound, high‐quality research evidence. The findings of this study provide insight into the perceived research knowledge, attitudes, practices of and barriers to Australian paediatric occupational therapists, enabling specific strategies to be implemented to increase the use of EBP and RU within the profession.     

Implementing guidelines for smoking cessation: comparing the efforts of nurses and medical assistants

BACKGROUND: It is unclear how different types of intake clinicians (registered nurses [RNs], and less costly licensed practical nurses [LPNs] and medical assistants [MAs]) compare in the performance of smoking-cessation activities recommended in the Agency for Healthcare Research and Quality (AHRQ) smoking-cessation clinical practice guideline. METHODS: A secondary analysis of data from a randomized controlled trial of guideline implementation was performed. Exit interviews of consecutive adult smokers who presented to nine primary care clinics for routine, non-emergency care were conducted during the period February 2000 to May 2001; a total of 1221 patients with adequate data were analyzed. Intake clinicians were surveyed prior to guideline training. Hierarchical logistic regression models were used to determine the association between type of intake clinician and performance of cessation counseling at the clinic visit, after adjustment for patient-level covariates, intake clinicians' characteristics, and study site. RESULTS: Performance of all guideline-recommended counseling activities were significantly greater for all intake clinicians at test versus control sites. MAs were significantly less likely to assess willingness to quit (adjusted odds ratio [AOR]=0.4, 95% confidence interval [CI]=0.2-0.8, p =0.005) and tended to offer advice and assistance in quitting less often than RNs. Similar findings were observed for LPNs (AOR=0.5, 95% CI=0.3-1.0, p =0.03, for assessing willingness to quit). Subset analysis in subjects with complete survey data revealed that being seen by a MA was no longer associated with statistically significant differences in performance, after accounting for personal beliefs, self-efficacy, and role satisfaction in cessation counseling. CONCLUSIONS: Although both MAs and LPNs showed marked improvements in performance in response to the guideline intervention, patients seen by these intake clinicians were less likely to receive guideline-recommended counseling, compared to those patients seen by RNs. Given their important role in the delivery of preventive care, MAs and LPNs should receive proper training in cessation counseling, should have strong physician and administrative support, and should be included in efforts to implement smoking-cessation guidelines in primary care.     

Implementing clinical guidelines in stroke: A qualitative study of perceived facilitators and barriers

Background

Clinical guidelines are frequently used as a mechanism for implementing evidence-based practice. However research indicates that health professionals vary in the extent to which they adhere to these guidelines. This study aimed to study the perceptions of stakeholders and health professionals on the facilitators and barriers to implementing national stroke guidelines in Ireland.

Methods

Qualitative interviews using focus groups were conducted with stakeholders (n = 3) and multidisciplinary team members from hospitals involved in stroke care (n = 7). All focus group interviews were semi-structured, using open-ended questions. Data was managed and analysed using NVivo 9 software.

Results

The main themes to emerge from the focus groups with stakeholders and hospital multidisciplinary teams were very similar in terms of topics discussed. These were resources, national stroke guidelines as a tool for change, characteristics of national stroke guidelines, advocacy at local level and community stroke care challenges. Facilitators perceived by stakeholders and health professionals included having dedicated resources, user-friendly guidelines relevant at local level and having supportive advocates on the ground. Barriers were inadequate resources, poor guideline characteristics and insufficient training and education.

Conclusions

This study highlights health professionals’ perspectives regarding many key concepts which may affect the implementation of stroke care guidelines. The introduction of stroke clinical guidelines at a national level is not sufficient to improve health care quality as they should be incorporated in a quality assurance cycle with education programmes and feedback from surveys of clinical practice.     

Tobacco smoking cessation management: integrating varenicline in current practice

Tobacco smoking is widespread and is one of the world’s most prevalent modifiable risk factors for morbidity and mortality. It is important to facilitate smoking cessation better in order to reduce the health consequences of tobacco use. The most effective approach assisting smokers in their quit attempts combines both pharmacotherapy and nonpharmacological interventions. This review summarizes the latest international epidemiological data available on tobacco use, considers the associated effects on health, and reviews existing policies against tobacco use. Among the interventions for smoking cessation, the three major pharmacotherapies (which have demonstrated efficacy when combined with behavioral support) are discussed: nicotine replacement therapy (NRT), bupropion, and varenicline. As the newest pharmacotherapy made available in this area, particular consideration is given to varenicline, and a review of our clinical experience is offered.     

Stop smoking advice by practice assistants after routine cervical screening in general practice: A qualitative exploration of potential barriers and enablers

BackgroundCervical screening could be an appropriate routine moment to provide female smokers with tailored stop smoking advice. In Dutch general practice, cervical smears are performed by practice assistants.ObjectivesThis study was performed in preparation for a randomised trial to identify potential barriers and enablers for a brief stop smoking strategy performed by trained practice assistants after routine cervical screening.MethodsBetween December 2016 and March 2017 three focus group meetings were held with ten practice assistants, three nurses, and six general practitioners to explore their views and expectations towards the proposed approach. We analysed data using thematic analysis. Identified factors are presented within the framework of the Social-Ecological Model.ResultsPotential barriers and enablers were identified at individual, interpersonal, and workplace levels. Practice assistants, nurses and GPs did not consider assistants to have a role in stop smoking care. They believed it is feasible to register smoking status but had reservations towards providing advice by assistants, for which knowledge and skills are needed. Practice assistants’ own beliefs about smokers and smokers’ response to stop smoking advice might influence how assistants and smokers interact. An explanation of why advice is given could help, provided assistants have enough time and experience with the smear. The nurses’ availability and general practitioners’ view on prevention might affect the delivery of the strategy by the assistant.ConclusionAt individual, interpersonal, and workplace levels, several factors could influence the provision of a stop smoking strategy by a practice assistant.     

Guidelines for assessing postnatal problems: introducing evidence-based guidelines in Australian general practice

BACKGROUND: Postnatal morbidity is high, and many GPs lack the confidence and knowledge to deal with common postnatal problems. There is a high consultation rate, but few women disclose common health problems. OBJECTIVE: The aim of the present study was to increase the knowledge and skills of GPs to enable them to identify and manage common health problems experienced by women in the year following childbirth. METHODS: An educational programme [Guidelines for Assessing Postnatal Problems (GAPP)] embedded within a large randomized community intervention trial [Program of Resources, Information and Support for Mothers (PRISM)] with a before/after evaluation was undergone by Australian GPs working in four metropolitan and four rural communities. The programme comprised audit, interactive workshops, role-play and evidence-based guidelines, and was evaluated at baseline and 6 months through written questionnaires and a surgery consultation with a trained simulated patient evaluator. RESULTS: A total of 68 (86%) GPs took part in the full GAPP programme. The odds of a GP improving on the knowledge items ranged from 1.0 to 16, with the greatest change occurring in knowledge about the effectiveness of cognitive behavioural therapy for maternal depression. Of the GPs with an incorrect response at baseline, the percentage demonstrating improved knowledge at follow-up ranged from 22 to 100%. Around half of the GPs demonstrated excellent communication skills at baseline. Of the remaining GPs, more than half demonstrated greatly improved skills to detect common postnatal problems at follow-up. At baseline simulated patient visit, 70% of GPs inquired about sexual problems yet none inquired about the possibility of abuse, whereas at follow-up 94% inquired about sexual problems and 51.5% facilitated the disclosure of physical and emotional abuse. Anonymous feedback on the programme by participating GPs showed that 89% believed the programme positively influenced their actual practice. Interestingly, GPs demonstrated greater knowledge and skills in the simulated setting than on the written questionnaire. CONCLUSIONS: This relatively brief multifaceted educational programme assisted many participants in improving their knowledge and the skills required to improve both physical and emotional health after birth. Despite being experienced clinicians and participating actively in a programme on interviewing skills, half of the GPs did not facilitate disclosure of the underlying sensitive issue (abuse) during the follow-up consultation and could benefit from further in-depth training in effective communication skills.     

Best practices guidelines for nurse practitioners regarding smoking cessation in American Indian and Alaskan Native youth

The greatest prevalence of tobacco use in the United States occurs with the American Indian and Alaskan Native (AI/AN). A critical need exists for a culturally specific tobacco cessation option for AI/AN youth. The nurse practitioner is positioned to provide a culturally specific commercial tobacco cessation option by incorporating the transcultural nursing theory into the development of a decision tree to expand understanding of culturally appropriate best practices regarding screening and management of tobacco smoking cessation in AI/AN youth. Presented is the Nurse Practitioner Culturally Specific American Indian and Alaskan Native Youth Decision Tree for Smoking Cessation with supporting evidence-based best practices.     

Necessity and readiness for smoking cessation intervention in dental clinics in Japan

Background

The necessity and readiness for smoking cessation intervention in dental clinics was assessed by investigating smoking status and stage of behavior change in patients and the attitudes of dentists toward the effects of smoking on their patients, respectively.

Methods

A self-administered questionnaire was mailed to 1022 dentists randomly selected from the Japanese Dental Association database. The questionnaire survey consisted of 1 section for dentists and 1 for patients aged 20 years or older and was scheduled to be completed at the dentists’ clinics on a designated day in February 2008.

Results

The response rate to the questionnaire was 78.2% from among target dental clinics and 73.7% and 74.7% for patient and dentist questionnaires, respectively. Data from 11 370 patients and 739 dentists were analyzed. The overall smoking prevalence among the patients (25.1%) was similar to that reported by the National Health and Nutrition Examination Survey, and young female patients had a markedly higher smoking prevalence. More than 70% of patients who smoked were interested in quitting. Although the prevalence of current smoking among dentists (27.1%) was significantly higher than that reported among Japanese physicians (15.0%), approximately 70% of dentists were concerned about the effects of smoking on patient health and prohibited smoking inside their clinic.

Conclusions

Many smokers who were interested in quitting, particularly young women, visited dental clinics, and most dentists believed that smoking was harmful for their patients. These results indicate that smoking cessation intervention in dental settings is necessary and that dentists are ready to provide such interventions.Key words: dentist, patient, health care survey, smoking, smoking cessation     

A controlled trial to integrate smoking cessation advice into primary care practice: Doctors Helping Smokers, Round III.

BACKGROUND. Although most physicians believe that smoking cessation assistance is important for their patients, the majority of smokers report that they have not received smoking cessation advice from a physician. We therefore tested whether on-site recruitment, training, and organizational assistance in incorporating a smoking intervention system of documented efficacy into nonvolunteer primary care practices would result in higher rates of smoking cessation advice to patients. METHODS. This was a nonrandomized trial comparing all 10 primary care clinics in an intervention area to all 8 primary care clinics from a geographically separate control area. The evaluation was based on the smoking intervention activities of each of the clinics as reported on preintervention and postintervention mail surveys of cohorts of regular smokers seen in the clinics. RESULTS. Preintervention, 22.9% +/- 11.2% of the intervention clinic cohort and 21.9% +/- 9.6% (P = .84) of the control clinic cohort reported that they had been asked about tobacco during a clinic visit in the prior 6 months. Postintervention, the intervention clinic cohort was significantly more likely to report that someone had asked them if they smoked (39.8% +/- 12.3% vs 26.0% +/- 12.2%; P less than .05), that their physician asked them to quit if they were currently smoking (40.5% +/- 12.1% vs 26.4% +/- 14.6%; P less than .05), and that someone had commended them if they had recently quit smoking (28.2% +/- 19.8 vs 11.3% +/- 11.8%; P less than .05). CONCLUSIONS. The intervention significantly increased the rates at which a population of primary care clinics identified their patients who smoked, advised them to quit smoking, and commended those who had recently quit smoking.     

The attitude toward tobacco dependence and barriers to discussing smoking cessation: a survey among Turkish general practitioners

Objectives  

To evaluate the general attitude of a sample of Turkish general practitioners (GPs) toward tobacco dependence and to assess their knowledge and behavior regarding smoking cessation (SC).     

Indigenous women and smoking during pregnancy: knowledge, cultural contexts and barriers to cessation

Despite active tobacco control efforts in Australia, smoking prevalence remains disproportionately high in pregnant Indigenous women. This study investigated the place of smoking in pregnancy and attitudes towards smoking within the broader context of Indigenous lives. Focus groups and in-depth interviews were used to collect data from 40 women, and ten Aboriginal Health Workers (AHWs) in Perth, Western Australia. The research process and interpretation was assisted by working with an Indigenous community reference group. Results demonstrated the impact of contextual factors in smoking maintenance, and showed that smoking cessation even in pregnancy was not a priority for most women, given the considerable social and economic pressures that they face in their lives. Overwhelmingly, smoking was believed to reduce stress and to provide opportunities for relaxation. Pregnancy did not necessarily influence attitudes to cessation, though women's understanding of the consequences of smoking during pregnancy was low. Reduction of cigarette intake during pregnancy was seen as an acceptable and positive behaviour change. The AHWs saw their role to be primarily one of support and were conscious of the importance of maintaining positive relationships. As a result, they were often uncomfortable with raising the issue of smoking cessation with pregnant women. The stories of Indigenous women and AHWs provided important insight into smoking during pregnancy and the context in which it occurs.     

Stages of change, smoking characteristics, and cotinine concentrations in smokers: setting priorities for smoking cessation

ObjectiveWe assessed whether the salivary cotinine content of daily smokers varied with the readiness to quit and smoking characteristics.MethodsThis cross-sectional study was conducted in Barcelona, Spain (n = 1245) in 2004–2005. We administered a questionnaire to assess smoking behaviour and collected saliva to determine the cotinine content. We determined the distribution of 278 adult daily smokers across different stages of change and categorised them by individual and smoking characteristics. We used medians and interquartile ranges (IQR) to relate cotinine concentrations to different stages of change, tobacco consumption, and nicotine dependence based on the Fagerström Test for Nicotine Dependence (FTND).ResultsAround 68%, 22%, and 11% of smokers were in precontemplation, contemplation, and preparation stages, respectively. A mean of 17.0 cigarettes was smoked daily, with no differences among stages of change. The median cotinine concentration was 151.3 ng/ml (IQR: 83.2–227.8 ng/ml), with no differences among stages of change. The cigarette consumption scores, FTND, and time to first cigarette of the day were positively associated with cotinine concentration.ConclusionsThe cotinine concentration was similar among the stages of change, but varied within each stage according to the number of cigarettes smoked, time to first cigarette of the day, and nicotine dependence.     

Translating an adolescent smoking cessation program into policy and practice in an Australian context

Although Australia's restrictive tobacco control policies have made it an international leader in reducing smoking prevalence, and only 7% of teens smoke weekly, cessation efforts are still needed among adolescents. Of the campaigns and programs implemented in Australia to reduce this problem among adolescents, most have provided only abstinence messages and few have been effectively evaluated and translated into policy and practice. This article describes the translation of a harm minimization cessation program for teens, the Smoking Cessation for Youth Project (SCYP), derived from an approach developed with adults. In addition, the article describes the unique sociopolitical context of Australia in which the SCYP program was developed and the significant conceptual, contextual, and methodological factors that enabled and limited this program's effective implementation and translation.