Training physicians in counseling about smoking cessation. A randomized trial of the "Quit for Life" program

STUDY OBJECTIVE: To test whether physicians who receive a continuing education program ("Quit for Life") about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients who smoke. DESIGN: Randomized trial with blinded assessment of principal outcomes. SETTING: Four health maintenance organization medical centers in northern California. SUBJECTS: Eighty-one internists assigned by blinded randomization to receive training (40) or serve as controls (41). Consecutive samples of smokers visiting each physician (mean, 25.6 patients per experimental and 25.2 per control physician). INTERVENTIONS: Internists received 3 hours of training about how to help smokers quit. Physicians and their office staff also were given self-help booklets to distribute free to smokers and were urged to use a system of stickers on charts to remind physicians to counsel smokers about quitting. MEASUREMENTS AND MAIN RESULTS: On the basis of telephone interviews with patients after visiting the physician, we determined that internists who attended the Quit for Life program discussed smoking with more patients who smoked, spent more time counseling them about smoking, helped more patients set dates to quit smoking, gave out more self-help booklets, and made more follow-up appointments to discuss smoking than did internists in the control group. One year later, the rate of biochemically confirmed, long-term (greater than or equal to 9 months) abstinence from smoking was 1% higher among all patients of trained internists than among patients of controls (95% CI, -0.1% to +2.3%), and 2.2% (+0.2% to +4.3%) higher among the patients who most wanted to quit smoking. CONCLUSIONS: This continuing education program substantially changed the way physicians counseled smokers. As a result, a few more patients who wanted to quit smoking achieved long-term abstinence.     

A survey of physicians' smoking counseling practices

Several techniques used in smoking cessation counseling have been shown to be useful in physicians' efforts to help their patients quit smoking. The use of these techniques by Tulsa physicians was assessed through a survey of private practice internists, internal medicine residents, and family practice residents in a university-based community hospital. The majority of physicians (85%) reported they brought up the subject of smoking with their patients. Other techniques were used less frequently, with 34% of physicians never giving their patients self-help materials, 83% never using a quit date contract, and 73% never making appointments mainly to discuss smoking. Private practice physicians reported using more techniques than did the residents. Internists who practice a subspecialty reported using fewer techniques, and this was especially true in the younger physicians. Ten percent of physicians were often satisfied with their efforts, and 14% had formal training in smoking counseling techniques. Some physicians apparently learn how to better use these techniques as their experience increases. Training physicians while they are in residency and early subspecialty practice may accelerate this process and enable more smokers to quit with their physicians' help.     

Training physicians about smoking cessation

Study objective:To test the hypotheses that physicians in private practice who receive a continuing education program (entitled “Quit for Life”) about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients. Design:Randomized trial with blinded assessment of principal outcomes. Setting:Private practices of internal medicine and family practice. Subjects:Forty-four physicians randomly assigned to receive training (24) or serve as controls (20) and consecutive samples of smokers visiting each physician (19.6 patients per experimental and 22.3 per control physician). Interventions:Physicians received three hours of training about how to help smokers quit. Physicians and their office staffs were also given self-help booklets to distribute to smokers and were urged to use a system of stickers on charts as reminders to counsel smokers about quitting. Measurements and main results:Based on telephone interviews with patients, physicians in the experimental group were more likely to discuss smoking with patients who smoked (64% vs. 44%), spent more time counseling smokers about quitting (7.5 vs. 5.2 minutes), helped more smokers set dates to quit smoking (29% vs. 5% of smokers), gave out more self-help booklets (37% vs. 9%), and were more likely to make a follow-up appointment about quitting smoking (19% vs. 11% of those counseled) than physicians in the control group. One year later, the rates of biochemically confirmed, long-term (≥9 months) abstinence from smoking were similar among patients in the experimental (3.2%) and control (2.5%) groups (95% confidence interval for the 0.7% difference: −1.7 to +3.1%). Conclusions:The authors conclude that this continuing education program substantially changed the way physicians counseled smokers, but had little or no impact on rates of long-term smoking cessation among their patients. There is a need for more effective strategies to help physicians help their patients to quit smoking. Supported by Grant # CA38337 from the National Cancer Institute and by the Henry J. Kaiser Foundation Faculty Fellowship in General Internal Medicine (SRC).     

Quitting smoking

OBJECTIVE: To describe why medical patients quit smoking and the methods they use. DESIGN: Cross-sectional and prospective cohort design. Patient smokers were enrolled in a study of physician counseling about smoking. One year later, 2,581 of the patients were asked about quit attempts and methods used. Of those, 245 former smokers whose quitting had been biologically validated were interviewed about why and how they had quit. SETTING: Offices of internists and family practitioners in private practice and a health maintenance organization. SUBJECTS: Consecutive sample of ambulatory patients who smoked. MEASUREMENTS AND MAIN RESULTS: Baseline questionnaires included demographic data, smoking history, and symptoms and diagnoses related to smoking. After one year, subjects were interviewed about smoking status and methods used in attempting to quit. Cessation was confirmed by biochemical testing. Those who had quit were asked about reasons for quitting. Seventy-seven percent of successful quitters gave health-related reasons for quitting and the quitters ranked "harmful to health" as the most important reason for quitting. In a multivariate analysis, those who had a college education, who had social pressures to quit, and who had greater confidence in being able to quit were more likely to have quit smoking one year later, while those who smoked their first cigarette within 15 minutes of awakening and who had more diagnoses related to smoking were less likely to have quit smoking one year later. Participation in a treatment program and having been counseled by a physician or nurse practitioner were positively related to successful quitting, while use of filters or mouthpieces was negatively related. CONCLUSIONS: Concerns about health are the most common reason patients give for quitting, and addiction is the most important barrier to quitting. Education, social pressure, provider advice, and formal programs, but not over-the-counter devices, appear to increase the chances that smokers will quit.     

The older smoker. Status, challenges and opportunities for intervention

Smoking is a significant cause of morbidity and mortality among older adults. Cessation of smoking benefits older adults almost immediately. Little is known, however, about how older adults quit and how to help them. No smoking cessation programs have been designed for this population. Here we report the findings of a random survey of American Association of Retired Persons members conducted to learn more about older smokers, their smoking and health characteristics, their quitting motivations and experiences, and the role of physicians' advice to quit. We obtained data on 339 current smokers aged 50 to 102. Current smokers were more likely to be heavy, highly addicted smokers. They also reported more smoking-related symptoms and conditions and fewer preventive tests and check-ups than never-smokers or former smokers. Although 44 percent of smokers were interested in quitting, only 39 percent reported that they had been advised to stop smoking by their physicians in the previous year. Physicians who treat older patients can have a significant impact on helping them to stop smoking by giving them a strong recommendation to quit and by providing appropriate interventions.     

Self-help smoking cessation interventions in pregnancy: a systematic review and meta-analysis

Aims   Self-help smoking cessation interventions for pregnant smokers are of importance due to their potential to be wide-reaching, low-cost and their appeal to pregnant smokers who are interested in quitting smoking. To date, however, there has been no systematic assessment of their efficacy. This systematic review aimed to assess the efficacy of self-help interventions for pregnant smokers and to investigate whether self-help material intensity, type or delivery are associated with cessation.
Methods   The literature was searched for randomized and quasi-randomized controlled trials of self-help smoking cessation interventions for pregnant smokers without significant cessation counselling. Fifteen trials met the inclusion criteria and relevant data were extracted independently.
Results   The primary meta-analysis pooled 12 trials comparing usual care (median quit rate 4.9%) with self-help (median quit rate 13.2%) and yielded a pooled odds ratio (OR) of 1.83 [95% confidence interval (CI) 1.23–2.73], indicating that self-help interventions on average nearly double the odds of quitting compared with standard care. However, a further meta-analysis failed to find evidence that intervention materials of greater intensity increase quitting significantly over materials of lesser intensity (pooled OR = 1.25, 95% CI 0.81–1.94). There was insufficient evidence to determine whether the tailoring of materials or levels of one-to-one contact were related to intervention efficacy.
Conclusions   Self-help interventions appear to be more effective than standard care although, due mainly to a lack of trials, it is unclear whether more sophisticated and intensive approaches increase intervention effectiveness.     

Promoting smoking cessation among the elderly: what are the predictors of intention to quit and successful quitting?

PURPOSE: To assess the predictors of smoking cessation and intention to quit among the Chinese elderly smokers. DESIGN: A cross-sectional survey of elderly smokers. Setting: Shamsuipo district, Hong Kong. Subject: A total of 1,318 elderly were interviewed (response rate = 83%). Measures: A structured questionnaire was used for data collection. The questionnaire sought information on the subject's sociodemographic background and smoking habits. The predictors for successful quitting and intention to quit were assessed by chi-square tests and multiple logistic regression. RESULTS: Of the respondents, 20.2% were current smokers, 25.4% were ex-smokers, and 54.4% were never smokers. Of the smoker (current and ex-smokers) respondents, 55.7% (335/601) had successfully quit at the time of enumeration. The predictors of quitting were living with others, receiving assistance for mobility, being nondrinkers, smoking for shorter duration, and smoking more cigarettes per day. Having health problems in the past, smoking for shorter duration, and smoking fewer cigarettes per day were predictors of intention to quit smoking. CONCLUSION: The study identified several predictors of successful quitting that could help improve the provision of current smoking cessation services. Population-based smoking cessation programs, especially those targeted to elderly, should take these predictors into consideration in the design of interventions.     

Smoking cessation counseling by resident physicians in internal medicine, family practice, and pediatrics

Residents in primary care specialties care for many patients who smoke cigarettes, but little is known about their smoking cessation counseling (SCC). We surveyed 309 residents (72 family practice, 171 internal medicine, and 66 pediatrics residents) in 13 programs to determine their practices, knowledge, attitudes, and training in SCC. More than 90% thought physicians are responsible for SCC, the majority routinely took smoking histories, and 80% attempted to motivate patients to quit smoking. However, 25% or fewer reported discussing obstacles to quitting, setting a quit date, prescribing nicotine gum, scheduling follow-up visits, or providing self-help materials. Family practice residents used more SCC techniques (1.8) than did internal medicine (0.8) and pediatrics (0.1) residents. Only 54% of residents reported recent SCC training and 13% reported formal SCC training. Recent training correlated with the number of counseling techniques used. Residents in primary care specialties report positive attitudes but inadequate practice and training in SCC.     

Readiness of older adults to stop smoking in a televised intervention

Smokers aged 60 and older who enrolled in a televised smoking cessation program were compared with older smokers in the target population, using data from telephone interviews. Multiple logistic regressions identified factors that differentiated older smokers at various stages of readiness to quit. Within the target population, smokers planning to quit someday (N = 238) were more likely to have had greater concern about health effects of smoking and perceived a stronger desire by others for them to quit than smokers with no such plan (N = 127). Compared with older smokers in the target population who were planning to quit someday, program registrants (N = 95) perceived greater severity of lung cancer, had greater concern about the health effects of smoking, perceived greater reduction of lung cancer risk from quitting, and had more determination to quit. These findings indicate important factors according to the stage in the smoking cessation process that must be considered when intervening with older smokers.     

Treatment of cigarette dependency. What American pulmonary physicians do

Physician advice and counseling can significantly help patients stop smoking. Consequently, we surveyed 588 of 2,207 actively practicing American pulmonary clinicians attending the 1983 Annual Meeting of the American Thoracic Society to determine what they did to help their patients stop smoking. Ninety-nine and one tenth percent of those pulmonary internists who had never smoked recorded the smoking habits of their patients and 100% advised smokers to stop. In contrast, pulmonary internists who themselves smoked cigarettes were significantly less inclined to do these two things; 84.6% and 92.3%, respectively (p less than 0.01). There was also a trend for more never smoking internists to provide additional services to patients wishing to stop smoking. Of the pulmonary internists, 86.8% wanted to learn new techniques to help their patients stop smoking. Essentially, 75% of the small sample of pediatric pulmonary specialists surveyed felt that determining whether their patients smoked or not and providing services to help them stop smoking was "not applicable" to their practice.     

Determinants of smoking and cessation in older women

BACKGROUND: although the benefits of quitting smoking even at an advanced age have been proved, few campaigns target the older population. The goals of this study were to analyse the characteristics of older women smokers help and support those wanting to quit. METHODS: we assessed the determinants of smoking cessation in a prospective cohort study performed in 7,609 older women. A questionnaire about smoking habits was sent to the 486 eligible smokers. Smoking dependence and smokers' readiness to quit was assessed. Participants who had quit smoking during follow-up were asked about their previous reasons for quitting and the methods used to quit. RESULTS: 372 women of the 424 (88%) responded to our questionnaire and were included. The most common reasons for smoking were relaxation, pleasure, and habit. Major obstacles to quitting smoking were 'no benefit to quitting at an advanced age', 'smoking few or "light" cigarettes yields no negative health consequences', and 'smoking does not increase osteoporotic risk'. During the 3-year follow-up period, 57 of the 372 (15%) women successfully quit smoking. Being an occasional smoker (OR=2.4) and reporting 'quitting is not difficult' (OR=3.7) were positively associated with having recently quit smoking. Only 11% of successful cessations were reported to have received physician advice. CONCLUSIONS: these data illustrate the specific smoking behaviour of older women, suggesting that cessation interventions ought to be tailored to these characteristics. Willingness to quit was associated with a low education level. The most frequent obstacles to quitting were all based on incorrect information.     

Direct telemarketing of smoking cessation interventions: will smokers take the call?

AIMS: Few smokers currently make use of available and effective cessation strategies, despite their expressed desire to quit and reported interest in cessation support. This study aimed to explore the feasibility of a telephone-based direct-marketing approach to delivering cessation strategies. DESIGN, SETTING, MEASUREMENTS AND PARTICIPANTS: A community survey was conducted to explore the views of current adult smokers regarding the acceptability, likely uptake and barriers to uptake of smoking cessation services offered by direct telephone marketing. FINDINGS: Three quarters (73.8%) of smokers contacted agreed to be surveyed. Of the 194 study participants, 75.3% reported that they would utilize vouchers for discount nicotine replacement therapy (NRT), 66.5% would use a mailed self-help booklet, 57.2% would take up the offer of regular mailings of personalized letters and self-help materials and 46.4% would utilize a 'we-call-you' telephone counselling service. The characteristics of those indicating likely uptake of these services were also explored. The two major barriers to uptake of services were preferring to quit without help and a belief that a particular service would not help the participant. CONCLUSIONS: The data suggest strong support for the direct marketing of smoking cessation strategies; they also highlight the need for further study of the cost-effectiveness of telephone-based direct marketing of smoking cessation strategies as a population-based strategy for reducing the prevalence of smoking in the community.     

Encouraging primary care physicians to help smokers quit. A randomized, controlled trial

STUDY OBJECTIVE: To increase the effect that primary care physicians have on their patients who smoke. DESIGN: Randomized, controlled trial with 112 general internists and their patients who smoke. PATIENTS: Sample of 1420 patients from a general medicine clinic of a city-county teaching hospital, who smoke at least one cigarette a day and were recruited regardless of their interest in quitting smoking. INTERVENTIONS: Physicians were randomly assigned to one of four groups: participants who received a protocol for smoking management and a lecture on the consequences and management of smoking (control); in addition, had nicotine gum freely available to patients (gum); had stickers attached to their smokers' charts (reminder); or had both gum and reminders (both). MEASUREMENTS AND MAIN RESULTS: The percentage of patients with a return visit at 6 months who quit smoking (alveolar carbon monoxide of less than nine parts per million) was 1.3% (control), 7.7% (gum), 7.0% (reminders), and 6.3% (both). At 1 year the percentages were 2.7%, 8.8%, 15.0%, and 9.6%, respectively. Subsequent pairwise comparisons showed that the three intervention groups were not significantly different, but that each was significantly different from the control group (P less than 0.05). Physicians in all three intervention groups spent significantly more time than did the physicians in the control group counseling their patients about smoking. CONCLUSIONS: The availability of nicotine gum or labeling the charts of smokers can help primary care physicians increase their success rates two- to six-fold in helping patients quit smoking. If all primary care physicians used these procedures, they could help an additional 2 million smokers quit.     

Smoking cessation counseling during periodic health examinations

Periodic health examinations are an excellent opportunity to counsel smokers to quit. The impact of a specialized smoking cessation counselor on the smoking behavior of patients having periodic health examinations was studied in a general internal medicine practice. One hundred fifty-five smokers having periodic health examinations were randomly assigned to a control group who received usual physician advice or an intervention group who received usual physician advice and two counseling sessions with a smoking cessation counselor. The two groups were similar in all demographic variables, smoking-related baseline variables, and baseline levels of motivation and intention to quit smoking. The smoking status of 97% of the subjects was assessed 6 months later. In the intervention group, 46% made quit attempts and 19% quit, compared with 34% and 12%, respectively, in the control group. Intervention-group smokers made more quit attempts (mean +/- SD, 5.0 +/- 2.5 vs 1.8 +/- 0.2) and had a greater reduction in daily cigarette use (8.4 +/- 1.5 vs 3.5 +/- 1.3). Of the 74% of smokers with higher levels of motivation to quit smoking, more intervention-group smokers attempted to quit (70.8% vs 45.5%) and succeeded in quitting at the 6-month follow-up (27.1% vs 10.9%). Periodic health examinations are an excellent opportunity to counsel smokers to quit, especially those smokers with higher levels of motivation to quit smoking.     

A multi‐level analysis of non‐significant counseling effects in a randomized smoking cessation trial

Aims To determine, in the context of a trial in which counseling did not improve smoking cessation outcomes, whether this was due to a failure of the conceptual theory identifying treatment targets or the action theory specifying interventions. Design Data from a randomized clinical trial of smoking cessation counseling and bupropion SR were submitted to multi‐level modeling to test whether counseling influenced real‐time reports of cognitions, emotions and behaviors, and whether these targets predicted abstinence. Setting Center for Tobacco Research and Intervention, Madison, WI. Participants A total of 403 adult, daily smokers without contraindications to bupropion SR use. Participants were assigned randomly to receive individual counseling or no counseling and a 9‐week course of bupropion SR or placebo pill. Cessation counseling was delivered in eight 10‐minute sessions focused on bolstering social support, motivation, problem‐solving and coping skills. Measurements Pre‐ and post‐quit ecological momentary assessments of smoking behavior, smoking triggers, active prevention and coping strategies, motivation to quit, difficulty quitting and reactions to initial lapses. Findings Counseling prompted avoidance of access to cigarettes, improved quitting self‐efficacy, reduced perceived difficulty of quitting over time and protected against guilt and demoralization following lapses. Results also supported the importance of limiting cigarette access, receiving social support, strong motivation and confidence and easing withdrawal distress during cessation efforts. Quitting self‐efficacy and perceived difficulty quitting may partially mediate counseling effects on abstinence. Conclusions Smoking cessation counseling may work by supporting confidence about quitting and reducing perceived difficulty quitting. Counseling did not affect other targets that protect against relapse.     

Cigarette smoking and the desire to quit among individuals living with HIV

Among individuals living with human immunodeficiency virus (HIV), studies have found that smokers are at greater risk than nonsmokers to develop bacterial pneumonia, oral lesions and acquired immune deficiency syndrome (AIDS) dementia complex. Information is lacking regarding the prevalence of cigarette smoking among people living with HIV or about their intentions to quit smoking. A survey was conducted with a sample of patients attending an HIV outpatient clinic at San Francisco General Hospital to assess the prevalence of cigarette smoking and the level of interest in quitting. In total, 228 assessments were completed. Study results revealed a high percentage of smokers among our sample of individuals living with HIV compared to the percentage of smokers found in the general adult population. A total of 123 individuals (54%) reported that they smoked cigarettes. Men were more than twice as likely to have made previous attempts at smoking cessation than were woman. The majority of cigarette smokers (63%) reported that they were currently thinking about quitting. Respondents' preferences for types of smoking cessation methods are discussed, and recommendations are proposed for identifying and treating tobacco dependence in this population.     

Attitudes toward smoking and smoking behaviors of patients with crohn''s disease

OBJECTIVE: To examine the smoking behaviors of people with Crohn's disease. In active smokers, we measured their willingness to quit, their degree of nicotine dependence, and the proportion that made a quit attempt within 6 months to determine if they were refractory to smoking cessation in comparison to the general population. We also examined factors that were important in their decision to smoke. METHODS: We conducted a cross-sectional survey of out-patients, supplemented by telephone interviews and a 6-month follow-up questionnaire of active smokers. Measures included disease activity, current smoking behaviors, intentions (stage of change), Fagerstrom Test for Nicotine Dependence, and factors related to their decision to smoke (decisional balance). RESULTS: The questionnaire was completed by 115 patients (78% response rate). Forty percent were active smokers. Of active smokers, 59% were considering quitting within the next 6 months, and of these, 15% were planning on quitting within the next 30 days. Those with moderate disease activity were more likely to be considering quitting than those with mild or severe activity. Nicotine dependence was rated as high in 33% and as moderate in 43%. Factors unrelated to Crohn's disease were more important in their decision to smoke than were Crohn's disease-related factors. After 6 months, 23% had made an attempt to quit and this attempt was strongly associated with their stated intentions at the baseline questionnaire. Two of three patients who had recently quit at baseline had resumed smoking. CONCLUSION: When compared to similar data for the general population, patients with Crohn's disease are no more refractory to smoking cessation.     

Comparison of five measures of motivation to quit smoking among a sample of hospitalized smokers

OBJECTIVE: To compare the predictive validity of several measures of motivation to quit smoking among inpatients enrolled in a smoking cessation program. METHODS: Data collected during face-to-face counseling sessions included a standard measure of motivation to quit (stage of readiness [Stage]: precontemplation, contemplation, or preparation) and four items with responses grouped in three categories: “How much do you want to quit smoking” (Want), “How likely is it that you will stay off cigarettes after you leave the hospital” (Likely), “Rate your confidence on a scale from 0 to 100 about successfully quitting in the next month” (Confidence), and a counselor assessment in response to the question, “How motivated is this patient to quit?” (Motivation). Patients were classified as nonsmokers if they reported not smoking at both the 6-month and 12-month interviews. All patients lost to follow-up were considered smokers. MAIN RESULTS: At 1 year, the smoking cessation rate was 22.5%. Each measure of motivation to quit was independently associated with cessation (p<.001) when added individually to an adjusted model. Likely was most closely associated with cessation and Stage was least. Likely had a sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of 70.2%, 68.1%, 39.3%, 88.6%, and 2.2, respectively. CONCLUSIONS: The motivation of inpatient smokers to quit may be as easily and as accurately predicted with a single question as with the series of questions that are typically used.     

Predictors of quitting among african american light smokers enrolled in a randomized, placebo-controlled trial

OBJECTIVE: To examine the predictors of quitting among African American (AA) light smokers (<10 cigarettes per day) enrolled in a smoking cessation trial. METHODS: Baseline variables were analyzed as potential predictors from a 2 x 2 cessation trial in which participants were randomly assigned to 1 of 4 treatment groups: nicotine gum plus health education (HE) counseling, nicotine gum plus motivational interviewing (MI) counseling, placebo gum plus HE counseling, or placebo gum plus MI counseling. Chi-square tests, 2 sample t-tests, and multiple logistic regression analyses were used to identify predictors of cotinine (COT) verified abstinence at month 6. RESULTS: In the final regression model, HE rather than MI counseling (odds ratio [OR]=2.26%, 95% confidence interval [CI]=1.36 to 3.74), older age (OR=1.03%, 95% CI=1.01 to 1.06), and higher body mass index (OR=1.04%, 95% CI=1.01 to 1.07) significantly increased the likelihood of quitting, while female gender (OR=0.46%, 95% CI=0.28 to 0.76),相似文献   

Smoking and Smoking Cessation During Pregnancy and Postpartum

Smoking cessation during and after pregnancy can confer many health benefits to women and their children. Smoking behavior can fluctuate from quitting or reducing during the first trimester to relapses later in pregnancy and postpartum. Abstinence during pregnancy is associated with level of addiction, socioeconomic status, level of education, maternal age, age to start smoking, partner's smoking habit, and secondhand smoke exposure. Low-barrier interventions that reach impoverished and disadvantaged women who are most at risk for smoking and also have the hardest time quitting are needed. At a minimum, pregnant smokers should be offered self-help materials and a 10-minute face-to-face psychosocial intervention. Offering incentives to pregnant women to quit smoking is the most effective intervention. Data are inconclusive regarding the efficacy of smoking cessation pharmacotherapy during pregnancy and postpartum. Because there are also safety concerns about fetal exposure, the use of pharmacotherapy for pregnant women remains controversial.