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.     

Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance

Aims This study aimed to assess the effects of opportunistic brief physician advice to stop smoking and offer of assistance on incidence of attempts to stop and quit success in smokers not selected by motivation to quit. Methods We included relevant trials from the Cochrane Reviews of physician advice for smoking cessation, nicotine replacement therapy (NRT), varenicline and bupropion. We extracted data on quit attempts and quit success. Estimates were combined using the Mantel–Haentszel method and heterogeneity assessed with the I² statistic. Study quality was assessed by method of randomization, allocation concealment and follow‐up blind to allocation. Results Thirteen studies were included. Compared to no intervention, advice to quit on medical grounds increased the frequency of quit attempts [risk ratio (RR) 1.24, 95% confidence interval (CI): 1.16–1.33], but not as much as behavioural support for cessation (RR 2.17, 95% CI 1.52–3.11) or offering NRT (RR 1.68, 95% CI: 1.48–1.89). In a direct comparison, offering assistance generated more quit attempts than giving advice to quit on medical grounds (RR 1.69, 95% CI: 1.24–2.31 for behavioural support and 1.39, 95% CI: 1.25–1.54 for offering medication). There was evidence that medical advice increased the success of quit attempts and inconclusive evidence that offering assistance increased their success. Conclusions Physicians may be more effective in promoting attempts to stop smoking by offering assistance to all smokers than by advising smokers to quit and offering assistance only to those who express an interest in doing so.     

Smoking cessation rates in elderly and nonelderly smokers after participating in an intensive care smoking cessation camp

Since it is a widely known fact that smoking cessation is beneficial physically and cognitively, efforts should be made to enable smokers to quit smoking through policy. Intensive care smoking cessation camps generally show a high smoking cessation success rate, but research is needed to determine which smokers should be admitted due to costeffectiveness. Although many studies have been conducted to find factors related to smoking cessation success, there is still controversy about the will and success rate of smoking cessation of elderly smokers. We performed this study to determine behavior characteristics and smoking cessation success rates in nonelderly and elderly smokers who participated in an intensive care smoking cessation camp.Heavy smokers participating in an intensive care smoking cessation camp at Chonnam National University Hospital between the August 2015 and December 2017 were classified into elderly (age ≥65 years old) or nonelderly (age <65 years old) groups after excluding missing data. Smokers were followed up at 4 weeks, 6 weeks, 12 weeks, and 6 months from the start of abstinence by self-report, measurement of carbon monoxide expiration levels or cotinine testing.A total of 351 smokers were enrolled in the study. At the 6-month follow-up, 56 of 107 (52.3%) elderly smokers and 109 of 244 (44.7%) nonelderly smokers continued to abstain from smoking. Elderly smokers showed a higher smoking cessation rate than that of nonelderly smokers, but it was not statistically significant (OR = 1.36, 95%CI: 0.862, 2.145). The most common causes of cessation failure in both groups were stress and temptation, followed by withdrawal symptoms.Smoking cessation rates in the elderly are comparable to that in the nonelderly after an intensive care smoking cessation camp. Intensive care smoking cessation camps can help both elderly and nonelderly smokers who intend to quit smoking by providing motivation, education and medication. Smoking cessation should be strongly recommended regardless of age.     

Increasing hospital-wide delivery of smoking cessation care for nicotine-dependent in-patients: a multi-strategic intervention trial

Aims, design and intervention   Smoking care provision to in-patients is important in assisting smoking cessation and for management of nicotine withdrawal. Limited studies have reported the effectiveness of interventions designed to increase the hospital-wide provision of such care. A quasi-experimental matched-pair trial, involving two intervention and two control hospitals in NSW, Australia, investigated whether a multi-strategic intervention increased hospital-wide smoking care provision.
Participants and measurements   Patient surveys ( n  = 274–347 per experimental condition), medical notes audits ( n  = 181–228) and health professional surveys ( n  = 229–302) were used to collect outcome data at baseline and follow-up.
Findings   Significantly greater increases in intervention hospitals compared to control hospitals were found for patient-reported offer of nicotine replacement therapy (NRT) (intervention 34% versus control 12%), provision of NRT (16% versus 4%) and provision of written resources (11% versus 2%), and for the recording in medical notes of smoking management discussion (13% versus 3%), offer of NRT (24% versus 3%) and provision of NRT (21% versus 5%). Intervention group health professionals reported significantly greater increases in the mean estimate of patients who: had their smoking management discussed (30% versus 17%); were offered or provided with NRT (30% versus 18%); were asked their intention to smoke post-discharge (22% versus 10%); and were provided with discharge NRT (21% versus 4%).
Conclusions   Implementation of a multi-strategic intervention is effective in increasing hospital smoking care delivery, particularly the provision of NRT. Research is required to identify methods to increase further the delivery of this and other forms of smoking care.     

How prevalent is smoking and nicotine dependence in primary care in Germany?

AIMS: Identifying, diagnosing and reducing nicotine use, dependence and related morbidity are considered key responsibilities of primary care physicians. Little is known, however, about the magnitude of the problem in primary care and the extent of treatment in Germany. This paper reports on (1) life-time and point prevalences of smoking and nicotine dependence among unselected consecutive German primary care attendees; (2) associations of smoking status with socio-demographic features and (3) rates of doctors' recognition and treatment patterns. DESIGN: Data came from the Smoking and Nicotine Dependence Awareness and Screening Study (SNICAS), a nationally representative two-stage epidemiological point prevalence study (stage I: prestudy characterization of a nation-wide sample of 889 primary care doctors; stage II: target day assessment of 28,707 unselected consecutive patients). RESULTS: (1) Of all primary care attendees, 71% reported having ever used a tobacco product (life-time regular smokers 51%; life-time occasional smokers 21.5%.). Point prevalence (4 weeks) of smoking was considerably lower (occasional use 4.7%, regular use 24.9%). The rate of DSM-IV nicotine dependence (13.9%) was highest among the youngest age groups. (2) Rates of regular and dependent smokers decreased markedly with age, mainly as a result of the steadily increasing numbers of male ex-smokers and low numbers of older female life-time ever smokers. Young age, unemployment, being single, divorced, widowed or separated from the partner were associated with higher rates of smoking or nicotine dependence. (3) In about 25% of patients, primary care doctors failed to recognize the patient's current smoking and/or nicotine dependence. Case recognition was highest for nicotine dependence (76%). Among recognized cases, 56% had ever received any kind of advice or counselling about quitting; yet only 12% had ever participated in any smoking cessation programme. CONCLUSIONS: Beyond the confirmation of the well-established finding of a high prevalence of smokers in primary care, this paper demonstrates (1) considerable point prevalence of DSM-IV nicotine dependence (14%); (2) that it is noteworthy, however, that the rates are not higher than those in community samples; and (3) a considerable variation by age group with highest rates among the young (22-31%), but considerably lower rates among subjects aged 50 and above (16% to 0.9% in the oldest). This substantial association with age seems to be due mainly to the low smoking rates in older women and the increasing numbers of successful, particularly male, quitters from 40 years onwards. Recognition of primary care patients' smoking status by primary-care practitioners was moderate, and the frequency of past and current primary care interventions was low. These findings call for systematic investigation into barriers that impede the implementation of smoking cessation interventions in primary care settings.     

Leveraging Primary Care in the Fight Against Lung Cancer

In recent years, the decline in youth smoking rates has stopped as the tobacco industry strives to successfully reclaim market areas where it has lost favor. The plateau in lung cancer incidence and stagnation in progress toward smoking abstinence illustrates the necessity for renewed efforts to fight tobacco use. Barriers to fighting tobacco use exist in both the clinical arena and within the general population, but can be overcome. Primary care physicians (PCPs) are uniquely poised to successfully treat nicotine dependence with strategic targeting of these barriers, improved training in smoking cessation techniques, and focused political efforts in tobacco control. Herein, this article describes the landscape of tobacco use in America and provides background, methodology, and resources for PCPs to help achieve the goals of Healthy People 2010 in reducing the illness, disability, and death that occur as a result of tobacco use and exposure to secondhand smoke.     

General practitioners' and family physicians' negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review

OBJECTIVE: To estimate the proportion of general practitioners (GPs) and family physicians (FPs) with negative beliefs and attitudes towards discussing smoking cessation with patients. METHODS: A systematic review. STUDY SELECTION: All studies published in English, in peer-reviewed journals, which allowed the extraction of the proportion of GPs and FPs with negative beliefs and attitudes towards discussing smoking cessation. DATA SYNTHESIS: Negative beliefs and attitudes were extracted and categorised. Proportions were synthesized giving greater weight to those obtained from studies with larger samples. Those assessed in two or more studies are reported. RESULTS: Across 19 studies, eight negative beliefs and attitudes were identified. While the majority of GPs and FPs do not have negative beliefs and attitudes towards discussing smoking with their patients, a sizeable minority do. The most common negative beliefs were that such discussions were too time-consuming (weighted proportion: 42%) and were ineffective (38%). Just over a quarter (22%) of physicians reported lacking confidence in their ability to discuss smoking with their patients, 18% felt such discussions were unpleasant, 16% lacked confidence in their knowledge, and relatively few considered discussing smoking outside of their professional duty (5%), or that this intruded upon patients' privacy (5%), or that such discussion were inappropriate (3%). CONCLUSIONS: In addition to providing skills training, interventions designed to increase the implementation of smoking cessation interventions by primary care physicians may be more effective if they address a range of commonly held negative beliefs and attitudes towards discussing smoking cessation. These include beliefs and values that influence primary care physicians' judgements about whether discussing smoking is an effective use of their time.     

Acute Effect of Inhaled Budesonide on Bronchial Inflammation in Asthmatic Rats

The aim of this study was to determine the level of asthma control and the concordance between physicians' and patients' opinions and the real patients' situation. A total of 777 subjects (55% female) with asthma were recruited. The study comprised a 4-week follow-up period, during which subjects completed a diary recording peak expiratory flow (PEF), symptoms, and use of rescue medication. At the end, both physicians and patients rated asthma control status. The level of control was evaluated using a composite measure. Agreement among subjective assessments of asthma control by patients and physicians and objective evaluation with the composite measure was assessed through kappa scores. A total of 518 (67%) patients had “not well-controlled asthma,” being the remaining “totally controlled” (8%) or “well-controlled” (25%). “Not well-controlled asthma” was more frequent in smokers (82%) than in ex-smokers (70%) or in non-smokers (62%; p = 0.0002). Kappa scores between patients' and physicians' opinions and the real patients' status were 0.02 (95% CI, 0.01–0.05) and 0.07 (95% CI, 0.03–0.09), respectively. In conclusion, current level of asthma control is suboptimal for a majority (67%) of patients in Spain. Besides, asthma control is worse in smokers. Neither patients' nor physicians' opinions agree with patients' real situation. Both patients and physicians accept as normal a suboptimal status of their disease.