ReviewStrategies to increase the delivery of smoking cessation treatments in primary care settings: A systematic review and meta-analysis
Introduction
Tobacco use remains the leading cause of premature morbidity and mortality worldwide (World Health Organization, 2002). Smoking cessation treatment is considered the ‘gold standard’ intervention in the prevention of chronic diseases (Eddy, 1992, Gaziano et al., 2007, Kahn et al., 2008). The cost per life-year-saved for smoking cessation is estimated to be between $2000 and $4000; it is the most cost-effective preventive intervention available to clinicians (Tengs et al., 1995, Benowitz, 2003, Kahn et al., 2008).
Most smokers will visit their primary care physician annually (Jaakkimainen et al., 2006, Health Canada, 1999, Zwar and Richmond, 2006, Centers for Disease Control and Prevention, 1993). A family doctor's advice to quit has been shown to increase a smoker's motivation to quit (Fiore et al., 2008, Eckert and Junker, 2001, Kreuter et al., 2000, Ossip-Klein et al., 2000, Pederson, 1982, Stead et al., 2008). Smoking cessation is more likely to occur when practitioners offer advice and support compared to no advice, and the effect appears greater as frequency and duration of the support increases. The pooled odds ratio (OR) of cessation is 1.3 [95% CI 1.01, 1.6] for brief counseling (< 3 min), 1.6 [95% CI 1.2–2.0] for low intensity counseling (3–10 min), and 2.3 [95% CI 2.0–2.7] for higher intensity counseling (> 10 min) (Fiore et al., 2008, Stead et al., 2008).
The United States Department of Health and Human Services (USDHHS) Clinical Practice Guideline for Treating Tobacco-Use and Dependence is a highly regarded and frequently cited reference manual concerning smoking cessation treatment in clinical settings (Fiore et al., 2008). The guideline specifically recommends five strategies as the basis for brief smoking cessation interventions in clinical settings. The “five As” (5As) strategies are: ask and record the smoking status of all patients at each visit; advise all smokers to quit; assess smokers' readiness to make a quit attempt; assist smokers in making a quit-attempt (e.g. provide self-help materials, set quit date, recommend and prescribe smoking cessation medications); and arrange follow-up.
Despite evidence supporting the importance of smoking cessation, there is a well-documented ‘practice gap’ in the rates at which smoking cessation is addressed by practitioners in clinical settings. International studies have documented that between 40 and 70% of smokers report having received cessation advice from their physicians (Longo et al., 2006, Young and Ward, 2001, Hu et al., 2003, CTUMS, 2006). While practitioners tend to deliver advice to quit at moderate rates, studies have shown that the rates of providing specific assistance with quitting (i.e. counseling, self-help materials, quit-smoking medications, or follow-up support) are below 20% (Longo et al., 2006, Young and Ward, 2001, Hu et al., 2003, Gottlieb et al., 2001, Curry, 2000, DePue et al., 2002, Piper et al., 2003). Several barriers to optimal cessation practice have been identified at the level of the patient, practitioner, practice, and system; all have been suggested to limit the delivery and uptake of cessation treatments in the primary care setting (Vogt et al., 2005).
While several published meta-analyses have examined the effect of physician advice and other provider interventions on smoking cessation, these reviews have not been specific to the primary care setting (Fiore et al., 2008, Stead et al., 2008, Lancaster et al., 2000).
Moreover, previously published reviews have been limited to reporting on smoking abstinence and have not examined the impact of these interventions on provider performance in the delivery of evidence-based smoking cessation treatments. The only published analysis of strategies to influence provider behaviour in the primary care setting reviewed literature published up to 2001 (Anderson and Jane-Llopis, 2004).
The aim of the present study was to conduct an up-to-date systematic review and meta-analysis of trials evaluating the effectiveness of strategies that increase the delivery of evidence-based cessation interventions as well as increase the rate of smoking cessation among patients in primary care settings.
Section snippets
Search strategy
The MEDLINE electronic database was used to identify studies published prior to January 1, 2009 using the MeSH headings “smoking” or “smoking cessation” and “primary health care” or “physicians” or “family practice”. Search limits were used to exclude non-English language publications (n = 811) and trials which were not indexed within MEDLINE as a randomized controlled trial, controlled clinical trial, or evaluation study (n = 5550). This was supplemented with hand searches of the bibliographies of
Study selection
Fig. 1 presents a flow chart of the selection process. A total of 38 comparisons from 37 published studies met the eligibility criteria and were included in the present review. A summary of the excluded studies can be accessed from the online version of this publication.
Description of studies
Table 1 summarizes the characteristics of the studies included in the present review. Table 2 provides an overview of the study design, description of comparator groups and outcomes of the 38 trials included within the review. A
Principal findings
Wide-spread, systematic dissemination of smoking cessation interventions has not occurred in clinical practice settings (Fiore et al., 2008, Ebbert and Hays, 2008).
Understanding which strategies hold the most promise for increasing the uptake of evidence-based smoking cessation interventions in primary-care practice will assist in guiding future research, policy, and most importantly practice.
Our review found evidence from multiple trials supporting the value of multi-component interventions in
Conclusion
This review provides new information on the value of strategies for enhancing the integration of clinical smoking cessation interventions into primary-care practice. The review suggests that there is no single intervention strategy that can assist with improving the delivery of all 5As. Multi-component interventions appear to hold promise for improving outcomes. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness
Conflict of interest statement
The authors declare there is no conflict of interest.
Acknowledgments
This work was supported by the Ontario Tobacco Research Unit and the Canadian Institute of Health Research Strategic Training Program in Tobacco Research and Population Intervention in Chronic Disease Prevention.
References (73)
- et al.
Provider feedback improves adherence with AHCPR Smoking Cessation Guideline
Prev. Med.
(2001) Cigarette smoking and cardiovascular disease: pathophysiology and implications for treatment
Prog. Cardiovasc. Dis.
(2003)- et al.
Randomized controlled trial of a computer strategy to increase general practitioner preventive care
Prev. Med.
(1999) Organizational interventions to encourage guideline implementation
Chest
(2000)- et al.
Scaling up interventions for chronic disease prevention: the evidence
Lancet
(2007) - et al.
An academic detailing intervention to disseminate physician-delivered smoking cessation counseling: smoking cessation outcomes of the Physicians Counseling Smokers Project
Prev. Med.
(2003) - et al.
Smoking cessation in primary care: a clinical effectiveness trial of two simple interventions
Prev. Med.
(2004) - et al.
Smokers ages 50+: who gets physician advice to quit?
Prev. Med.
(2000) Compliance with physician advice to quit smoking: a review of the literature
Prev. Med.
(1982)- et al.
Effectiveness of a minimal contact smoking cessation program for Dutch general practitioners: a randomized controlled trial
Prev. Med.
(2001)