Effectiveness of telephone-based follow-up support delivered in combination with a multi-component smoking cessation intervention in family practice: A cluster-randomized trial

Abstract

Objective

To determine whether telephone-based smoking cessation follow-up counseling (FC), when delivered as part of a multi-component intervention program is associated with increased rates of follow-up support and smoking abstinence.

Methods

A cluster randomized controlled-trial was conducted within family medicine practices in Ontario, Canada. Consecutive adult patients who smoked were enrolled at two time points, the baseline period (2009) and the post-intervention period (2009–2011). Smoking abstinence was determined by telephone interview 4 months following enrollment. Both groups implemented a multi-component intervention program. Practices randomized to the FC group could also refer patients to a follow-up support program which involved 5 telephone contacts over a 2-month period.

Results

Eight practices, 130 providers, and 928 eligible patients participated in the study. No statistically significant difference in 7-day point-prevalence abstinence was observed between intervention groups. There was a significant increase in referral to follow-up in both intervention groups. Significantly higher rates of smoking abstinence [25.7% vs. 11.3%; adjusted OR 3.1 (95% CI: 1.1, 8.6), p < 0.05] were documented among the twenty-nine percent of FC participants who were referred to the follow-up support program compared to the MC group.

Conclusion

Access to external follow-up support did not increase rates at which follow-up support was delivered.

Introduction

The United States Clinical Practice Guidelines for Treating Tobacco Use and Dependence recommends five strategies as the basis for smoking cessation interventions in clinical settings (Fiore et al., 2008). The “five As” (5As) strategies are: ask (identify smoking status); advise patients who smoke to quit; assess readiness to quit; assist with making a quit attempt; and arrange follow-up.

Despite the evidence supporting the efficacy of smoking cessation interventions, there is a well-documented practice gap in the rates at which 5As smoking cessation interventions are delivered by primary-care practitioners (Fiore et al., 2008, Papadakis et al., 2010, Stead et al., 2008).

It is known that between 36 and 75% of patients report receiving cessation advice from their primary care physician in the previous 12 months (Gottlieb et al., 2001, Ismailov and Leatherdale, 2010, Longo et al., 2006, Reid et al., 2012, Shaohua et al., 2003, Tong et al., 2010, Young and Ward, 2001). However, the rates at which specific assistance with quitting and, in particular, follow-up is provided to patients are much lower at 3–20% (Gottlieb et al., 2001, Ismailov and Leatherdale, 2010, Longo et al., 2006, Shaohua et al., 2003, Tong et al., 2010, Young and Ward, 2001).

Multi-component interventions that combine practice, provider and patient level intervention strategies have been shown to be the most effective method for increasing provider performance in the delivery of smoking cessation treatment and improving cessation rates among patients (Anderson and Jane-Llopis, 2004, Fiore et al., 2008, Grimshaw et al., 2001, Papadakis et al., 2010).

Given the low rates at which follow-up support is delivered in primary care settings, linking patients to follow-up counseling conducted by individuals external to a practice may serve as a feasible method of “extending treatment” when delivered in conjunction with an initial brief intervention by family medicine practitioners (Zwar et al., 2010). Lancaster et al. found in their meta-analysis of physician advice for smoking cessation a small benefit follow-up support. This review was not specific to family medicine practices. A second review specific to family practice, found seven trials which examined adjunct telephone counseling compared to standard care found evidence to support increased smoking abstinence (pooled odds ratio 1.7 [95% CI 1.5–2.0]) however the findings were mixed (An et al., 2006, Aveyard et al., 2007, Hollis et al., 1993, Murray et al., 2008, Papadakis et al., 2010, Sherman et al., 2007, Vetter and Ford, 1990, Young et al., 2008). The incremental value of such adjunct, telephone-based smoking cessation counseling delivered as part of a multi-component intervention has never been examined.

The aim of this study was to determine whether telephone-based smoking cessation follow-up counseling (FC), when delivered as part of a multi-component intervention program within primary care practices is associated with increased rates of referral to follow-up support and increased patient smoking abstinence compared to a multi-component intervention (MC) alone.