Integrating smoking cessation treatment into primary care: an effectiveness study

doi:10.1016/j.ypmed.2003.11.002

Preventive Medicine

Volume 38, Issue 4, April 2004, Pages 412-420

https://doi.org/10.1016/j.ypmed.2003.11.002 Get rights and content

Abstract

Background. Lack of interest has been cited as a reason not to offer cessation assistance to smokers, but research suggests that smokers accept treatments offered proactively. This study assessed acceptability, utilization, and effectiveness of free smoking cessation treatment among diverse primary care patients.

Method. Medical assistants invited 4,174 adult smokers to participate. Enrollees (1,869) self-selected or were assigned to receive free nicotine patch therapy alone or in combination with the Committed Quitters® program, and for some, individual counseling.

Results. In nearly 68% of cases, patients accepted a treatment invitation; 77% of eligible smokers enrolled; 85% of these picked up free patches. Given a choice of treatments, 75% of participants elected a psychosocial treatment in addition to patch therapy. Thirteen percent of treatment initiators achieved biochemically confirmed 7-day point-prevalence abstinence at 1 year, with no significant treatment effects. Minority patients showed greater initial interest but less utilization did than White patients.

Conclusions. Free, readily accessible smoking cessation treatment offered in primary care settings was accepted and used by the majority of unselected smokers of diverse racial/ethnic origins. Psychosocial treatment components did not significantly increase abstinence rates. Barriers, rather than lack of interest, may keep minority smokers from using cessation treatments.

Introduction

Among the most confounding paradoxes surrounding tobacco dependence in the United States is the reluctance of clinicians and health care delivery systems to address this cause of illness and death despite its high prevalence (23% among American adults) [1] and staggering costs. Over 440,000 tobacco-attributable deaths occur per year [2] and more than US$100 billion in added health care and other costs accrue annually [2]. Currently, primary care providers are not capitalizing on the many opportunities to treat this chronic disorder, although 70% of smokers visit a primary care clinician annually [3], 70% of smokers report being interested in quitting [1], and 40% of smokers make an attempt to quit each year [4]. Although empirically supported counseling and pharmacotherapeutic interventions exist [5], along with a clinical practice guideline for intervention in health care settings [6], only a minority of smokers use evidence-based treatments to quit under the care of a clinician [7]. Mobilizing the primary care delivery system to identify and intervene universally with tobacco users is a critical preventive health care challenge.

In the present study, we sought to assess acceptability, utilization, and effectiveness of free nicotine patch and psychosocial smoking cessation treatments in a diverse sample of primary care patients. Past research has suggested that only 5–14% of medical patients act on referrals for formal treatment programs [8], [9], [10]. However, patients referred to these programs still faced many barriers to accessing treatment (e.g., cost, inconvenience). We sought, therefore, to reduce barriers to utilization by using proactive recruitment [11], [12] during vital sign assessment at primary care clinics and providing free, convenient treatment.

In this study, we recruited a diverse sample of smokers. To date, most of the research on smoking cessation has been conducted with White, middle-class participants. Past research has demonstrated both gender [5], [7], [12], [13] and racial/ethnic differences [14] in smoking and cessation behavior (including use of nicotine patches [5], [15] and other formal treatments [1], [13], [16]). As argued elsewhere [17], these differences in smoking and quitting make it important to explore treatment willingness and effectiveness among smokers of both genders and diverse racial/ethnic backgrounds.

The current study was designed to assess utilization and effectiveness of free nicotine replacement therapy (NRT) and two psychosocial treatments differing in intensity. Numerous studies have shown that intensive psychosocial treatments are efficacious among “treatment seekers,” patients who seek treatment by volunteering for randomized clinical trials [6]. It is unclear, however, what proportion of smokers in a primary care population will accept such treatments (i.e., will be “treatment acceptors”). Moreover, it is unclear if intensive psychosocial treatments are effective among treatment acceptors. To determine treatment acceptance, some patients in this study were allowed to select their preferred treatment. Thus, unselected patients in primary care clinics were invited by medical assistants to participate in a treatment program involving free NRT and possible psychosocial treatment. Outcomes of clinic invitations were tracked, along with self-selected treatment intensity, use of patch and psychosocial treatment components, and smoking status over 1-year post-cessation. We addressed five key questions in this study:

1.
Are primary care patients who smoke willing to enter a free smoking cessation treatment program involving nicotine patches and possible counseling?
2.
What is the preferred intensity of psychosocial treatment among smokers?
3.
Do smokers adhere to the treatment regimen once enrolled?
4.
How effective are the combined pharmacological and psychological tobacco dependence treatments offered in this study, and does their effectiveness differ as a function of random assignment vs. self-selection of treatment?
5.
Do smokers of different genders and races/ethnicities respond differently to the treatments offered in this study in terms of acceptability, utilization, and benefit?

Section snippets

Study design

The study used a 2 (condition-assignment arm) × 3 (treatment condition) factorial design. Participants were randomly assigned to a condition-assignment arm in which they were either assigned randomly to a treatment condition (Random Arm), or able to select their own treatment condition (Selection Arm). (See Fig. 1) In each arm, the lowest intensity condition, Patch Only, included an 8-week course of free nicotine patches (supplied by SmithKline Beecham), the intermediate intensity condition,

Results

The demographic characteristics of patients who enrolled in the study are summarized in Table 1. Participants were recruited from 12 primary care clinics that returned more than 50 smoker interest forms to research staff. Five clinics were removed from recruitment analyses because the data suggested that clinic personnel did not reliably report smokers who were uninterested in treatment. Inspection of the data from these clinics revealed a record-keeping problem; over 50 invitation acceptances

Discussion

The results of this study suggest that the majority of primary care patients who smoke are willing to enter smoking cessation programs offered through their clinics, prefer more intensive treatment when given a choice, and will initiate a treatment regimen (e.g., pick up free NRT). At the 1-year follow-up, nearly 13% of treatment initiators achieved biochemically confirmed abstinence, with no apparent effect of the psychosocial treatments offered.

1. Are primary care patients who smoke willing

Acknowledgements

We thank the participating clinics and clinicians for recruiting participants; the research assistants who collected, entered, and verified data; the smoking cessation counselors who provided services for participants; Teague Ashburn for assistance with preliminary analyses, and Heather J. Vaughn for data management.

Preparation of this article was supported by National Cancer Institute Grant NCI 1 R01 CA71377 and by Transdisciplinary Tobacco Use Research Grant NCI 1 P50 CA84724 from the

References (34)

J.K. Ockene
Physician-delivered interventions for smoking cessation: strategies for increasing effectiveness
Prev. Med.
(1987)
S.H. Zhu et al.
Smoking cessation with and without assistance: a population-based analysis
Am. J. Prev. Med.
(2000)
H.A. Lando et al.
Survey of smoking patterns, attitudes, and interest in quitting
Am. J. Prev. Med.
(1991)
N. Owen et al.
Smokers' preferences for assistance with cessation
Prev. Med.
(1990)
Centers for Disease Control and Prevention
Cigarette smoking among adults—United States, 2000
MMWR
(2002 (Jul. 26))
Centers for Disease Control and Prevention
Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995–1999
MMWR
(2002 (Apr. 12))
Centers for Disease Control and Prevention
Cigarette smoking among adults—United States, 1999
MMWR
(2002 (Oct. 12))
M.C. Fiore et al.
Treating tobacco use and dependence. Clinical practice guideline
(2000 (June))
M.C. Fiore et al.
Methods used to quit smoking in the United States: do cessation programs help?
JAMA
(1990)
S. McIntosh et al.
Recruitment strategies and success in multi-county smoking cessation study
Nicotine Tob. Res.
(2000)

R.S. Thompson et al.

Effectiveness of smoking cessation interventions integrated into primary care practice

Med. Care

(1988)

E. Lichtenstein et al.

Patient referral to a smoking cessation program: who follows through?

J. Fam. Pract.

(1992)

H.A. Lando et al.

Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation

Am. J. Public Health

(1992)

J.P. Pierce et al.

Nicotine patch use in the general population: results from the 1993 California Tobacco Survey

J. Natl. Cancer Inst.

(1995)

N. Hymnowitz et al.

Past quit smoking assistance and doctors' advice for white and African-American smokers

J. Natl. Med. Assoc.

(1996)

J.M. Royce et al.

Smoking cessation factors among African Americans and whites

Am. J. Public Health

(1993)

M.E. Piper et al.

Gender and racial/ethnic differences in tobacco-dependence treatment: a commentary and research recommendations

Nicotine Tob. Res.

(2001)

Cited by (78)

Worry and e-cigarette cognition: The moderating role of sex
2021, Addictive Behaviors
Citation Excerpt :
Future work should examine these relationships in terms of exclusive users to delineate behavior and perceptions unique to this subpopulation. Lastly, although the data gathered across the online survey platform is a validated method of participant recruitment, future work may explore samples within alternative settings (i.e., primary care) as many studies have shown that clinical settings are a ‘first step’ of healthcare for many nicotine users (Fiore et al., 2004). Overall, the current investigation documents individual differences in worry and sex as factors that facilitate understanding e-cigarette cognition among adult e-cigarette users.
As electronic cigarette (e-cigarette) use continues to rise, it is important to identify individual characteristics that may influence e-cigarette use behavior and potential group-level moderators of effects, such as sex. Initial evidence has suggested that worry, defined as excessive, unrealistic thoughts focused on the possibility of future negative events, may contribute to e-cigarette use behavior. Yet, how these established relations differ across groups, such as male and female e-cigarette users, has not been explored. The present study evaluated the effect of worry on perceived barriers for quitting e-cigarettes, perceptions of benefits for e-cigarette use, and perceived negative consequences of e-cigarette use across sex. The sample included 584 current e-cigarette users (52.2% female, M_age = 35.15 years, SD = 10.27). Analyses indicated a significant interaction between sex and worry on each criterion variable (perceived benefits: b = 0.02, SE = 0.01, t = −2.73, p = .01; perceived barriers for quitting e-cigarettes: b = −0.45, SE = 0.08, t = −5.70, p ≤ 0.001; negative consequences to use: b = −0.033, SE = 0.01, t = −4.50, p < .001), such that worry was more strongly related to each outcome among males than females. These findings suggest that sex plays a role in e-cigarette use behaviors and that males may constitute a group that is especially vulnerable to the effects of worry on both positive and negative e-cigarette use perceptions and perceived barriers for quitting e-cigarettes.
MIFuzzy clustering for incomplete longitudinal data in smart health
2017, Smart Health
Citation Excerpt :
Behavioral interventions (e.g., physician advice; individual, group, or telephone counseling; self-help, including Internet use, and emerging use of wearable biosensors) (Sawicki Didjurgeit, M¨uhlhauser, & Berger, 1993; Marlow & Stoller, 2003; Mottillo et al., 2009; Barth, Bengel, & Critchley, 2006; Hennrikus et al., 2005; Allen, Pederson, & Leonard, 1998; Hajek, Taylor,& Mills, 2002; Jackson, Manan, Gani, Eldridge, & Carter, 2004; Miller, Smith, DeBusk, Sobel, & Taylor, 1997; Aveyard, Griffin, Lawrence, & Cheng, 2003; Molyneux et al., 2003; Mogielnicki et al., 1986; Jorenby et al., 1995; Lando et al., 1997; Carreiro et al., 2015; Fang et al., 2015) are commonly used to facilitate substance use treatments. Many such interventions have multiple components and are implemented over time, e.g., (Kim et al., 2015; Fiore et al., 2000, 2004; Glasgow & Lichtenstein, 1987; Glasgow Whitlock, Eakin, & Lichtenstein, 2000; Secker-Walker et al., 1994; Windsor et al., 2000; Weissfeld & Holloway, 1991; Slovinec D'Angelo et al., 2005; Omenn et al., 1987; Curry, Marlatt, Gordon, & Baer, 1988; Curry & McBride, 1994; Glasgow, Schafer, & O’Neill, 1981; Rabius, McAlister, Geiger, Huang, & Todd, 2004; Curry, McBride, Grothaus, Louie, & Wagner, 1995; Taylor, Houston-Miller, Killen, & DeBusk, 1990). Over the course of an intervention, patients display complex and varying behaviors such as relapsing or dropping out for various psychological, social and environmental reasons, e.g., (Schoedel, Hoffmann, Rao, Sellers, & Tyndale, 2004; Proudnikov Hamon, Ott, & Kreek, 2008; Dagher, Tannenbaum, Hayashi, Pruessner, & McBride, 2009; Anderson, Ramo, & Brown, 2006; Brown Vik, Patterson, Grant, & Schuckit, 1995; Longshore, 1997; Sabogal, Otero-Sabogal, Pasick, Jenkins, & Perez-Stable, 1996; Kravitz, Duan, & Braslow, 2004; Baker et al., 2011).
Missing data are common in longitudinal observational and randomized controlled trials in smart health studies. Multiple-imputation based fuzzy clustering is an emerging non-parametric soft computing method, used for either semi-supervised or unsupervised learning. Multiple imputation (MI) has been widely-used in missing data analyses, but has not yet been scrutinized for unsupervised learning methods, although they are important for explaining the heterogeneity of treatment effects. Built upon our previous work on MIfuzzy clustering, this paper introduces the MIFuzzy concepts and performance, theoretically, empirically and numerically demonstrate how MI-based approach can reduce the uncertainty of clustering accuracy in comparison to non- and single-imputation based clustering approach. This paper advances our understanding of the utility and strength of MIFuzzy clustering approach to processing incomplete longitudinal behavioral intervention data.
Combination Therapies for Smoking Cessation: A Hierarchical Bayesian Meta-Analysis
2016, American Journal of Preventive Medicine
Treatment guidelines recommend the use of combination therapies for smoking cessation, particularly behavioral therapy (BT) as an adjunct to pharmacotherapy. However, these guidelines rely on previous reviews with important limitations. This study’s objective was to evaluate the efficacy of combination therapies compared with monotherapies, using the most rigorous data available.
A systematic review and meta-analysis of RCTs of pharmacotherapies, BTs, or both were conducted. The Cochrane Library, Embase, PsycINFO, and PubMed databases were systematically searched from inception to July 2015. Inclusion was restricted to RCTs reporting biochemically validated abstinence at 12 months. Direct and indirect comparisons were made in 2015 between therapies using hierarchical Bayesian models.
The search identified 123 RCTs meeting inclusion criteria (60,774 participants), and data from 115 (57,851 participants) were meta-analyzed. Varenicline with BT increased abstinence more than other combinations of a pharmacotherapy with BT (varenicline versus bupropion: OR=1.56, 95% credible interval [CrI]=1.07, 2.34; varenicline versus nicotine patch: OR=1.65, 95% CrI=1.10, 2.51; varenicline versus short-acting nicotine-replacement therapies: OR=1.68, 95% CrI=1.15, 2.53). Adding BT to any pharmacotherapy compared with pharmacotherapy alone was inconclusive, owing to wide CrIs (OR=1.17, CrI=0.60, 2.12). Nicotine patch with short-acting nicotine-replacement therapy appears safe and increases abstinence versus nicotine-replacement monotherapy (OR=1.63, CrI=1.06, 3.03). Data are limited concerning other pharmacotherapy combinations and their safety and tolerability.
Evidence suggests that combination therapy benefits may be less than previously thought. Combined with BT, varenicline increases abstinence more than other pharmacotherapy with BT combinations.
Design of novel 3,6-diazabicyclo[3.1.1]heptane derivatives with potent and selective affinities for α<inf>4</inf>β<inf>2</inf> neuronal nicotinic acetylcholine receptors
2015, European Journal of Medicinal Chemistry
Citation Excerpt :
The multiple nAChR subunits form a plethora of different receptor subtypes among which the most abundant in the CNS are the α4β2* and the α7* receptors (the asterisk indicates the potential presence of other subunits), whereas the α3β4 receptor is the predominant subtype at ganglionic synapses [10,11]. The neuronal nAChRs are involved in a wide range of physiological and pathophysiological processes, and they have been proposed as potential therapeutic targets in a number of neurodegenerative disorders such as Alzheimer's disease [12] and Parkinson's disease [13], neurological disorders such as Tourette's syndrome [14], psychic disorders such as schizophrenia [15], anxiety and depression [16], epilepsy [17], in various form of pain [7], and nicotine addiction [18]. Recently, was also suggested their potential use in cancer therapy [19].
New analogues (3a–l) of the previously described α₄β₂ selective ligand 3-(6-halopyridin-3-yl)-3,6-diazabicyclo[3.1.1]heptanes (2a,b) have been synthesized and their binding activity for neuronal acetylcholine receptor subtypes α₄β₂ and α₇ were assayed.
Six of these compounds (3a,b,c,j,k and l) showed high affinity and selectivity for α₄β₂ receptors. The phenylpyridyl-diazabicycloheptane 3c displayed K_i value of 11.17 pM for α₄β₂, in line with that of the halogenated homologues 3a,b, although it was characterized by an improved selectivity (Ki = 17 μM for α₇ receptors). The influence of substitutions on the phenylpyridyl moiety on binding at both α₄β₂ and α₇ receptors has been examined through the Topliss decision tree analysis. Substitution with electron-donating groups (as CH₃ and OCH₃) resulted in a good affinity for α₄β₂ receptors and substantially no affinity for α₇. Amongst all the tested phenyl-substituted compounds, the p-NO₂-phenyl substituted analogue 3j exhibited the highest α₄β₂ affinity, with Ki value comparable to that of 3c.
Intrinsic α₄β₂ receptor mediated activity in [³H]-DA release assay was showed by compound 3a as well as by the reference analogue 2a, whereas phenyl substituted derivative 3c exhibited α₄β₂ antagonist activity.
Consensus report for the clinical care of smoking cessation in Spain
2013, Medicina Clinica
El consumo de tabaco presenta una rara confluencia de circunstancias: es una significativa y alta amenaza para la salud, hay una escasa motivación entre el personal sanitario para intervenir consecuentemente y, sin embargo, disponemos de intervenciones efectivas. Realmente es difícil identificar ningún otro condicionante de la salud que presente esta mezcla de letalidad, prevalencia y desatención, pese a que disponemos de tratamientos eficaces fácilmente disponibles. Por otra parte, la intervención en tabaco está considerada como el patrón oro de las intervenciones preventivas, muy por encima de otras medidas preventivas usadas comúnmente. Todo ello ha motivado al Comité Nacional de Prevención de Tabaquismo a elaborar un Documento de Consenso para la Atención Clínica al Tabaquismo en España. La finalidad de este trabajo, de carácter técnico y científico, es consensuar una propuesta básica de calidad sobre el abordaje de las personas fumadoras que sirva como guía orientativa en la práctica clínica en el contexto de nuestro país. Los objetivos de consenso son revisar la eficacia de los tratamientos existentes del tabaquismo, sintetizar la evidencia disponible sobre el tratamiento de las personas fumadoras, consensuar unos mínimos básicos que permitan orientar las actuaciones asistenciales de calidad en España, proponiendo recomendaciones clínicas para el manejo del paciente que fuma. El consenso aborda las estrategias y las evidencias que las sustentan, para intervenir sobre los fumadores en la consulta tanto en aquellos que no quieren dejar de fumar, como en el que quiere dejar de fumar, estableciendo los pasos para intervenir de la forma más adecuada.
Tobacco use presents an odd confluence of circumstances: it is a significant and high threat to health, and there is a lack of motivation among health workers to act accordingly. Yet we have effective interventions. It is really hard to identify any other determinant of health presenting this mixture of lethality, prevalence, and lack of care, despite having effective treatments readily available. On the other hand, smoking cessation interventions are considered as the gold standard of preventive interventions, far above other preventive measures commonly used. This has prompted the National Committee for Smoking Prevention to develop a consensus document for the Clinical Care of Smoking Cessation in Spain. The purpose of this technical and scientific document is to agree on a basic proposal of quality of care to tackle smokers to quit. This document would serve as a guideline in the clinical practice in our country. The aims of this agreement are to review the effectiveness of the existing therapies for smoking cessation, to synthesize their available evidence, and to set the basic minimum standards of care in the clinical practice of patients who smoke. The consensus sets the strategies, and the evidences that support them, in order to assist both the smokers who want to quit, and the smokers who do not, setting out the steps to intervene in the most adequate.
From good to great: The role of performance coaching in enhancing tobacco-dependence treatment rates
2018, Annals of Family Medicine
The purpose of this study was to examine the incremental effect of performance coaching, delivered as part of a multicomponent intervention (Ottawa Model for Smoking Cessation [OMSC]), in increasing rates of tobacco-dependence treatment by primary care clinicians.
In a cluster-randomized controlled trial, 15 primary care practices were randomly assigned to 1 of the following active-treatment conditions: OMSC or OMSC plus performance coaching (OMSC+). All practices received support to implement the OMSC. In addition, clinicians in the OMSC+ group participated in a 1.5-hour skills-based coaching session and received an individualized performance report. All clinicians and a cross-sectional sample of their patients were surveyed before and 4 months after introduction of the interventions. The primary outcome measure was rates of tobacco-dependence treatment strategy (Ask, Advise, Assist, Arrange) delivery. Secondary outcomes were patient quit attempts and smoking abstinence measured at 6 months’ follow-up.
Primary care clinicians (166) and patients (1,990) were enrolled in the trial. Clinicians in the OMSC+ group had statistically greater rates of delivery for Ask (adjusted odds ratio [AOR] = 1.69; 95% CI, 1.05-2.72), Assist (AOR = 1.64; 95% CI, 1.08-2.49), and Arrange (AOR = 2.01; 95% CI, 1.22-3.31). Sensitivity analysis found that the rate of delivery for Advise was greater only among those clinicians who attended the coaching session (AOR = 1.65; 95% CI, 1.10-2.49; P = .02). No differences were documented between groups for cessation outcomes.
Performance coaching significantly increased rates of tobacco-dependence treatment by primary care clinicians when delivered as part of a multicomponent intervention.

View all citing articles on Scopus

¹: Currently at: Wilkinson Medical Clinic, Oconomowoc, WI, 53066, USA.

View full text

Integrating smoking cessation treatment into primary care: an effectiveness study

Abstract

Introduction

Section snippets

Study design

Results

Discussion

Acknowledgements

Prev. Med.

Am. J. Prev. Med.

Am. J. Prev. Med.

Prev. Med.

Cigarette smoking among adults—United States, 2000

MMWR

Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995–1999

MMWR

Cigarette smoking among adults—United States, 1999

MMWR

Treating tobacco use and dependence. Clinical practice guideline

Methods used to quit smoking in the United States: do cessation programs help?

JAMA

Recruitment strategies and success in multi-county smoking cessation study

Nicotine Tob. Res.

Effectiveness of smoking cessation interventions integrated into primary care practice

Med. Care

Patient referral to a smoking cessation program: who follows through?

J. Fam. Pract.

Brief supportive telephone outreach as a recruitment and intervention strategy for smoking cessation

Am. J. Public Health

Nicotine patch use in the general population: results from the 1993 California Tobacco Survey

J. Natl. Cancer Inst.

Past quit smoking assistance and doctors' advice for white and African-American smokers

J. Natl. Med. Assoc.

Smoking cessation factors among African Americans and whites

Am. J. Public Health

Gender and racial/ethnic differences in tobacco-dependence treatment: a commentary and research recommendations

Nicotine Tob. Res.