Addicted to Nicotine
A National Research Forum

Section VI: Treatment of Nicotine Dependence
John Hughes, M.D., Chair

PRIMARY CARE-BASED INTERVENTIONS

Judith K. Ockene, Ph.D., M.Ed.
Division of Preventive and Behavioral Medicine
University of Massachusetts Medical School

Introduction

The primary care setting is an important place for promoting smoking cessation because a high percentage of people who smoke visit each year. In 1993, 80 percent of smokers had at least one contact with a primary care physician, with the number of average yearly contacts about six per adult. Physicians are creditable and respected, and patients are aware of their health at the time of the visit.

What We Know

Randomized clinical trials (RCTs) present excellent evidence that a brief physician-delivered intervention for smoking cessation, in a primary care setting, significantly increases patients' smoking cessation rates. As the portion of the physician-delivered intervention increases (ranging from 50 seconds to 15 minutes), so does the effect. RCTs have also demonstrated that the addition of pharmacotherapy and interventions by other providers and other modalities significantly enhances the effect of physician-delivered smoking intervention. In addition, RCTs conducted with targeted populations such as pregnant women and disease-specific populations have demonstrated greater efficacy of physician-delivered interventions with these populations compared with a general population of primary care patients. The physician as educator, facilitator, or counselor can be a powerful agent for smoking cessation in the primary care setting.

Unfortunately, despite widespread dissemination of preventive services guidelines and positive physician attitudes toward such services, the current level of smoking cessation intervention by physicians is not high. It is therefore a major research and public health concern. Reports indicate that fewer than 50 percent of smokers are counseled for cessation during office visits. Data also indicate that the likelihood of having been counseled to quit smoking is directly related to the number of health care visits.

Given that physician-delivered interventions have a positive effect on smoking cessation rates, it is important to consider interventions that increase the rate of implementation. Interventions to change provider behavior can be grouped broadly into three types: (1) provider education, (2) clinical systems and procedures, and (3) organizational policy. Education and training have been the primary methods used to alter provider care, the clinical system has made systematic use of medical record and computer reminders, and organizations have relied on performance measures and covered benefits. From an educational perspective, the dissemination of practice guidelines alone does not produce improvement nor do traditional Continuing Medical Education activities. When reminders are used alone, there are conflicting reports regarding their effect on physicians' implementation of smoking cessation intervention. There is a greater degree of implementation of intervention and of subsequent smoking cessation when education and reminders are used together.

What We Need To Know More About

There has been an evolving awareness that a policy intervention component is needed that includes the use of covered prevention benefits, incentives, feedback, and other reinforcements if providers are to be motivated to intervene in real-world settings. However, the elimination of financial barriers has not always seemed adequate. The role of public and organizational policy alternatives for increasing physician-delivered interventions needs testing.

Given the positive effect that physician-delivered and primary care-based interventions can have on smoking cessation, it is important to investigate a variety of methods to increase their rate of delivery and effectiveness. Examples of questions regarding systems interventions and policy interventions include the following: What are the best incentives or combination of incentives for physicians and patients? What are the most effective strategies that can be used to remind providers to intervene? How can each of these strategies best be implemented in different types of settings and systems?

Other research questions should address a stepped-care and patient-treatment matching model such as the one proposed by Abrams and colleagues for delivery of smoking cessation treatment into mainstream health care in order to be able to treat the general population of smokers at reasonable cost. The model includes brief counseling by physicians for the easier smokers and moves to more extensive interventions for the more difficult-to-treat smokers. The proposed model has not been tested and lends itself to the refinement of hypotheses and development of assessment and intervention methods to eventually be able to determine the efficacy and effectiveness of such a model and its application in real-world settings. Some sample questions are as follows: What is the most effective combination of physician and other provider interventions? What are the most essential elements of physician intervention? What is the best way to include pharmacotherapy? In addition, what interventions are effective for smokers with multiple risk behaviors?

Solberg and colleagues raised an important research question: How do we implement guidelines? They noted there is little evidence anyone has learned how to do this well. Studies conducted under well-controlled experimental conditions, as well as demonstration projects conducted under less well-controlled conditions in the clinical setting, provide the foundation for the next generation of effectiveness studies that address the role of various factors in the health care environment in the delivery of services. However, such factors (e.g., reimbursement policies, covered benefits) do not lend themselves well to tightly controlled randomized trials. Use of quasi-experimental designs and application of qualitative strategies are needed.

Recommended Reading

Abrams, D.B.; Orleans, C.T.; Niaura, R.S.; Goldstein, M.G.; Prochaska, J.O.; and Velicer, W. Integrating individual and public health perspectives for treatment of tobacco dependence under managed health care: A combined step care and matching model. Ann Behav Med 18(4):290-304, 1996.

Fiore, M.C.; Bailey, W.C.; Cohen, S.J.; Dorfman, S.F.; Goldstein, M.G.; Gritz, E.R.; Heyman, R.B.; and Holbrook, J. Smoking Cessation: Clinical Practice Guideline No. 18. AHCPR Pub. No. 96-0692. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1996.

Ockene, J.; McBride, P.; Sallis, J.; Bonollo, D.; and Ockene, I. Synthesis of lessons learned from cardiopulmonary preventive interventions in health care practice settings. Ann Epidemiol S7:S32-S45, 1997.

Ockene, J., and Zapka, J. Physician-based smoking intervention: A rededication to a five-step strategy to smoking research. Addict Behav 22:835-848, 1997.

Solberg, L.I.; Kottke, T.E.; Brekke, M.L.; Calomeni, C.A.; Conn, S.A.; and Davidson, G. Using continuous quality improvement to increase preventive services in clinical practice--going beyond guidelines. Prev Med 25:259-267, 1996.