Elsevier

Preventive Medicine

Volume 51, Issues 3–4, September–October 2010, Pages 199-213
Preventive Medicine

Review
Strategies to increase the delivery of smoking cessation treatments in primary care settings: A systematic review and meta-analysis

https://doi.org/10.1016/j.ypmed.2010.06.007Get rights and content

Abstract

Objectives

A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics.

Methods

The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for “5As” (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies.

Results

Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing “5As” delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6–2.1] for “ask”, 1.6 [95% CI 1.4–1.8] for “advice”, 9.3 [95% CI 6.8–12.8] for “assist” (quit date) and 3.5 [95% CI 2.8–4.2] for “assist” (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5–2.0] and multi-component interventions [OR 2.2; 95% CI 1.7–2.8] were found to significantly increase smoking abstinence.

Conclusion

Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.

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.

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