Regular articleAn academic detailing intervention to disseminate physician-delivered smoking cessation counseling: smoking cessation outcomes of the Physicians Counseling Smokers Project
Introduction
Cigarette smoking is the leading cause of preventable morbidity and mortality in the United States [1], and smoking-related medical care expenditures are estimated to be over 50 billion dollars annually [2]. Although there was a steady decline in smoking prevalence in the United States from the late 1960s to the early 1990s, there has been little to no change in these rates from 1990 to 1998 [3], [4], underscoring the need for dissemination of effective smoking cessation interventions. This article reports smoking cessation outcomes from a controlled trial of an academic detailing intervention to disseminate smoking cessation interventions among community-based primary care practices.
The unique and central role of primary care physicians in enhancing smoking cessation efforts was initially emphasized in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline for Smoking Cessation [5] and reemphasized in the most recent edition of this guideline, Treating Tobacco Use and Dependence [6]. More than 70% of smokers have contact with a physician each year [7] and primary care physicians have multiple occasions to provide personalized cessation interventions to patients who smoke. The guideline panel’s comprehensive review of the literature concluded that smokers who received even brief clinical interventions compared to those who received no advice demonstrated significantly increased cessation rates [6]. In addition, a strong dose–response relationship exists between the intensity of person-to-person contact and successful cessation outcome [6].
Primary care clinicians are not taking full advantage of opportunities to intervene with their patients who smoke. Surveys of patients have found that only about half of current smokers report that their physicians have either asked them about smoking or urged them to quit [8], [9], [10]. Thorndike and colleagues [11] found that smoking cessation counseling rates by physicians increased from 16% of smokers in 1991 to 29% in 1993, and then decreased to 21% in 1995. Our own research indicates that, among a population-based sample of smokers who had seen a physician during the previous year, only 51% reported that they were “talked to” about their smoking; 45.5% were advised to quit; 14.9% were offered specific assistance; and 3% had a follow-up appointment arranged [8]. Although most physicians believe in the importance of addressing smoking with their patients [12], [13], [14], [15], incorporating counseling into routine practice remains a challenge [16], [17], [18], [19], [20], [21].
Previous controlled trials have demonstrated the efficacy of intervention strategies designed to increase physicians’ adoption of smoking cessation interventions. Efficacious strategies for increasing the frequency and intensity of clinician-delivered smoking cessation interventions include linking identification of smoking status with the use of a vital sign stamp [5], [22], using reminders to prompt physicians to intervene [6], [23], [24], [25], training physicians in counseling skills [23], [26], [27], [28], and providing patients with access to nicotine replacement and educational materials in the medical office setting [6], [24], [26], [29].
However, most of the studies completed to date were efficacy trials that did not utilize representative samples of community physicians. For example, physician subjects represented only 5–43% of those eligible to participate in several of the seminal National Cancer Institute (NCI)-funded studies conducted in the late 1980s [28], [30], [31]. The experimental interventions in these efficacy trials were implemented in clinical settings by research staff, rather than by the physicians or office staff. Several other studies were conducted in residency training programs or with university-based faculty practices [26], [27], [29]. Dissemination trials are needed to test strategies which will enhance the adoption of efficacious smoking cessation interventions within a population of community-based primary care physicians.
The specific aim of the Physicians Counseling Smokers (PCS) trial was to test the effectiveness of a multicomponent office-based intervention to increase primary care physicians’ adoption, implementation, and maintenance of the NCI “4As” smoking cessation strategy [32], [33]. We based our multicomponent office-based intervention on an “academic detailing” model because of reports supporting its utility in enhancing physician adoption of preferred clinical practices [34]. Academic detailing is a form of educational outreach that features personal educational visits to clinicians in their own practice setting [35]. Academic detailing provides an opportunity for the educator, or “office practice consultant,” to assess the needs and motivation of the targeted clinician and subsequently tailor the educational intervention to the particular needs, barriers, and motivational readiness of the targeted audience and the specific practice environment [34], [36].
Using a quasi-experimental design, we tested the impact of this intervention in a community-based sample of 259 primary care physicians providing direct care to adults in Rhode Island [20]. A detailed description of the baseline data are published in a previous article [20]. The primary outcome of the PCS trial, smoking cessation rates within a population-based sample of Rhode Island smokers, is the focus of this article. Our hypothesis is that physicians in the experimental intervention areas will be significantly more likely to adopt and deliver smoking cessation counseling than physicians in the control areas and that this will be reflected in higher levels of smoking cessation in the population of smokers they serve.
Section snippets
Design
The Physicians Counseling Smokers study was funded by the National Cancer Institute as a component of the Rhode Island Cancer Prevention Research Consortium (CPRC). Community-based samples of both physicians and patients were recruited to enhance the generalizability of the study. A quasi-experimental design was used to examine the effect of disseminating the physician office-based intervention within Rhode Island (RI) counties (see Fig. 1). All five counties of the state of Rhode Island were
Sample characteristics
Characteristics of the 2346 study participants who reported a physician visit during the intervention period are presented in Table 1. Those who visited a physician were slightly older (P = 0.001), were more likely to be female (P = 0.001), had a higher educational level (P = .001), reported poorer perceived health (P = 0.005), and were more likely to be in the preparation stage for quitting smoking (P = 0.001) than those who did not visit a physician. Demographic differences between
Discussion
This study reports the results of a controlled trial that tested a strategy to disseminate clinical smoking cessation interventions within a community-based sample of primary care physicians. Our principal finding is that smokers who resided in geographic areas where the experimental PCS office-based academic detailing intervention was delivered were more likely to report that they had quit smoking at 24 months than smokers who resided in control areas where there was no PCS office-based
Acknowledgements
This study was supported by Grant PO1CA50087 (James Prochaska, Principal Investigator) from the National Cancer Institute, Washington, D.C. The authors acknowledge David B. Abrams, Ph.D, James O. Prochaska, Ph.D., and Wayne Velicer, Ph.D., who contributed to the design and methodology of the study and provided support and guidance as senior scientists of the Rhode Island Cancer Prevention Consortium. We also acknowledge Catherine Dube, Ed.D., Nancy M. Gross, M.P.H., C.H.E.S., Alexander
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