Elsevier

Preventive Medicine

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

Integrating smoking cessation treatment into primary care: an effectiveness study

https://doi.org/10.1016/j.ypmed.2003.11.002Get 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)

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

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