Advertisement

Journal of General Internal Medicine

, Volume 22, Issue 4, pp 478–484 | Cite as

Randomized Controlled Trial of a Computer-Based, Tailored Intervention to Increase Smoking Cessation Counseling by Primary Care Physicians

  • Marina UnrodEmail author
  • Meredith Smith
  • Bonnie Spring
  • Judith DePue
  • William Redd
  • Gary Winkel
Original Article

Objective

The primary care visit represents an important venue for intervening with a large population of smokers. However, physician adherence to the Smoking Cessation Clinical Guideline (5As) remains low. We evaluated the effectiveness of a computer-tailored intervention designed to increase smoking cessation counseling by primary care physicians.

Methods

Physicians and their patients were randomized to either intervention or control conditions. In addition to brief smoking cessation training, intervention physicians and patients received a one-page report that characterized the patients’ smoking habit and history and offered tailored recommendations. Physician performance of the 5As was assessed via patient exit interviews. Quit rates and smoking behaviors were assessed 6 months postintervention via patient phone interviews. Intervention effects were tested in a sample of 70 physicians and 518 of their patients. Results were analyzed via generalized and mixed linear modeling controlling for clustering.

Measurements and Main Results

Intervention physicians exceeded controls on “Assess” (OR 5.06; 95% CI 3.22, 7.95), “Advise” (OR 2.79; 95% CI 1.70, 4.59), “Assist–set goals” (OR 4.31; 95% CI 2.59, 7.16), “Assist–provide written materials” (OR 5.14; 95% CI 2.60, 10.14), “Assist–provide referral” (OR 6.48; 95% CI 3.11, 13.49), “Assist–discuss medication” (OR 4.72;95% CI 2.90, 7.68), and “Arrange” (OR 8.14; 95% CI 3.98, 16.68), all p values being < 0.0001. Intervention patients were 1.77 (CI 0.94, 3.34,p = 0.078) times more likely than controls to be abstinent (12 versus 8%), a difference that approached, but did not reach statistical significance, and surpassed controls on number of days quit (18.4 versus 12.2, p < .05) but not on number of quit attempts.

Conclusions

The use of a brief computer-tailored report improved physicians’ implementation of the 5As and had a modest effect on patients’ smoking behaviors 6 months postintervention.

Key words

smoking cessation computer-tailored intervention primary care 

Notes

Acknowledgement

The authors thank and acknowledge Shannon Erisman and Quinne Leyden for their contributions in data collection.

Potential Financial Conflicts of Interest

None disclosed.

References

  1. 1.
    Centers for Disease Control and Prevention. Annual smoking—attributable mortality, years of potential life lost, and productivity losses—United States, 1997–2001. MMWR Morb Mortal Wkly Rep. 2005;54:625–8.Google Scholar
  2. 2.
    Fiore M, Bailey W, Cohen S, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville MD: U.S. Department of Health and Human Services, U.S. Public Health Service; 2000.Google Scholar
  3. 3.
    Davis RM. Uniting physicians against smoking: the need for a coordinated national strategy. J Am Med Assoc 1988;259:2900–1.CrossRefGoogle Scholar
  4. 4.
    Fiore MC, Jorenby DE, Schensky AE, Smith SS, Bauer RR, Baker TB. Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clin Proc 1995;70(3):209–13.PubMedCrossRefGoogle Scholar
  5. 5.
    Gorin SS, Heck JE. Meta-analysis of the efficacy of tobacco counseling by health care providers. Cancer Epidemiol Biomark Prev 2004;13(12):2012–22.Google Scholar
  6. 6.
    Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279:604–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Doescher MP, Saver BG. Physicians’ advice to quit smoking: the glass remains half empty. J Fam Pract 2000;49:543–7.PubMedGoogle Scholar
  8. 8.
    Ellerbeck EF, Ahluwalia JS, Jolicoeur DG, Gladden J, Mosier MC. Direct observation of smoking cessation activities in primary care practice. J Fam Pract 2001;50:688–93.PubMedGoogle Scholar
  9. 9.
    Gilpin EA, Pierce JP, Johnson M, Bal D. Physicians advice to quit smoking: results from the 1990 California Tobacco Survey. J Gen Intern Med 1993;8:549–53.PubMedCrossRefGoogle Scholar
  10. 10.
    Goldstein MG, Niaura R, Willey-Lessner C, et al. Physicians counseling smokers. Arch Intern Med 1997;157:1313–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Prochaska JO, DiClemente CC, Velicer WF, Rossi JS. Standardized, individualized, interactive and personalized self-help programs for smoking cessation. Health Psychol 1993;12:399–405.PubMedCrossRefGoogle Scholar
  12. 12.
    Prochaska JO, Velicer WF, Fava JL, Rossi JS, Tsoh JY. Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation. Addict Behav 2001;26(4):583–602.PubMedCrossRefGoogle Scholar
  13. 13.
    Prochaska JO, Velicer WF, Redding C, et al. Stage-based expert systems to guide a population of primary care patients to quit smoking, eat healthier, prevent skin cancer, and receive regular mammograms. Prev Med 2005;41(2):406–16.PubMedCrossRefGoogle Scholar
  14. 14.
    Strecher VJ, Kreuter M, Den Boer DJ, Kobrin S, Hospers HJ, Skinner CS. The effects of computer-tailored smoking cessation messages in family practice settings. J Fam Pract 1994;39(3):262–70.PubMedGoogle Scholar
  15. 15.
    Strecher VJ, Shiffman S, West R. Randomized controlled trial of a web-based computer-tailored smoking cessation program as a supplement to nicotine patch therapy. Addiction 2005;100(5):682–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Dijkstra A, De Vries H, Roijackers J. Long-term effectiveness of computer-generated tailored feedback in smoking cessation. Health Educ Res 1998;13(2):207–14.PubMedCrossRefGoogle Scholar
  17. 17.
    Dijkstra A, De Vries H, Roijackers J, van Breukelen G. Tailored interventions to communicate stage-matched information to smokers in different motivational stages. J Consult Clin Psychol. 1998;66(3):549–57.PubMedCrossRefGoogle Scholar
  18. 18.
    Biener L, Abrams DD. The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol 1991;10:360–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Abrams DB, Biener L. Motivational characteristics of smokers at the workplace: a public health challenge. Prev Med 1992;21:679–87.PubMedCrossRefGoogle Scholar
  20. 20.
    Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol 1983;51:390–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom test for nicotine dependence: a revision of the Fagerstrom tolerance questionnaire. Br J Addict 1991;86(9):1119–27.PubMedCrossRefGoogle Scholar
  22. 22.
    Pomerleau CS, Carton SM, Lutzke ML, Flessland KA, Pomerleau OF. Reliability of the Fagerstrom tolerance questionnaire and the Fagerstrom test for nicotine dependence. Addict Behav 1994;19(1):33–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Dijkstra A, DeVries H, Bakker M. Pros and cons of quitting, self-efficacy, and the stages of change in smoking cessation. J Consult Clin Psychol 1996;64:758–63.PubMedCrossRefGoogle Scholar
  24. 24.
    Velicer WF, DiClemente CC, Rossi JS, Prochaska JO. Relapse situations and self-efficacy: an integrative model. Addict Behav 1990;15:271–83.PubMedCrossRefGoogle Scholar
  25. 25.
    Soumerai SB, Avorn J. Principles of educational outreach (‘academic detailing’) to improve clinical decision making. JAMA 1990;263:549–56.PubMedCrossRefGoogle Scholar
  26. 26.
    Goldstein MG, Niaura R, Willey-Lessner C, et al. Physicians counseling smokers. Arch Intern Med 1997;157:1313–19.PubMedCrossRefGoogle Scholar
  27. 27.
    Wadland WC, Stoffelmayr B, Ellen E, Crombach A, Ives K. Enhancing smoking cessation rates in primary care. J Fam Pract 1999;48(9):711–8.PubMedGoogle Scholar
  28. 28.
    Farkas A, Pierce J, Gilpin E, et al. Is stage of change a useful measure of the likelihood of smoking cessation? Annals Behav Med 1996;18(2):79–86.CrossRefGoogle Scholar
  29. 29.
    Milch CE, Edmunson JM, Beshansky JR, Griffith JL, Selker HP. Smoking cessation in primary care: a clinical effectiveness trial of two simple interventions. Prev Med 2004;38(3):284–94.PubMedCrossRefGoogle Scholar
  30. 30.
    Fiore MC, McCarthy DE, Jackson TC, et al. Integrating smoking cessation treatment into primary care: an effectiveness study. Prev Med 2004;38(4):412–20.PubMedCrossRefGoogle Scholar
  31. 31.
    Katz DA, Muehlenbruch DR, Brown RL, Fiore MC, Baker TB; AHRQ Smoking Cessation Guideline Study Group. Effectiveness of implementing the agency for healthcare research and quality smoking cessation clinical practice guideline: a randomized, controlled trial. J Natl Cancer Inst 2004;96(8):594–603.PubMedCrossRefGoogle Scholar
  32. 32.
    Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004;18(4):CD000165.Google Scholar
  33. 33.
    Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99:29–38.PubMedCrossRefGoogle Scholar
  34. 34.
    Ahluwalia JS, Gibson CA, Kenney E, Wallace DD, Resnicow K. Smoking status as a vital sign. J Gen Intern Med 1999;14:402–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. Adult tobacco use levels after intensive tobacco control measures: New York City, 2002–2003. Am J Public Health 2005;95(6):1016–23.PubMedCrossRefGoogle Scholar
  36. 36.
    Ockene JK, Kristeller J, Goldberg R, et al. Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial. J Gen Intern Med 1991;6(1):1–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Stretcher VJ, O’Malley MS, Villagra VG, et al. Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial. J Gen Intern Med 1991;6(1):9–17.CrossRefGoogle Scholar
  38. 38.
    Ossip-Klein DJ, McIntosh S. Quitlines in North America: evidence base and applications. Am J Med Sci 2003;326(4):201–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Zwar NA, Richmond RL. Role of the general practitioner in smoking cessation. Drug Alcohol Rev 2006;25(1):21–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Sciamanna CN, Marcus BH, Goldstein MG, et al. Feasibility of incorporating computer-tailored health behaviour communications in primary care settings. Informatics in Primary Care. 2004;12:40–8.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Marina Unrod
    • 1
    • 5
    Email author
  • Meredith Smith
    • 1
  • Bonnie Spring
    • 2
  • Judith DePue
    • 3
  • William Redd
    • 1
  • Gary Winkel
    • 4
  1. 1.Department of Oncological SciencesMount Sinai School of MedicineNew YorkUSA
  2. 2.Department of Preventive MedicineNorthwestern UniversityEvanstonUSA
  3. 3.Centers for Behavioral and Preventive MedicineMiriam Hospital/Brown Medical SchoolProvidenceUSA
  4. 4.Department of PsychologyCity University of New YorkNew YorkUSA
  5. 5.Tobacco Research & Intervention ProgramH. Lee Moffitt Cancer Center & Research InstituteTampaUSA

Personalised recommendations