A Systematic Literature Review of Self-Reported Smoking Cessation Counseling by Primary Care Physicians.
ABSTRACT: Tobacco consumption is a risk factor for chronic diseases and worldwide around six million people die from long-term exposure to first- or second-hand smoke annually. One effective approach to tobacco control is smoking cessation counseling by primary care physicians. However, research suggests that smoking cessation counseling is not sufficiently implemented in primary care. In order to understand and address the discrepancy between evidence and practice, an overview of counseling practices is needed. Therefore, the aim of this systematic literature review is to assess the frequency of smoking cessation counseling in primary care. Self-reported counseling behavior by physicians is categorized according to the 5A's strategy (ask, advise, assess, assist, arrange). An electronic database search was performed in Embase, Medline, PsycINFO, CINAHL and the Cochrane Library and overall, 3491 records were identified. After duplicates were removed, the title and abstracts of 2468 articles were screened for eligibility according to inclusion/exclusion criteria. The remaining 97 full-text articles reporting smoking cessation counseling by primary care physicians were assessed for eligibility. Eligible studies were those that measured physicians' self-reported smoking cessation counseling activities via questionnaire. Thirty-five articles were included in the final review (1 intervention and 34 cross-sectional studies). On average, behavior corresponding to the 5A's was reported by 65% of physicians for "Ask", 63% for "Advise", 36% for "Assess", 44% for "Assist", and 22% of physicians for "Arrange", although the measurement and reporting of each of these counseling practices varied across studies. Overall, the results indicate that the first strategies (ask, advise) were more frequently reported than the subsequent strategies (assess, assist, arrange). Moreover, there was considerable variation in the items used to assess counseling behaviour and developing a standardized instrument to assess the counseling strategies implemented in primary care would help to identify and address current gaps in practice.
Project description:The focus on acute care, time pressure, and lack of resources hamper the implementation of smoking cessation guidelines in the emergency department (ED). The purpose of this study was to determine whether an emergency nurse- initiated intervention based on the 5A's (Ask-Advise-Assess-Assist-Arrange) framework improves quit rates.We conducted a pre-post implementation trial in 789 adult smokers who presented to two EDs in Iowa between August 13, 2008 and August 4, 2010. The intervention focused on improving delivery of the 5A's by ED nurses and physicians using academic detailing, charting/reminder tools, and group feedback. Performance of ED cessation counseling was measured using a 5A's composite score (ranging from 0 to 5). Smoking status was assessed by telephone interview at 3- and 6-month follow-up (with biochemical confirmation in those participants who reported abstinence at 6-month follow-up).Based on data from 650 smokers who completed the post-ED interview, there was a significant improvement in the mean 5A's composite score for emergency nurses during the intervention period at both hospitals combined (1.51 vs. 0.88, difference = 0.63, 95% confidence interval [CI] [0.41, 0.85]). At 6-month follow-up, 7-day point prevalence abstinence (PPA) was 6.8 and 5.1% in intervention and preintervention periods, respectively (adjusted odds ratio [OR] = 1.7, 95% CI [0.99, 2.9]).It is feasible to improve the delivery of brief smoking cessation counseling by ED staff. The observed improvements in performance of cessation counseling, however, did not translate into statistically significant improvements in cessation rates. Further improvements in the effectiveness of ED cessation interventions are needed.
Project description:INTRODUCTION:Although evidence-based, the 5A's (Ask, Advise, Assess, Assist, and Arrange) for smoking cessation are often incompletely delivered by primary care providers. This study examines whether a computer tablet 5A's intervention improves primary care provider adherence to the 5A's. STUDY DESIGN:Cluster RCT. SETTING/PARTICIPANTS:All primary care providers in three urban, adult primary care clinics were randomized for participation. Any English- or Spanish-speaking patient with a primary care appointment who had smoked >100 lifetime cigarettes and at least one cigarette in the past week was eligible. INTERVENTION:A cluster RCT comparing computer-facilitated 5A's with usual care assessed effects on provider adherence to each of the 5A's as determined by patient report. Intervention subjects used a computer tablet to complete the 5A's immediately before a primary care appointment. A tailored, patient handout and a structured, clinician guide were generated. Data were collected in 2014-2015 and analyzed in 2016-2017. MAIN OUTCOME MEASURES:Provider adherence to the 5A's. RESULTS:Providers (N=221) saw 961 patients (n=412 intervention, n=549 control) for a total of n=1,340 encounters with n=1,011 completed post-visit interviews (75.4% completion). Intervention providers had significantly higher odds of completing Assess (AOR=1.32, 95% CI=1.02, 1.73) and Assist (AOR=1.45, 95% CI=1.08, 1.94). When looking at first study visits only, intervention providers had higher odds for Arrange (AOR=1.72, 95% CI=1.23, 2.40) and all 5A's (AOR=2.04, 95% CI=1.35, 3.07) but study visit did not influence receipt of the other 5A's. CONCLUSIONS:A computer-facilitated 5A's delivery model was effective in improving the fidelity of provider-delivered 5A's to diverse primary care patients. This relatively low-cost, time-saving intervention has great potential for smoking cessation and other health behaviors. Future studies should identify ways to promote and sustain technology implementation. TRIAL REGISTRATION:This study is registered at www.clinicaltrials.gov NCT02046408.
Project description:The National Lung Screening Trial (NLST) found a reduction in lung cancer mortality among participants screened with low-dose computed tomography vs chest radiography. In February 2015, Medicare announced its decision to cover annual lung screening for patients with a significant smoking history. These guidelines promote smoking cessation treatment as an adjunct to screening, but the frequency and effectiveness of clinician-delivered smoking cessation interventions delivered after lung screening are unknown.To determine the association between the reported clinician-delivered 5As (ask, advise, assess, assist [talk about quitting or recommend stop-smoking medications or recommend counseling], and arrange follow-up) after lung screening and smoking behavior changes.A matched case-control study (cases were quitters and controls were continued smokers) of 3336 NLST participants who were smokers at enrollment examined participants' rates and patterns of 5A delivery after a lung screen and reported smoking cessation behaviors.Prevalence of the clinician-delivered 5As and associated smoking cessation after lung screening.Delivery of the 5As 1 year after screening were as follows: ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%. Receipt of ask, advise, and assess was not significantly associated with quitting in multivariate models that adjusted for sociodemographic characteristics, medical history, screening results, nicotine dependence, and motivation to quit. Assist was associated with a 40% increase in the odds of quitting (odds ratio, 1.40; 95% CI,?1.21-1.63), and arrange was associated with a 46% increase in the odds of quitting (odds ratio, 1.46; 95% CI,?1.19-1.79).Assist and arrange follow-up delivered by primary care providers to smokers who were participating in the NLST were associated with increased quitting; less intensive interventions (ask, advise, and assess) were not. However, rates of assist and arrange follow-up were relatively low. Our findings confirm the need for and benefit of clinicians taking more active intervention steps in helping patients who undergo screening to quit smoking.
Project description:A minority of hospitalized smokers actually receives assistance in quitting during hospitalization or cessation counseling following discharge. This study aims to determine the impact of a guideline-based intervention on 1) nurses' delivery of the 5A's (Ask-Advise-Assess-Assist-Arrange follow-up) in hospitalized smokers, and 2) nurses' attitudes toward the intervention.We conducted a pre-post guideline implementation trial involving 205 hospitalized smokers on the inpatient medicine units at one US Department of Veterans Affairs (VA) medical center. The intervention included: 1) academic detailing of nurses on delivery of brief cessation counseling, 2) modification of the admission form to facilitate 5A's documentation, and 3) referral of motivated inpatients to receive proactive telephone counseling. Based on subject interviews, we calculated a nursing 5A's composite score for each patient (ranging from 0 to 9). We used linear regression with generalized estimating equations to compare the 5A's composite score (and logistic regression to compare individual A's) across periods. We compared 29 nurses' ratings of their self-efficacy and decisional balance ("pros" and "cons") with regard to cessation counseling before and after guideline implementation. Following implementation, we also interviewed a purposeful sample of nurses to assess their attitudes toward the intervention.Of 193 smokers who completed the pre-discharge interview, the mean nursing 5A's composite score was higher after guideline implementation (3.9 vs. 3.1, adjusted difference 1.0, 95 % CI 0.5-1.6). More patients were advised to quit (62 vs. 48 %, adjusted OR = 2.1, 95 % CI = 1.2-3.5) and were assisted in quitting (70 vs. 45 %, adjusted OR = 2.9, 95 % CI = 1.6-5.3) by a nurse during the post-implementation period. Nurses' attitudes toward cessation counseling improved following guideline implementation (35.3 vs. 32.7 on "pros" subscale, p = 0.01), without significant change on the "cons" subscale.A multifaceted intervention including academic detailing and adaptation of the nursing admission template is an effective strategy for improving nurses' delivery of brief cessation counseling in medical inpatients.
Project description:The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians' (EPs) and nurses' (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A's framework (Ask-Advise-Assess-Assist-Arrange) in the ED.We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts.The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients' receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A's in the ED.There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies.ClinicalTrials.gov registration number NCT00756704.
Project description:The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange) and 2) assess ED nurses' and physicians' perceptions of smoking cessation counseling.The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses' and physicians' self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates.Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses' self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in "pros" and "cons" attitudes toward smoking cessation in either ED nurses or physicians.Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.
Project description:<h4>Introduction</h4>The study objective was to assess tobacco screening and cessation counseling practices of pediatric emergency department (PED) and urgent care (UC) nurses and physicians, and factors associated with these practices. Secondarily, we assessed factors associated with performing tobacco smoke exposure reduction and tobacco cessation counseling.<h4>Methods</h4>We conducted a cross-sectional survey of 30 PED/UC nurses and physicians working at one large, urban, Midwestern children's hospital. Measures included current practices of performing the 5 As of tobacco counseling (Ask, Advise, Assess, Assist, Arrange), and attitude and practice factors that may influence practices.<h4>Results</h4>Overall, 90.0% of participants had not received recent tobacco counseling training, 73.3% were unaware of the 5 As, and 63.3% did not have a standardized, routine screening system to identify patients exposed to secondhand smoke. The majority of participants reported that they: asked about patients' secondhand smoke exposure status (70.0%) and parents' tobacco use status (53.3%), and advised parental smokers to not smoke around their child (70.0%) and to quit smoking (50%). One in five participants reported they assessed smokers' interest in quitting smoking, and 16.7% talked with smokers about cessation techniques and tactics; of these, 10% referred/enrolled smokers to the Tobacco Quitline or cessation program, and 6.7% made a quit plan or recommended nicotine replacement therapy medication.<h4>Conclusions</h4>Key findings identified are the need for professional tobacco counseling training, standardizing efforts during visits, and emphasizing pediatric patients' potential health benefits. This information will be used for developing a PED/ UC-based parental tobacco cessation and child tobacco smoke exposure reduction intervention.
Project description:BACKGROUND:Pregnancy is an opportunity for health providers to support women to stop smoking. OBJECTIVES:Identify the pooled prevalence for health providers in providing components of smoking cessation care to women who smoke during pregnancy. DESIGN:A systematic review synthesising original articles that reported on (1) prevalence of health providers' performing the 5As ('Ask', 'Advise', 'Assess', 'Assist', 'Arrange'), prescribing nicotine replacement therapy (NRT) and (2) factors associated with smoking cessation care. DATA SOURCES:MEDLINE, EMBASE, CINAHL and PsycINFO databases searched using 'smoking', 'pregnancy' and 'health provider practices'. ELIGIBILITY CRITERIA FOR SELECTING STUDIES:Studies included any design except interventions (self-report, audit, observed consultations and women's reports), in English, with no date restriction, up to June 2017. PARTICIPANTS:Health providers of any profession. DATA EXTRACTION, APPRAISAL AND ANALYSIS:Data were extracted, then appraised with the Hawker tool. Meta-analyses pooled percentages for performing each of the 5As and prescribing NRT, using, for example, 'often/always' and 'always/all'. Meta-regressions were performed of 5As for 'often/always'. RESULTS:Of 3933 papers, 54 were included (n=29?225 participants): 33 for meta-analysis. Health providers included general practitioners, obstetricians, midwives and others from 10 countries. Pooled percentages of studies reporting practices 'often/always' were: 'Ask' (n=9) 91.6% (95% CI 88.2% to 95%); 'Advise' (n=7) 90% (95% CI 72.5% to 99.3%), 'Assess' (n=3) 79.2% (95% CI 76.5% to 81.8%), 'Assist (cessation support)' (n=5) 59.1% (95% CI 56% to 62.2%), 'Arrange (referral)' (n=6) 33.3% (95% CI 20.4% to 46.2%) and 'prescribing NRT' (n=6) 25.4% (95% CI 12.8% to 38%). Heterogeneity (I2) was 95.9%-99.1%. Meta-regressions for 'Arrange' were significant for year (p=0.013) and country (p=0.037). CONCLUSIONS:Health providers 'Ask', 'Advise' and 'Assess' most pregnant women about smoking. 'Assist', 'Arrange' and 'prescribing NRT' are reported at lower rates: strategies to improve these should be considered. PROSPERO REGISTRATION NUMBER:CRD42015029989.
Project description:Tobacco dependence counseling is recommended to be included as core curriculum for US medical students. To date, there has been little information on students' self-reported skills and practice opportunities to provide 5A's (Ask, Advise, Assess, Assist, and Arrange) counseling for tobacco cessation.We conducted anonymous surveys of second year and fourth year students at multiple US medical schools between February 2004 and March 2005 (overall response rate 70%). We report on the tobacco control practices of the 860 second year and 827 fourth year students completing the survey.Fourth year students reported multiple opportunities to learn tobacco counseling in case-based discussions, simulated patient encounters, and clinical skills courses. They reported more instruction in family medicine (79%) and Internal Medicine (70%) than Pediatrics (54%), Obstetrics/Gynecology (41%), and Surgery clerkships (16%). Compared with asking patients about smoking, advising smokers to quit, and assessing patient willingness to quit, fourth year students were less likely to have multiple practice opportunities to assist the patient with a quit plan and arrange follow-up contact. More than half of second year students reported multiple opportunities for asking patients about smoking but far fewer opportunities for practicing the other 4 As.By the beginning of their fourth year, most students in this group of medical schools reported multiple opportunities for training and practicing basic 5A counseling, although clear deficits for assisting patients with a quit plan and arranging follow-up care exist. Addressing these deficits and integrating tobacco teaching through tailored specific instruction across all clerkships, particularly in Surgery, Pediatrics, and Obstetrics/Gynecology is a challenge for medical school education.
Project description:Government regulations have created new incentives for health systems to implement changes in electronic health records (EHRs) to reduce tobacco use among patients. The purpose of this study is to conduct a content analysis of EHR modifications aimed at supporting tobacco cessation and to document these modifications using a 5 A's framework (i.e., Ask, Advise, Assess, Assist, Arrange). Fourteen trials were identified that met inclusion criteria. A content analysis of EHR functionality in these trials was conducted by two independent reviewers between February and June 2015. For "Ask," all trials provided for the documentation of smoking status in the EHR. For "Advise," 35.7 % of EHRs provided functionality related to helping a clinician provide advice to quit. For "Assess," more than half (57.1 %) of EHRs included a feature to document a patient's willingness to quit. For "Assist," EHRs offered features for medication prescribing (78.6 %), providing educational materials to patients (57.1 %), referring a patient to the quitline (50.0 %), referring a patient to a tobacco treatment specialist (42.9 %), and documenting the provision of counseling (35.7 %). Finally, for "Arrange," EHRs supported the following up of patients (35.7 %) and allowed tobacco treatment specialists to "pass back" patient notes to primary care providers (28.6 %). Studies that have modified EHRs for tobacco treatment have done so across the steps in the 5 As model, with most modifications occurring to support documenting smoking status (Ask) and assisting with medication prescribing (Assist). As health systems attempt to comply with Meaningful Use regulations, an understanding of the range of EHR modifications to support tobacco treatment is warranted.