iii

Foreword

Foreword

As we approach the end of the 20th century, smoking continues to decline

in the United States, with fewer than 1 in 4 adults reporting they use cigarettes

on a regular basis. Per capita cigarette consumption currently stands at a level

not seen since the early 1940s, and total consumption of cigarettes declined by

140 billion units in the past decade alone.

This stands in sharp contrast to the midpoint of the century when smoking rates were increasing, especially among women, and per capita cigarette

consumption did not reach its peak until 1963, the year preceding publication

of the first Surgeon General’s report. Like America in 1950, cigarette manufacturers were enjoying unparalleled success and showing no sign of weakening.

Then the cigarettes of choice were not the Marlboro, Winston, and Salems of

today, but unfiltered Camels, Lucky Strike, Chesterfield, and Philip Morris.

These four brands accounted for more than 75 percent of all brands sold in the

United States. Camels, which had battled with Luckies for the top spot in the

U.S. market for decades, had regained that position in 1949 and in 1950 had a

27-percent market share, leading Lucky Strike’s 23 percent. Marlboro, the topselling cigarette brand among the current generation of smokers with a 25

percent market share, had less than one-half of one percent.

At the beginning of the 1950s, the practice of cigarette smoking enjoyed

nearly universal acceptance and widespread social appeal, not only in this

country but also in many other parts of the world. Cigarette smoking was

practiced by a substantial majority of adult males, with some age groups

experiencing 70 to 75 percent smoking rates. Regular use of pipes and cigars

was also common among men. The prevalence of smoking among physicians

and dentists was equal to and even exceeded that seen in the general male

population, whereas today less than 10 percent of physicians or dentists report

themselves as cigarette smokers.

Smoking among women still lagged behind that of men, but by the mid1950s nearly 3 of every 10 women reported they smoked cigarettes regularly.

Just a few decades earlier women had been openly criticized for smoking,

especially in public. However, by the end of the second world war, major

social and environmental change that affected women’s lifestyle choices,

including smoking, had already begun. These changes, fueled by aggressive

cigarette advertising and marketing, led to a rapid rise in the number of

women smoking. By the end of the 1950s, smoking by women became not

only socially acceptable but the expected norm among some strata of women.

It is useful to examine some of the processes by which the cigarette manufacturers were able to produce this widespread social acceptance and high level

of cigarette use, and particularly for the purposes of this monograph, it is

enlightening to examine how the credibility of physicians, dentists, and other

health personnel was used to create a positive image for cigarette smoking.

The reassuring image of physicians and other health care practioners was used
Smoking and Tobacco Control Monograph No. 5

iv

extensively to convince the public that cigarette smoking was safe, acceptable,

and without risk.

The growing public recognition of scientific methods was used to convince

the consumer that smoking was healthy and to create confusion about the

scientific certainty with which smoking had been established as a cause of

disease. Both the health care and scientific communities were slow to recognize and respond to the cigarette manufacturers’ use of their credibility to aid

in the sale of cigarettes, and we therefore carry a special burden of responsibility in dealing with what is currently our largest preventible cause of death and

disability.

The same authority and credibility that was used by cigarette manufacturers to sell cigarettes must now be applied by the health care community to

reduce and eliminate the damage caused by tobacco in our society. This

monograph is intended to present a comprehensive picture of what physicians,

dentists, and other health care providers can do for their patients and communities to eliminate the needless disease and suffering produced by tobacco use.

It is also a call to arms so that they can understand and combat the misuse of

science and health imagery in the promotion of tobacco.

USE OF HEALTH The first modern blended U.S. cigarette—Camels—was introTHEMES AND duced in 1913. Accompanying this change in manufacturing

MEDICAL PERSONNEL technique was the application of newly developed mass

IN CIGARETTE marketing approaches and advertising campaigns that relied

ADVERTISING heavily on health themes to promote cigarette consumption.

During the period from the mid-1920s through the end of the 1950s, all the

major cigarette manufacturers in the United States used health-based themes

in their advertising. These themes usually consisted of one or more of the

following concepts:

• direct health claims—wherein a particular brand of cigarettes was

promoted as having a “desirable” health benefit compared with

competitors;

• images of health professionals—using models of physicians, dentists,

or nurses, they were often used in conjunction with ads purporting

a health benefit; and

• medical statements and testimonials—usually quoting scientists or

doctors or citing information from surveys of health professionals or

Government reports in an effort to minimize the perceived health risks

of smoking or to imply that smoking a specific brand of cigarettes was

safe or safer than other brands.

WHEN HEALTH During the late 1920s and early 1930s, health themes began to

BECAME AN ISSUE appear increasingly in cigarette advertisements. As early as 1927,

Lucky Strike was claiming that dangerous irritants in tobacco should be

removed through heating. “It’s toasted” was a slogan used for years in all

Lucky Strike ads. “Toasting,” according to these ads, removed “tobacco’s
v

Foreword

harmful corrosive ACRIDS.” One ad in this series even asserted that the

dangerous irritants removed from Lucky Strike tobaccos were sold to chemical

companies.

Camels stressed how they “increase your flow of energy,” and famous

athletes affirmed that Camels “don’t get your wind . . . you can smoke all

you want!” Old Gold cigarettes promised “not a cough in a carload,” and

Philip Morris instructed the smoker, “Sure you inhale, so play safe with your

throat . . . scientifically proved less irritating . . . .”

Perhaps one of the most notorious

cigarette ad campaigns ever began in 1928

with Lucky Strike’s “Reach for a Lucky Instead of a Sweet.” Designed especially to

entice women into the smoking ranks, this ad

theme and its variations ran for several years

and often featured well-known entertainers

or sports figures attesting to the fact that

Luckies kept them slim and petite. Even

today, many cigarette ads promote the

concept that smoking helps control weight—

thus implying a health benefit. Brands such

as “Virginia Slims” and “Superslims” directly

foster this

concept and

are marketed

exclusively as

female brands.

Some ads were obviously intended to

convince both smokers and would-be smokers

that not only was smoking safe, it was possibly

even good for you. In many such advertisements, models

portraying

physicians,

nurses, or

scientists were

prominently

displayed.

We know today that such health claims

were not grounded in science but were fabricated by Madison Avenue in a direct attempt

to calm people’s growing fears about the

dangers of smoking.

The Filtered Fifties The publication in the early 1950s

of the first retrospective and prospective

studies to conclusively link smoking with lung
Smoking and Tobacco Control Monograph No. 5

vi

cancer led to a new barrage of health claims and medical

“testimonials” based on the cigarette industry’s newest

technological “breakthrough”—the filtered cigarette.

Filter cigarettes were not entirely new, however, but

merely a variation of an existing concept, the “tipped” or

“mouthpiece” cigarette. Even prior to 1900 filter cigarettes such as Obak and Imperiale were marketed in this

country from Europe, but the first major U.S. development in this field occurred in 1931 when Benson and

Hedges introduced Parliament filter cigarettes. Viceroy

brand cigarettes, marketed 5 years later, originally contained a hollow cotton tube and changed to

a cellulose acetate filter in 1954. As the first

such company to use cellulose, Brown and

Williamson made the point of promoting

the “20,000 individual filters in every

Viceroy tip.” Cellulose acetate became the

industry standard for filter cigarettes and is

used to this day. Kool cigarettes came with

a cork-tipped mouthpiece, whereas

Marlboro, initially promoted as a cigarette for women, came

with a choice of ivory tips and beauty tips (in red) in addition

to their “plain end.” Until health became an issue, however,

no brand of tipped or filtered cigarettes ever enjoyed much

popular or commercial success.

Filter cigarettes soon became the “new” technology that

the manufacturers exploited to reassure smokers that regardless

of any bad things in cigarettes, “science” now had

a solution. At the same time that medical science

was increasingly implicating smoking as a health

threat, cigarette advertising extolled filter cigarettes as the scientific answer

to the health “question.” In

addition to print advertising,

the companies increasingly used the new

medium of television to promote these new

cigarette product lines as safe. Even popular

television shows such as the “Ben Casey,

M.D.” and “Dr. Kildare” medical dramas were

brought into millions of homes each week via

cigarette sponsorship—and health protection

was a commonly implied theme.

What can be labeled the greatest health

fraud in cigarette history occurred in March

1952, when Lorillard Tobacco Company

introduced Kent cigarettes with its new
vii

Foreword

“Micronite filter” that was “developed by

researchers in atomic energy plants.” Lorillard

ad copy stressed that the new filter removed

seven times more tar and nicotine than any

other brand. To bolster its claim, Lorillard cited

none other than the Journal of the American

Medical Association as its source.

After strenuous objections from the AMA,

Kent discontinued any direct reference to that

organization but continued to picture health

professionals and used the “health protection”

theme in both print and television ads for

years, sometimes citing pseudoscientific test

results in an effort to lend a degree of medical

credibility to their claims.

Ironically, the substance in the Kent

micronite filter that allegedly provided “health protection” turned out to be

asbestos—one of the more dangerous occupational lung carcinogens known.

Without any public disclosure whatsoever, the company quietly replaced the

asbestos with cellulose

in 1957. Millions of

smokers who had

switched to Kents were

never informed either

that the filter had

contained asbestos or

that the asbestos had

been replaced.

As the decade of

the fifties drew to a

close, filter cigarettes,

virtually nonexistent at

the beginning of the

decade, had captured

50 percent of the U.S.

market. This dramatic

change in brand market share provides indisputable evidence that cigarette

advertising can alter consumer demand. A survey conducted by the Memorial

Sloan-Kettering Cancer Center showed that 70 percent of smokers who

switched from regular to filter-tipped cigarettes did so for reasons of health.

Today, nearly 98 percent of all cigarettes sold in the United States are filtered.

Some Health Health claims in advertising did not end with the 1950s but continued

Themes in well after the Surgeon General issued his now-famous 1964 report. By

Contemporary the beginning of the 1960s, the scientific consensus on the health

Advertising consequences of smoking was overwhelming, and use of health professionals in cigarette ads could no longer be justified. Nonetheless, health

themes are evident even in today’s cigarette advertisements.
Smoking and Tobacco Control Monograph No. 5

viii

After the 1964 Surgeon General’s report,

the cigarette companies began citing official

Government sources and statistics to promote

some brands that were reportedly lower in tar

and nicotine. Carlton cigarettes for years used

Federal Trade Commission (FTC) test results to

proclaim, “Latest U.S. Gov’t Report Confirms

Carlton is Lowest” or “U.S. Gov’t Report: A

whole carton

of Carlton has

less tar than a

single pack of

. . . .” Now

cigarette ads

stated, “Now is

Lowest” in tar;

Pall Mall Extra

Mild used FTC

data to compare its cigarette brand to

others with

“2800 mg tar a

week you can

lose . . . with

Pall Mall Extra

Mild.” Later, it would be found that many

cigarette brands had been purposefully engineered to test low in tar/nicotine content

based on machine measurement but that they

generated much higher yields when smoked

by people.

Direct Attack Earlier cigarette advertising was

on Smoking intended to create doubt among

Health Risk smokers and would-be smokers

Information regarding the “alleged” association

between smoking and health, but a series

of R.J. Reynolds ads in 1984 took a more

direct approach. Published in national

news magazines, Reynolds emphatically

stated that “studies which conclude that

smoking causes disease have regularly

ignored significant evidence to the contrary.” This statement was made 30 years

after the publication of numerous studies

linking smoking to lung cancer and other

diseases and 20 years after the Surgeon

General’s report provided a clear scientific
ix

Foreword

consensus that “Cigarette smoking is a

health hazard of sufficient importance

in the United States to warrant appropriate remedial action.”

In a followup ad, Reynolds even

boasts, “We believe in science. That is

why we continue to provide funding for

independent research into smoking and

health.”

It is difficult to determine exactly

what effect such ads have on the public.

At the very least, they serve to create

doubt in some smokers’ mind about

whether the link between smoking and

health is real, especially among those

individuals who are considering quitting

and who may delay taking action that

could benefit their health. However,

there is no question that these ads are a

deliberate misrepresentation of the scientific knowledge of the disease risks

associated with cigarette smoking.

Tobacco and This monograph provides important information on how health care

The Clinician professionals can contribute to the national effort to reduce smoking

both among individual patients and in our communities. Health professionals

have a responsibility to ensure that the 50 million people who continue to

smoke fully understand the true health consequences of their behavior, and

where appropriate, the health professional should provide direct assistance to

help them become nonsmokers.

Equally important, we need to become smoking experts within our communities to counter tobacco industry-sponsored misrepresentation of scientific

fact. Whether it is providing justification for policies protecting nonsmokers

from the harm caused by passive smoking, preventing underage youth from

having easy access to tobacco, or restricting certain types of cigarette promotions, health professionals need to acquire the skills necessary to effectively

address these issues. After all, if we don’t, who will?

Philip R. Lee, M.D.

Assistant Secretary for Health
Smoking and Tobacco Control Monograph No. 5

x
xi

Preface

Preface

This monograph, the fifth in the NCI Smoking and Tobacco Control

series, provides important information for clinicians interested in reducing the

tremendous burden of disease caused by cigarettes and other tobacco products.

As health professionals we can and must contribute to this effort, both by

assisting individual patient cessation and by contributing to broader tobacco

control activities in our communities.

Cigarette smoking is still this Nation’s largest cause of premature death

and disability and remains the only product that, when used as intended by

the manufacturer, will kill the consumer.

Every physician and dentist can and should

become a smoking expert to counter the

pervasive attempts by the tobacco industry to

convince smokers and would-be smokers that

smoking is desirable, sexy, or fun.

We need to remind ourselves that for

decades the cigarette industry blatantly used

the medical profession in cigarette advertising

and enticed entire generations into believing

that smoking was safe. Even today, 30 years

after it became known with overwhelming

scientific certainty that smoking was a major

health threat, cigarette advertisers still portray

smoking as free from any significant health

risk.

Health professionals have been an integral part of the national effort to

reduce smoking in the United States, and in fact, the first major smoking

information campaign launched by the U.S. Public Health Service was based

on changes in physicians’ smoking behavior.1 However, we must do more.

TOBACCO AND Today more than 400,000 of our citizens die needlessly each year

THE CLINICIANS’ because they smoke cigarettes. Additional thousands more will die

RESPONSIBILITY or experience a diminished quality of life because of diseases that

result from use of other tobacco products. As health professionals, we have

the responsibility to stem this tide of needless suffering by providing assistance

to those patients who want to stop smoking and by becoming more active in

our communities, supporting policies that can reduce smoking among all

segments of society, especially the young.

1 The campaign, consisting of a series of office posters and public service print ads placed on all

U.S. Postal Service delivery trucks, was short-lived because the cigarette industry aggressively

attacked both the validity of the survey and the campaign, forcing the postal service to

withdraw its support.
Smoking and Tobacco Control Monograph No. 5

xii

Assisting patients to quit adds to the number of nonsmokers and facilitates the growing social unacceptability of smoking in general. Although the

percentage of physicians who routinely counsel smokers to quit has doubled

in the past 15 years, it is disheartening that only about 50 percent of current

smokers report they have ever received such advice from a physician. However, on a cost-benefit basis advice about smoking cessation is more costeffective than many other valuable medical interventions, including preventive measures for hypertension and hypercholesterolemia. The cost was

estimated at $748 per year of life saved. It would be unthinkable for a physician not to routinely monitor patients for high blood pressure, yet many

physicians and dentists do not have an office system for even identifying

patients who smoke.

Involvement in community-based smoking control activities poses a

different, but no less important, challenge. Medical professionals’ responsibility for the health of patients cannot be limited solely to those procedures

performed in an office practice. Indeed, we need to recognize that the tobacco industry views the community as “a vector” to help spread the disease

of tobacco addiction, and it is our responsibility to prevent it from doing so.

As this monograph points out, the promotion of tobacco in our communities

is still widespread. All kinds of events—from auto races to rock concerts to

athletic contests and even community charity fundraisers—are often sponsored with tobacco industry money. Sponsorship of these events is intended

to buy social acceptance and legitimacy, and health professionals must take

the lead in discouraging such tobacco-promotion activities to the extent

possible.

THE NCI In 1984 the National Cancer Institute began funding a series of 12

NATIONAL clinical trials in an effort to develop more effective intervention

HEALTH methods for use by physicians, dentists, and other health care

PROFESSIONAL professionals with their patients who smoke. More than 100,000

TRAINING patients and 6,100 physicians and dentists were involved in these

PROGRAM trials.

 Brief Physician and Dentist Protocol for

 Patient Smoking Cessation

1. ASK about smoking at every opportunity.

2. ADVISE all smokers to stop.

3. ASSIST patients with stopping by setting a quit date, providing

self-help materials, and prescribing nicotine replacement therapy

as appropriate.

4. ARRANGE followup visits to foster maintenance and prevent relapse.

This monograph distills from these and other related studies a clear

picture of not only what interventions work but also how to recruit and
xiii

Preface

motivate clinicians to provide assistance and how to institutionalize the

provision of cessation assistance within the health care delivery system.

The monograph also provides many practical tips for involvement in community-based smoking control activities.

Recognizing that health practitioners committed to

cessation assistance require training

and skills to successfully deliver such

services, the National Cancer Institute

initiated a national training program

for clinicians with the goal of training

100,000 primary care physicians and

50,000 oral health professionals.

When these goals are realized, the program will produce

between 1 and 2 million additional former smokers each year.

And last year, in cooperation

with the American Academy of

Pediatrics, NCI expanded its

training protocol to include

primary prevention of smoking

for those primary care providers

who routinely see children and

adolescents in their practices.

Results from this national

training program will have a

substantial impact on the health

and well-being of the Nation

and will ultimately save billions

of health care dollars as well.

Samuel Broder, M.D.

Director, National Cancer Institute
Smoking and Tobacco Control Monograph No. 5

xiv
xv

Acknowledgments

Acknowledgments

Tobacco and the Clinician: Interventions for Medical and Dental Practice was

developed under the general editorship of the Smoking and Tobacco Control

Program (STCP), Donald R. Shopland, Coordinator, National Cancer Institute, Bethesda, Maryland. The senior scientific editor was David M. Burns,

M.D., Professor of Medicine, University of California, San Diego; Dr. Burns

also served as scientific editor for Chapters 1 and 5. The scientific editors for

Chapters 2, 3, and 4, respectively, were

Stuart J. Cohen, Ed.D., M.A.

Director of Primary Care Research

AMC Cancer Research Center

Denver, Colorado

Thomas E. Kottke, M.D., M.S.P.H.

Section of Clinical Epidemiology

Department of Health Sciences Research

Mayo Clinic

Rochester, Minnesota

Ellen R. Gritz, Ph.D.

Professor in Residence, Department of Surgery

Director, Division of Cancer Control

Jonsson Comprehensive Cancer Center

University of California, Los Angeles

Los Angeles, California

The STCP staff gratefully acknowledges the authors who made

this monograph possible. Attributions for each chapter, in alphabetical order, are as follows:

Chapter 1 Strategies for Office- Alan Blum, M.D.

Based Smoking Department of Family Medicine

Cessation Assistance Baylor College of Medicine

Houston, Texas

David M. Burns, M.D.

University of California, San Diego

San Diego, California

Elizabeth Gilpin, M.S.

Department of Cancer Prevention

and Control

Cancer Center

University of California, San Diego

La Jolla, California
Smoking and Tobacco Control Monograph No. 5

xvi

Chapter 1 (continued) Thomas P. Houston, M.D.

Department of Preventive Medicine

American Medical Association

Chicago, Illinois

John P. Pierce, Ph.D.

Department of Cancer Prevention

and Control

Cancer Center

University of California, San Diego

La Jolla, California

John W. Richards, Jr., M.D.

Department of Family Medicine

Medical College of Georgia

Augusta, Georgia

Anthony Biglan, Ph.D.

Oregon Research Institute

Eugene, Oregon

Mark J. Brekke, M.A.

Brekke Associates

Minneapolis, Minnesota

Milo L. Brekke, Ph.D.

Brekke Associates

Minneapolis, Minnesota

Thomas J. Coates, Ph.D.

University of California, San Francisco

San Francisco, California

Stuart J. Cohen, Ed.D., M.A.

AMC Cancer Research Center

Denver, Colorado

Shirley A. Conn, R.N., M.S., M.S.N.

Blue Plus, Blue Cross/Blue Shield

of Minnesota

St. Paul, Minnesota

Steven R. Cummings, M.D.

University of California, San Francisco

San Francisco, California

Jack F. Hollis, Ph.D.

Kaiser Permanente Center for

Health Research

Portland, Oregon

Chapter 2 Recruitment and

Training of Practicing

Physicians, Dentists,

And Their Office Staffs
xvii

Acknowledgments

Chapter 2 (continued) John R. Hughes, M.D.

University of Vermont

Burlington, Vermont

Sue A. Kelly, C.D.A.

Oral Health Research Institute

Indiana University School of Dentistry

Indianapolis, Indiana

Thomas E. Kottke, M.D., M.S.P.H.

Section of Clinical Epidemiolgy

Department of Health Sciences Research

Mayo Clinic

Rochester, Minnesota

Edward Lichtenstein, Ph.D.

Oregon Research Institute

Eugene, Oregon

Elizabeth A. Lindsay, Ph.D.

COMMIT, Waterloo Smoking Projects

University of Waterloo

Waterloo, Ontario, Canada

Patricia Maxwell, R.N.

Pacific Medical Clinic

Bellevue, Washington

Roger H. Secker-Walker, M.B., F.R.C.P.

College of Medicine

University of Vermont

Burlington, Vermont

Herbert Severson, Ph.D.

Oregon Research Institute

Eugene, Oregon

Leif I. Solberg, M.D.

Minneapolis, Minnesota

Mort J. Stein, M.D.

Kaiser Permanente

San Francisco, California

Victor Stevens, Ph.D.

Northwest Kaiser Permanente

Portland, Oregon

George K. Stookey, Ph.D.

Oral Health Research Institute

Indiana University School of Dentistry

Indianapolis, Indiana
Smoking and Tobacco Control Monograph No. 5

xviii

Chapter 2 (continued) Neil D. Swan

R.O.W. Sciences, Inc.

Rockville, Maryland

Thomas M. Vogt, M.D.

Kaiser Permanente Center for

Health Research

Portland, Oregon

William C. Wadland, M.D.

College of Human Medicine

Michigan State University

East Lansing, Michigan

Douglas M. Wilson, M.D.

McMaster University Health

Sciences Centre

Hamilton, Ontario, Canada

Chapter 3 Training of Physicians Elizabeth E. Campbell, M.D.

In Training Department of Medicine

University of North Carolina

Chapel Hill, North Carolina

Suzanne W. Fletcher, M.D.

Annals of Internal Medicine

Philadelphia, Pennsylvania

Robert Goldberg, Ph.D.

University of Massachusetts

Medical School

Worcester, Massachusetts

Jorge J. Gonzalez, M.D.

Internal Medicine Teaching Program

New Hanover Memorial Hospital

Wilmington, North Carolina

Thomas G. Irons, M.D.

East Carolina University

School of Medicine and Medical Center

Greenville, North Carolina

Katherine Kalan

University of Massachusetts

Medical School

Worcester, Massachusetts

Richard D. Kenney, M.D.

Director of Pediatrics

Scottish Rite Children’s Med. Ctr.

Atlanta, Georgia
xix

Acknowledgments

Chapter 3 (continued) Thomas E. Kottke, M.D., M.S.P.H.

Section of Clinical Epidemiology

Department of Health Sciences Research

Mayo Clinic

Rochester, Minnesota

Jean Kristeller, Ph.D.

Department of Psychology

Indiana State University

Terre Haute, Indiana

Mary F. Lyles, M.D.

Department of Medicine

Bowman Gray School of Medicine

Winston-Salem, North Carolina

Judith K. Ockene, Ph.D.

University of Massachusetts

Worcester, Massachusetts

Michael S. O’Malley, M.D.

School of Public Health

University of North Carolina

Chapel Hill, North Carolina

C. Stewart Rogers, M.D.

Internal Medicine Teaching Service

Moses Cone Memorial Hospital

Greensboro, North Carolina

Clare J. Sanchez, M.D.

Department of Medicine and Psychiatry

Dorothea Dix Hospital

Raleigh, North Carolina

Victor J. Strecher, Ph.D.

School of Public Health

University of North Carolina

Chapel Hill, North Carolina

Frank T. Stritter, Ph.D.

University of North Carolina

School of Medicine

Chapel Hill, North Carolina

Robert C. Turner, M.D.

Department of Medicine

East Carolina University

School of Medicine

Greenville, North Carolina
Smoking and Tobacco Control Monograph No. 5

xx

Chapter 3 (continued) Victor G. Villagra, M.D.

Department of General Internal Medicine

Geisinger Medical Center

Danville, Pennsylvania

Susanne T. White, M.D.

Louisiana State University

School of Medicine

New Orleans, Louisiana

Chapter 4 Special Practice John Beumer, D.D.S., M.S.

Settings University of California, Los Angeles,

School of Dentistry

Los Angeles, California

Steven Cahill, M.P.H.

Department of Epidemiology

and Family Medicine

University of Maryland

Baltimore, Maryland

Clifford R. Carr, Ed.D.

Jonsson Comprehensive Cancer Center

University of California, Los Angeles

Los Angeles, California

Cindy Chang, M.S.

Jonsson Comprehensive Cancer Center

University of California, Los Angeles

Los Angeles, California

Timothy R. Cline, Ph.D.

University of Mississippi

Jackson, Mississippi

Barbara L. Frankowski, M.D., M.P.H.

College of Medicine

University of Vermont

Burlington, Vermont

Ellen R. Gritz, Ph.D.

Jonsson Comprehensive Cancer Center

University of California, Los Angeles

Los Angeles, California

Laura C. Leviton, Ph.D.

Health Services Administration

University of Pittsburgh

Pittsburgh, Pennsylvania
xxi

Acknowledgments

Chapter 4 (continued) David A. Rapkin, Ph.D.

Jonsson Comprehensive Cancer Center

University of California, Los Angeles

Los Angeles, California

Roger H. Secker-Walker, M.B., F.R.C.P.

College of Medicine

University of Vermont

Burlington, Vermont

Mary Sexton, Ph.D., M.P.H.

Department of Epidemiology

and Family Medicine

University of Maryland

School of Medicine

Baltimore, Maryland

Saul Shiffman, Ph.D.

Department of Psychology

University of Pittsburgh

Pittsburgh, Pennsylvania

Joan Stine, M.H.S., M.S., C.H.E.S.

Department of Epidemiology

and Family Medicine

University of Maryland

School of Medicine

Baltimore, Maryland

Paul H. Ward, M.D.

University of California, Los Angeles

Los Angeles, California

Larry Berger, M.D.

Health Services Division

Lovelace Medical Foundation

Albuquerque, New Mexico

Joyce Adair Bird, Ph.D.

Division of General Internal Medicine

University of California, San Francisco

San Francisco, California

David M. Burns, M.D.

University of California, San Diego

San Diego, California

Catherine Dubé, Ed.D.

Brown University School of Medicine and

the Miriam Hospital

Providence, Rhode Island

Chapter 5 Dissemination,

Facilitation, and

Maintenance of OfficeBased Cessation Advice
Smoking and Tobacco Control Monograph No. 5

xxii

Chapter 5 (continued) Roselyn P. Epps, M.D., M.P.H.

Public Health Applications Research

Branch

National Cancer Institute

Bethesda, Maryland

Don Fordham, M.P.H.

Division of General Internal Medicine

University of California, San Francisco

San Francisco, California

Michael G. Goldstein, M.D.

Brown University School of Medicine and

the Miriam Hospital

Providence, Rhode Island

Corinne Husten, M.D., M.P.H.

Public Health Applications Research

Branch

National Cancer Institute

Bethesda, Maryland

Norman Hymowitz, Ph.D.

Department of Psychiatry and Mental

Health Sciences

University of Medicine and Dentistry

of New Jersey

Newark, New Jersey

Elizabeth A. Lindsay, Ph.D.

COMMIT, Waterloo Smoking Projects

University of Waterloo

Waterloo, Ontario, Canada

Nancy A. MacDonald, M.P.H., C.H.E.S.

Brown University and the Miriam Hospital

Providence, Rhode Island

Marc Manley, M.D.

Public Health Applications Research

Branch

National Cancer Institute

Bethesda, Maryland

Stephen J. McPhee, M.D.

Division of General Internal Medicine

University of California, San Francisco

San Francisco, California

Robert Mecklenburg, D.D.S., M.P.H.

R.O.W. Sciences, Inc.

Rockville, Maryland
xxiii

Acknowledgments

Chapter 5 (continued) Raymond Niaura, Ph.D.

Brown University School of Medicine and

the Miriam Hospital

Providence, Rhode Island

Judith K. Ockene, Ph.D.

University of Massachusetts

Worcester, Massachusetts

Emilie H. Osborn, M.D., M.P.H.

Division of General Internal Medicine

University of California, San Francisco

San Francisco, California

Paul Pomrehn, M.D., M.S.

Department of Family Medicine

University of Iowa

Iowa City, Iowa

Jonathan E. Rodnick, M.D., M.P.H.

Division of General Internal Medicine

University of California, San Francisco

San Francisco, California

Leif I. Solberg, M.D.

Minneapolis, Minnesota

Douglas M. Wilson, M.D.

McMaster University

Health Sciences Centre

Hamilton, Ontario, Canada

The editors gratefully acknowledge also the following distinguished scientists, researchers, and others, both in and outside

government, who contributed critical reviews:

John J. Ambre, M.D., Ph.D.

Department of Toxicology and Drug Abuse

American Medical Association

Chicago, Illinois

Frederick Bass, M.D.

Stop Smoking Program

British Columbia Medical Association

Vancouver, B.C., Canada

Renaldo N. Battista, M.D., Sc.D.

Montreal General Hospital

Montreal, Quebec, Canada

David S. Brody, M.D.

Mercy Catholic Medical Center

Darby, Pennsylvania
Smoking and Tobacco Control Monograph No. 5

xxiv

Steven Brunton, M.D.

Long Beach Memorial Medical Center

Long Beach, California

Arden G. Christen, D.D.S., M.S.D., M.A.

Indiana University School of Dentistry

Indianapolis, Indiana

Michael P. Eriksen, Sc.D.

Office on Smoking and Health

Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

Atlanta, Georgia

Paul M. Fischer, M.D.

Medical College of Georgia

Augusta, Georgia

Gary Giovino, Ph.D.

Office on Smoking and Health

Center for Chronic Disease Prevention and Health Promotion

Centers for Disease Control and Prevention

Atlanta, Georgia

Dorothy Hatsukami, M.D.

Department of Psychiatry

University of Minnesota

Minneapolis, Minnesota

Shirley B. Lansky, M.D.

Illinois Cancer Center

Chicago, Illinois

J. Michael McGinnis, M.D.

Office of Disease Prevention and Health Promotion

Office of the Assistant Secretary for Health

Department of Health and Human Services

Washington, D.C.

Robert Mecklenburg, D.D.S., M.P.H.

R.O.W. Sciences, Inc.

Rockville, Maryland

Clifford H. Miller, D.D.S.

Division of Education

American Dental Association

Chicago, Illinois

Karen Monaco

American Lung Association

Chapel Hill, North Carolina
xxv

Acknowledgments

Walter W. Rosser, M.D.

Department of Family and Community Medicine

University of Toronto

Toronto, Ontario, Canada

Dr. Carlo Senore

Montreal General Hospital

Montreal, Quebec, Canada

J. Christopher Shank, M.D.

Hassler Center for Family Medicine

Fairview General Hospital

Cleveland, Ohio

Susan Sullivan, Ph.D., M.P.H.

Cancer Control Research Program

Duke Comprehensive Cancer Center

Duke University Medical Center

Durham, North Carolina

Richard B. Warnecke, Ph.D.

Survey Research Laboratory

University of Illinois at Chicago

Chicago, Illinois

Richard A. Windsor, Ph.D., M.P.H.

National Heart, Lung, and Blood Institute

Bethesda, Maryland

The editor acknowledges the contributions of the following

staff members of R.O.W. Sciences, Inc., Rockville, Maryland, who

provided technical and editorial assistance in the preparation of

this monograph:

Richard H. Amacher, Project Manager

Douglas Bishop, Art Director

Jean Brady, Research Assistant

Karen Bray, Technical Assistant

Rebecca Charton, Librarian

Catherine Godfrey, Word Processing Specialist

Faye A. Grant, Administrative Secretary

Susan E. Jones, Administrative Secretary

James R. Libbey, Coordinator, Proofreader

Janet Mullaney, Copy Editor

Frances Nebesky, Copy Editor
Smoking and Tobacco Control Monograph No. 5

xxvi

Theodora Radcliffe, Copy Editor, Indexer

Donna Selig, Proofreader

Barbara Shine, Managing Editor

Keith W. Stanger, Graphics Specialist

Sonia Van Putten, Word Processing Specialist

William Ward, Copy Editor

Debra Waugh, Copy Editor

Ronald W. Wolf, Senior Copy Editor.
Contents

xxvii

Contents

Page

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Chapter 1. Strategies for Office-Based

Smoking Cessation Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Overview of Office-Based Smoking Cessation Assistance . . . . . . . . . . . 3

David M. Burns

Trends in Physicians’ Smoking Behavior and

Patterns of Advice To Quit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

John P. Pierce and Elizabeth Gilpin

The Health Professional’s Responsibility in

Smoking Cessation: Strategies for

Office and Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

John W. Richards, Jr., Thomas P. Houston, and Alan Blum

Appendix A. Magazines Without Tobacco Advertising . . . . . . . . . . . . 38

Chapter 2. Recruitment and Training of Practicing

Physicians, Dentists, and Their Office Staffs . . . . . . . . . . . . . . 41

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Stuart J. Cohen

Effects of Training Family Physicians in a

Comprehensive Smoking Cessation Intervention . . . . . . . . . . . . . . . . 48

Elizabeth A. Lindsay and Douglas M. Wilson

Doctors Helping Smokers: Development of a

Clinic-Based Smoking Intervention System. . . . . . . . . . . . . . . . . . . . . 69

Thomas E. Kottke, Leif I. Solberg, Milo L. Brekke,

Shirley A. Conn, Patricia Maxwell, and Mark J. Brekke

Prompting Smoking Cessation in Family Practice . . . . . . . . . . . . . . . . 92

William C. Wadland, John R. Hughes,

and Roger H. Secker-Walker

Smoking Cessation in Primary Care Practice:

Summary of Results From the Quit for Life Project . . . . . . . . . . . . . . . 102

Steven R. Cummings, Thomas J. Coates, Mort J. Stein,

Neil D. Swan, and the Quit for Life Research Group
Smoking and Tobacco Control Monograph No. 5

xxviii

Physician and Dentist Interventions

For Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Stuart J. Cohen, George K. Stookey, and Sue A. Kelly

The Tobacco Reduction and Cancer Control

(TRACC) Program: Team Approaches to

Counseling in Medical and Dental Settings . . . . . . . . . . . . . . . . . . . . . 143

Jack F. Hollis, Thomas M. Vogt, Victor Stevens,

Anthony Biglan, Herbert Severson, and Edward Lichtenstein

Appendixes

A. Screening Form for Study on

Assessing Patient's Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

B. Study on Physician Advice for

Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

C. Entry Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

D. Medical Screening Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

E. Generic Reminder Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

F. Reminder Sheet for Gum Group . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

G. Reminder Sheet for No-Gum Group . . . . . . . . . . . . . . . . . . . . . . . . 177

H. Physician Data: Initial Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

I. Exit Questionnaire #1 (All Patients) . . . . . . . . . . . . . . . . . . . . . . . . 179

J. Exit Questionnaire #2 (No-Gum Group) . . . . . . . . . . . . . . . . . . . . 181

K. Exit Questionnaire #3 (Nicotine Gum Group) . . . . . . . . . . . . . . . . 182

L. One- to Two-Week Followup for

Smoking Cessation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

M. Six-Month Followup for

Smoking Cessation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

N. Followup Questionnaire on the

Use of Nicotine Gum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Chapter 3. Training of Physicians in Training . . . . . . . . . . . . . . . . . . . . . . . 187

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Thomas E. Kottke

Interventions for Smoking Prevention and Cessation . . . . . . . . . . . . . 191

Robert Goldberg, Judith K. Ockene,

Katherine Kalan, and Jean Kristeller

Effects of Two Realistic Interventions To Teach

Smoking Cessation Counseling to

Primary Care Residents: A Randomized Trial. . . . . . . . . . . . . . . . . . . . 207

Victor J. Strecher, Michael S. O’Malley, Victor G. Villagra,

Elizabeth E. Campbell, Jorge J. Gonzalez, Thomas G. Irons,

Richard D. Kenney, Robert C. Turner, C. Stewart Rogers,

Mary F. Lyles, Susanne T. White, Clare J. Sanchez,

Frank T. Stritter, and Suzanne W. Fletcher
Contents

xxix

Appendixes

A. Smoking Intervention Communication Grid . . . . . . . . . . . . . . . . . 223

B. Outline of the Advice and Counseling

Smoking Intervention Approaches . . . . . . . . . . . . . . . . . . . . . . . . . 224

C. Physician Responses to Patients’ Concerns . . . . . . . . . . . . . . . . . . 226

Chapter 4. Special Practice Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Ellen R. Gritz

Pediatricians’ Role in

Smoking Prevention and Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Barbara L. Frankowski and Roger H. Secker-Walker

Smoking Intervention by

Providers of Health Care for Women . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Mary Sexton, Joan Stine, and Steven Cahill

A Physician- and Dentist-Delivered Smoking Cessation

Intervention for Head and Neck Cancer Patients . . . . . . . . . . . . . . . . . 259

Ellen R. Gritz, Clifford R. Carr, David A. Rapkin,

Cindy Chang, John Beumer, and Paul H. Ward

Medical Advice as a Communication About

Risks of Smoking and Benefits of Quitting . . . . . . . . . . . . . . . . . . . . . . 272

Laura C. Leviton, Timothy R. Cline, and Saul Shiffman

Appendixes

A. Smoking Materials for Pediatricians . . . . . . . . . . . . . . . . . . . . . . . . 287

B. Algorithms for Delivery of

Smoking Cessation Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

C. Protocol Developed by University of

North Carolina Faculty Development Program . . . . . . . . . . . . . . . 292

D. Self-Efficacy Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

E. Transcript From a

Self-Efficacy Counseling Session . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

Chapter 5. Dissemination, Facilitation, and Maintenance

Of Office-Based Cessation Assistance . . . . . . . . . . . . . . . . . . . . . . 299

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

David M. Burns

Smoking Cessation as a

Clinic Quality Improvement Project . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

Leif I. Solberg

Computerized Reminder System

To Aid Physicians in Assessment and

Counseling of Patients Who Smoke . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Stephen J. McPhee, Joyce Adair Bird, Don Fordham,

Jonathan E. Rodnick, and Emilie H. Osborn
Smoking and Tobacco Control Monograph No. 5

xxx

Physicians’ and Dentists’ Roles in COMMIT—

The Community Intervention Trial for

Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Elizabeth A. Lindsay, Judith K. Ockene, Larry Berger,

Norman Hymowitz, Paul Pomrehn, and Douglas M. Wilson

Dissemination of Physician-Based

Smoking Cessation Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342

Michael G. Goldstein, Nancy A. MacDonald,

Raymond Niaura, and Catherine Dubé

Clinical Interventions in Tobacco Control:

A National Cancer Institute Training Program

For Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

Marc Manley, Roselyn P. Epps,

Robert Mecklenburg, and Corinne Husten

Appendix A. Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
1

Chapter 1

Chapter 1

Strategies for Office-Based

Smoking Cessation Assistance

CONTENTS Overview of Office-Based Smoking

Cessation Assistance

David M. Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Comprehensive Tobacco Control Strategies . . . . . . . . . . . . . . . . . 4

Development and Maintenance of

Office-Based Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Trends in Physicians’ Smoking Behavior and

Patterns of Advice To Quit

John P. Pierce and Elizabeth Gilpin . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

How Smoking Fits Into a Generalist’s Practice . . . . . . . . . . . . . . . 12

Smoking Behavior of Physicians . . . . . . . . . . . . . . . . . . . . . . . . . 15

Physicians’ Advice, as Reported by Patients . . . . . . . . . . . . . . . . . 17

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

The Health Professional’s

Responsibility in Smoking Cessation:

Strategies for Office and Community

John W. Richards, Jr., Thomas P. Houston, and Alan Blum . . . . . . . . 24

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

In the Practitioner’s Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Individualizing Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Strategies for Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Community Awareness and Action . . . . . . . . . . . . . . . . . . . . . . . 33

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Appendix A. Magazines Without Tobacco Advertising . . . . 38
Smoking and Tobacco Control Monograph No. 5

2
3

Chapter 1

Overview of Office-Based

Smoking Cessation Assistance

David M. Burns

INTRODUCTION The burden of premature death and avoidable disability caused

by tobacco use in the United States (US DHHS, 1989) and the benefits of

cessation (US DHHS, 1990) are well documented. Despite the widespread

acceptance of this information by the public and the high frequency with

which physicians report that they advise their patients to quit smoking,

almost one-half of smokers report never having been told to quit by their

physician. Patients do report that they would be likely to try to quit if told

by their physician to quit. Because 70 percent of smokers see a physician

each year and 60 percent visit a dentist, the potential for the health care

community to affect smoking prevalence in the United States is both large

and substantially underutilized.

To increase the effectiveness of the health care community in promoting

smoking cessation, the National Cancer Institute has funded research efforts

to develop more effective intervention methods for use by physicians and

dentists and to facilitate the adoption of these methods. This monograph

distills from those projects a clear picture of what interventions work, how to

recruit and motivate clinicians to provide advice, and how to institutionalize

the delivery of smoking cessation assistance within the health care delivery

system.

The outcome results of the studies in this report have been published in

the peer-reviewed literature. The purpose of this monograph goes beyond a

review of the cessation outcome literature to include detailed descriptions

of the program content and strategies. In addition, the investigators who

drafted the descriptions of their programs were asked to assess which

approaches were effective, which were ineffective, and what they would

do differently if they could repeat their projects. This departure from the

traditional scientific and data-based approach is intentional. It was the

experience with what worked and did not work at the program level that

formed the core of the interventions tested in the trials described here. It

should therefore be no surprise that current concepts of effective approaches

to clinician-provided smoking cessation assistance have evolved beyond

those that were used to design these research trials, which were funded in

the early 1980’s. The long delay from the design of a trial and request for

funding to publication of the results in the peer-reviewed literature means

that the current knowledge of how to implement practice-based smoking

cessation assistance frequently has advanced beyond that documented in

the literature. This monograph presents the current best judgment of how

to implement and sustain an effective office-based cessation effort, by

combining the knowledge from both controlled scientific investigation

and trial-and-error experience.
Smoking and Tobacco Control Monograph No. 5

4

COMPREHENSIVE The current state of the art in comprehensive tobacco control

TOBACCO CONTROL strategies combines multiple environmental changes with

STRATEGIES multiple programs directed at individuals in different stages

of the initiation and cessation processes (US DHHS, 1991). No single

approach is best for all smokers, and different smokers are most attracted

to and most affected by different programs. Perhaps more importantly, no

single channel reaches all smokers and no single time is best for all smokers

to make a quit attempt. Persistent and inescapable messages to quit, or to

not start, coupled with continuous support for individual cessation efforts

provided through multiple channels reinforced by environmental incentives

to be a nonsmoker currently characterize comprehensive tobacco control

strategies.

An essential corollary of this understanding of tobacco control is that

smoking cessation assistance provided by physicians and dentists represents

only one channel in a multichannel effort and that cessation efforts

supported by clinicians are likely to be most effective when they draw on

and are integrated with other forces promoting smoking cessation. The

traditional therapeutic model, in which treatment is designed to be effective

regardless of the factors in the patient’s environment, is unlikely to be

successful in stopping cigarette smoking when environmental factors

determine both the personal, psychological, and sociological utility of

smoking and the motivation for cessation. Rather than perceiving the

clinician as the provider of a clinically proven “magic bullet” that will cure

a patient forever, it may be more realistic to see the physician’s or dentist’s

function as that of focusing and magnifying the forces promoting cessation.

This change in perspective may help to reduce the frustration and futility

that many practitioners have when working with their smoking patients.

To understand the role of the physician or dentist in smoking cessation,

it is useful to have an understanding of the processes of smoking initiation

and cessation and of the interventions that can influence the stages in that

process. One formulation of the influences involved in cigarette initiation

and cessation is presented in Figure 1. Exploration and initiation of regular

use of cigarettes are largely confined to adolescence, with regular use and

dependence occurring during late adolescence and early adulthood.

Experimentation with cigarettes and initial cigarette use are influenced

by the factors that affect adolescent development, whereas dependency

develops when the psychological and sociological utility of smoking is

incorporated into the approaches used by the smoker to function in and

cope with the adult world. Many adolescents experiment with tobacco use

but never become regular smokers; some adolescent regular smokers stop

before they develop dependence on cigarette use.

The process of stopping smoking is often a cyclical one, with the smoker

making a number of attempts to quit before finally succeeding. Nationally,

the vast majority of smokers would like to quit and approximately one-third

of current smokers attempt to quit each year. Ninety percent or more of
5

Chapter 1

Figure 1

The processes of smoking initiation and cessation

those quit attempts fail (Pierce and Hatziandreu, 1989). Smokers have

been categorized into three groups:

• Those who are not thinking about quitting (in precontemplation);

• Those who are thinking about quitting (in contemplation); and

• Those who are in the act of quitting.

Clearly those who have attempted to quit and failed need motivation

to make another attempt, and the cessation process is one in which smokers

cycle through the stages of cessation, with a few more smokers succeeding

in their cessation efforts each time. One goal of practice-based smoking

Source: US DHHS, 1991.

Never-Smoker

Thinking About Smoking

Regular Use

Nonsmoker

Dependent Smoker

Quit

Short-Term Success Contemplation

Action

Long-Term Success

Experimentation

Adulthood Adolescence
Smoking and Tobacco Control Monograph No. 5

6

interventions is moving smokers from one position in the cessation cycle to

the next, rather than using long-term cessation as the only goal.

The cyclical pattern of precontemplation, contemplation, and attempting

to quit generates a new set of nonsmokers each time a group of smokers passes

around the cycle (Prochaska and DiClemente, 1986). One formulation of

the process of cessation and the points at which the multiple channels of a

comprehensive tobacco control effort can influence cessation is presented

in Figure 2. This figure simplifies the effects of these tobacco control efforts

but provides an overview of the possible interactions in a comprehensive

tobacco control program.

Many of the environmental influences and tobacco control programs

influence smokers at different points in this cycle. Public information

Source: US DHHS, 1991.

Figure 2

The process of cessation

Precontemplation

Short-Term Success

Action

Long-Term Success

Addiction

Contemplation

Personal and 

Environmental Stress

Negative Images

Peers and Family 

Who Smoke

Restriction on Smoking

Social Norms

Nicotine Gum/Patch

Acceptability of

Smoking at Work

Followup Interaction 

by Physician/Dentist

Maintenance Components 

of Cessation Programs

Clinic-Based Cessation Programs

Environmental Restrictions on Smoking

Self-Help Programs

Telephone Hotlines

Cost

Acute Illness

Media Campaigns

Social Pressure

Cessation Events

Physician/Dentist 

Advice To Quit

Public Information 

Physician/Dentist 

Warning of Risk

Being a Good 

Example

Concern About 

Dependence
7

Chapter 1

campaigns and physician or dentist warnings about the risks associated

with smoking move smokers from the precontemplation to the contemplation stage. However, there are other reasons why smokers think about

quitting, including concerns about dependency and interest in setting a

good example for others. Recently the negative image of the smoker and

the social unacceptability of smoking have also provided strong reasons

why smokers think about quitting. Individual tobacco control programs

have been targeted at altering the frequency and intensity with which these

motivational issues are presented to the smoker.

The move from thinking about quitting to trying to quit is often triggered

by environmental stimuli. The cost of cigarettes can be a powerful trigger for

cessation attempts. Physician advice to quit, particularly at the time of an

acute illness, is also a powerful trigger for cessation activity, with up to half

of the patients who are advised to quit making a cessation effort. Media

campaigns, especially when coupled with cessation events such as the Great

American Smokeout, are also able to trigger a large number of cessation attempts (Gunby, 1984). Changes in rules to restrict smoking in the workplace

have been associated with quit attempts by substantial numbers of workers.

Triggering cessation efforts is an important tobacco control strategy

because each round of cessation activity results in a few more nonsmokers.

The large number of smokers who attempt to quit each year attests to the

success of those components of the tobacco control effort that move smokers

from precontemplation to contemplation and from contemplation to action.

The major gap in current tobacco control efforts is in converting a cessation

attempt into a long-term success.

Self-help programs, telephone hotlines, and nicotine replacement therapy

enhance short-term cessation success, and clinic-based cessation programs

have a substantial benefit for long-term cessation for those who participate

(Schwartz, 1987). The recruitment of smokers into clinic-based cessation

programs is one of the areas in which office-based effort can be particularly

effective. However, the major barriers to long-term success remain difficult

to alter and are, for the most part, in the smoker’s environment. Barriers

include social norms and workplace rules that promote smoking and facilitate

relapse, the continued smoking behavior of peers and family members,

tobacco advertising, and unusual episodes of personal or environmental

stress that lead the smoker to fall back on old coping strategies, including

smoking. Recognizing these influences and customizing advice for the

smoker is one way that physicians and dentists can integrate their cessation

assistance into a comprehensive tobacco control effort.

DEVELOPMENT AND Just as the process of smoking initiation and cessation can be

MAINTENANCE OF thought of as a series of stages, so too the process of developing

OFFICE-BASED and sustaining an office-based smoking cessation program can

ASSISTANCE be divided into stages with different forces acting at the different

stages. Figure 3 diagrams this process and divides the factors acting at each

stage into those components that act on a single clinician or within a practice

and those that are part of the health care delivery environment.
Smoking and Tobacco Control Monograph No. 5

8

Figure 3

Development and maintenance of office-based smoking cessation assistance

Acceptance of the

provision of cessation

advice as a standard

of care

Individual factors

acting on the

clinician

Discovery

Peer contact

Peer example

Published results

Grand rounds presentations

Training

Medical school and residency

 training

National, state, and local

 programs

Programs by professional

 organizations

Development of

effective strategies

to promote

cessation

Endurance

Nomination of a lead clinician

 and lead staff person

Identification and tracking of

 all smokers in a practice

Sustaining a

practice pattern

that includes

cessation advice

System and

environmental factors

acting on clinicians

Motivation

Patient request for nicotine

 replacement

Reimbursement

Consistency

Restructuring practice style

Training office staff

Integration with efforts by

 nurses and hygienists

Followup of cessation advice

Institutionalization

Academic detailing

Audits of practice patterns

Incorporation in clinic quality 

 improvement

Requirements by third party 

 payers
9

Chapter 1

Because individual clinicians may be at different points on this continuum, the strategies to change behavior and the behavioral changes expected will differ. For clinicians who do not perceive cessation advice as part

of their practice, the offer of training in the skills to counsel smokers to quit

may be less effective than a grand rounds that defines the importance and

success rates of clinician-based cessation programs. Conversely, it is unlikely

that clinicians interested in improving the effectiveness of cessation advice

can get the skills training needed in a single 45-minute grand-rounds-type

session. The need to devote time and energy to both short and long training

sessions can be confusing unless one recognizes that they are directed at

different practitioners with different levels of interest and experience.

The first change needed in clinicians is the recognition that they have

a responsibility to every patient who smokes to present the risks associated

with smoking and to urge them to quit at an appropriate point in their care.

This responsibility goes beyond providing advice to quit to those who have

smoking-related disease processes, where cessation may be of therapeutic

importance; it includes that larger segment of the smoking population for

whom cessation advice is provided exclusively for preventive benefits. Interactions with peers and the example of peers are a major part of the process

by which clinicians define standards of care and evaluate their performance

relative to those standards. As more physicians and dentists deliver routine

cessation assistance, the standards shift and performance pressure mounts

on those practitioners who lag behind. One of the tools used to define and

advance practice standards is publication of the results of studies and consensus positions. This tool can be effective, albeit slowly, in influencing that

vast majority of clinicians who are committed to high-quality care.

Physicians and dentists are in a service delivery profession and are, therefore, influenced by patient expectations and demands. The introduction of

nicotine gum, and now the transdermal nicotine patch, both of which require

physician or dentist prescriptions, mandates physician and dentist involvement with patients’ efforts to quit smoking. The wide recognition of these

products by the general public has led to patients’ requesting prescriptions

from their physicians or dentists. Such requests have led some practitioners

to incorporate cessation assistance into their practice; without the need to

write a prescription, they might not have done so.

Reimbursement is a significant motivator in health care delivery, and

many health care structures now include preventive services in their contracts

with physicians. As the standards of care shift to include cessation as a

mandatory component of preventive services, and as payers reimburse clinicians on the basis of documentation of the delivery of these services, practitioners who had not considered smoking assistance as part of their role will

be obligated to reconsider.

Those practitioners who are committed to cessation assistance will need

the training and skills to deliver cessation advice. Many medical school,

dental school, and residency curricula are beginning to provide this training

(see Chapter 3). Efforts to provide training to those practitioners who have
Smoking and Tobacco Control Monograph No. 5

10

already completed their training are described in Chapter 2, and it is likely

that these training efforts are, at least in part, responsible for the increase in

the proportion of smokers who report having received advice to quit from

their physician or dentist.

Training of the practitioner has a limited effect on the actual office

practice. Almost universally, the programs described in this monograph

stress the importance of changing the patient intake process and information flow in the office and the training and participation of the office staff.

Similarly, the integration of physician or dentist advice with cessation advice

and assistance provided by nurses, hygienists, or other office staff facilitates

the effectiveness of the advice and the likelihood that it will be offered

consistently. The identification and tracking of smokers also are critical

to the consistent delivery of advice and, perhaps more importantly, to

followup of that advice on subsequent visits.

The most difficult barrier to the successful long-term change in an office

practice is the maintenance of that change once the initial enthusiasm of

instituting change dissipates. Changes in the office personnel and members

of the practice, alterations in the volume of patient visits, and time available

for counseling can lead to the failure to sustain a change in office practice,

even without a conscious decision to go back to prior procedures. The need

to orient new professional and administrative staff members to the smoking

cessation assistance approaches used in the practice can create an educational

burden that the practice cannot sustain. The identification of individuals in

the office who accept the responsibility for the continuity of the cessation

approach and the availability of “academic detail” personnel who can come

into the office periodically to provide and upgrade training are two of the

approaches discussed in Chapter 5.

Building smoking cessation assistance into the continuous quality

improvement or audit mechanisms that are a part of the quality assurance

programs both within the practice setting and by those agencies responsible

for reimbursement is a powerful tool to promote cessation advice in health

care. A computer-based system for tracking smokers in a practice and for

generating the summary data needed to incorporate cessation assistance

in a quality assurance program is also described in Chapter 5.

The remainder of this first chapter discusses the roles that practitioners

can play in a tobacco control effort and the actual smoking behavior and

counseling practices of physicians and dentists. Subsequent chapters

present detailed descriptions of what works in physician and dental

practices (Chapter 2), in residency training programs (Chapter 3), and

in special practice settings (Chapter 4). Chapter 5 describes the efforts

to disseminate and maintain office-based smoking cessation assistance.
11

Chapter 1

REFERENCES

Gunby, P. Smokeout could preface “smoke-free

society.” Journal of the American Medical Association

252: 2803-2804, 1984.

Pierce, J., Hatziandreu, E. Report of the 1986 Adult Use

of Tobacco Survey. U.S. Department of Health and

Human Services, Public Health Service, Centers for

Disease Control, Office on Smoking and Health.

Publication No. 10491, 1989.

Prochaska, J.O., DiClemente, C.C. Toward a

comprehensive model of change. In: Treating

Addictive Behaviors: Processes of Change, W.R. Miller

and N. Heather (Editors). New York: Plenum Press,

1986, pp. 3-27.

Schwartz, J.L. Review and Evaluation of Smoking

Cessation Methods: The United States and Canada,

1978-1985. U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, National Cancer Institute, Division of

Cancer Prevention and Control. NIH Publication

No. 87-2940, 1987.

U.S. Department of Health and Human Services. The

Health Benefits of Smoking Cessation: A Report of the

Surgeon General. U.S. Department of Health and

Human Services, Public Health Service, Centers for

Disease Control, Center for Chronic Disease

Prevention and Health Promotion, Office on

Smoking and Health. DHHS Publication No. (CDC)

90-8416, 1990.

U.S. Department of Health and Human Services.

Reducing the Health Consequences of Smoking: 25 Years

of Progress. A Report of the Surgeon General. U.S.

Department of Health and Human Services, Public

Health Service, Centers for Disease Control, Center

for Chronic Disease Prevention and Health

Promotion, Office on Smoking and Health. DHHS

Publication No. (CDC) 89-8411, 1989.

U.S. Department of Health and Human Services.

Strategies To Control Tobacco Use in the United States:

A Blueprint for Public Health Action in the 1990’s. U.S.

Department of Health and Human Services, Public

Health Service, National Institutes of Health,

National Cancer Institute. NIH Publication No. 92-

3316, 1991.
Smoking and Tobacco Control Monograph No. 5

12

Trends in Physicians’ Smoking

Behavior and Patterns of

Advice To Quit

John P. Pierce and Elizabeth Gilpin

INTRODUCTION In this section, we first discuss the smoking profile of patients in

a medical practice. How many patients are smokers, and what do we know

about them? How much work is involved for a physician to implement the

National Cancer Institute guidelines? Next, we look at the prevalence of

smoking among physicians and medical students. We address the issue of

physicians advising smokers to quit, from the patient’s perspective. Is there

any evidence that physicians are advising more patients to quit? How many

and what type of smokers perceive that they have been so advised?

HOW SMOKING FITS In two separate samples (rounds I and III) of Kottke and

INTO A GENERAL- associates’ Doctors Helping Smokers studies, approximately

IST’S PRACTICE 20 percent of those who visited the general practice were

smokers (Kottke et al., 1989, and Chapter 2, this volume).

Who Are This result is identical to that from the 1990 California Tobacco

The Smokers? Survey, which identified 20 percent of all patients who had seen

a physician in the last year as smokers (Burns and Pierce, 1992). Also, in the

California Tobacco Survey, 20 percent of all patient visits in the year prior to

the survey had been made by smokers.

The California Tobacco Survey also provides a demographic analysis

of smokers who report visiting a physician in the last year (Table 1).

Altogether 25.8 percent of the population who had not visited a physician

in the previous 12 months were smokers, compared with 20.0 percent who

visited a physician.

Among the population who visit a physician, the proportion of men

who are smokers is slightly higher than the proportion of women (22.1 vs.

18.2 percent). Indeed, the proportion of smokers visiting a physician in

most subgroups is about 20 percent, with the following exceptions: those

over the age of 65 years (10.9 percent), Hispanics (16.5 percent), blacks

(27.4 percent), Asians (15.5 percent), and those with a college degree

(11.8 percent) (Burns and Pierce, 1992).

The self-reported level of health for those who visited a physician varied

according to whether or not the patient was a smoker (Table 2). Nonsmokers

are more likely to consider themselves to be in excellent health, whereas

smokers are more likely to rate their health as poor, fair, or good. Approximately two-thirds of nonsmokers who visited a physician in the last year

considered themselves to be in either excellent or very good health compared
13

Chapter 1

Table 1

Demographics of smokers, by visit to physician in last 12 months, California, 1990

Visited Physician in Last Year

Percentage

Yes No Ratio

Total 20.0% 25.8% 0.76

Sex

Male 22.1 28.8 0.77

Female 18.2 21.0 0.86

Age

18 to 24 yr 20.9 35.5 0.82

25 to 44 22.5 26.7 0.84

45 to 64 20.3 25.9 0.78

65+ 10.9 20.2 0.54

Ethnicity

Hispanic 16.5 20.4 0.81

Non-Hispanic 20.7 28.6 0.72

Race

White 19.8 25.8 0.76

Black 27.9 34.0 0.81

Asian/Pacific Islander 12.0 19.7 0.61

Education

< 12 yr 24.5 28.5 0.86

12 23.1 29.2 0.79

13 to 15 19.8 25.1 0.79

16+ 11.8 15.5 0.76

Source: 1990 California Tobacco Survey, as cited in Burns and Pierce, 1992.

with about 53 percent of smokers. About 18 percent of smokers indicated

that they were in fair or poor health, compared with about 13 percent of

nonsmokers. Nevertheless, the majority of smokers who visit a general

practice will feel that they are in good health (Burns and Pierce, 1992).

Whom Can Physicians The four principles for physician and dentist intervention

And Dentists Help? outlined by NCI are ask, advise, assist, and arrange. From the

studies reported in this monograph, we can estimate the likely percentages

of smokers with whom a physician or dentist will be able to undertake

each of these activities successfully.

Ask If an effective smoking-advice system is to be achieved in a general

practice, each patient’s smoking status must be known and the medical

or dental charts must be flagged to prompt the physician or dentist to discuss

smoking with the appropriate patients. As described earlier, this system
Smoking and Tobacco Control Monograph No. 5

14

Table 2

Health status of patients who visited a physician in the last year, California, 1990

Percentage of Percentage of

 Smokers Nonsmokers

Self-Reported Status

Excellent health 19.6% 30.4%

Very good health 33.2 33.4

Good health 29.3 23.3

Fair health 14.6 10.6

Poor health 3.3 2.3

Source: 1990 California Tobacco Survey, as cited in Burns and Pierce, 1992.

should result in flags on about 20 percent of all charts from any particular

day. Two methods have been popular for determining whether a patient is

a smoker: (1) the receptionist obtains the information at the front desk or

(2) the nurse or dental hygienist asks the patient while recording vital signs.

With either approach, determination of smoking status requires a slight

change in the practice’s system. Elsewhere in this monograph, researchers

discuss various methods to implement this change.

Advise Anecdotal experience from physician and dentist trials suggests that, if

a comprehensive program is used, nearly all smokers who visit a physician or dentist can be counseled to quit (T. Kottke, personal communication;

A. Christen, personal communication). Generally, there are two situations

in which patients are not counseled to quit: when the patient is too distraught to concentrate and when the clinician is too far behind schedule

to be completely in control of the patient encounter. Experience in the

Nokomis Clinic in Minnesota suggests that these situations arise in about

15 percent of all physician visits (T. Kottke, personal communication).

Assist The level of assistance that the health care provider can offer varies

considerably, including assessing whether the smoker is ready to quit,

discussing quitting, eliciting barriers and fears about making a quit attempt,

helping to set a quit date, and in some cases prescribing a nicotine substitute.

With an aggressive approach, physicians, dentists, or their smoking cessation

coordinators can get many of their smoking patients to set a quit date (see

Cummings et al., Chapter 2, this volume). Prescribing of a nicotine supplement as an aid to quitting has been studied extensively.

The most successful systems for smoking advice include designation

of a smoking advice coordinator who first discusses smoking with the

patient. Then, the physician or dentist gives 1 to 2 minutes of strong

advice to encourage the patient to quit. Because this system involves
15

Chapter 1

minimum physician or dentist time to urge the patient to set a quit date,

approximately 90 percent of clinicians are comfortable complying with

this smoking advice strategy. More than 80 percent of patients seem

prepared to discuss their smoking further with the designated smoking

coordinator, and about 30 percent are prepared to negotiate a quit date

(see Hollis et al., Chapter 2, this volume).

Arrange The majority of smoking cessation attempts are not successful.

Nationally, approximately 30 percent of smokers reported that they

had tried to quit in any given year (Hatziandreu et al., 1990), but very few

of those smokers sought any external aid to help them succeed (Fiore et al.,

1990). In the Nokomis Clinic in Minnesota, researchers estimate that

approximately 1 in 1,000 smokers actively seek information on programs

to help them quit.

Arranging for help to quit and for followup has been the most difficult

step in the comprehensive smoking-advice system. As described in Chapter 2

(Hollis et al.), only 10 percent of smokers attended a scheduled followup visit

to review their progress.

SMOKING BEHAVIOR The smoking behavior of U.S. physicians has been surveyed

OF PHYSICIANS regularly since 1949. In that year, some 60 percent of

physicians smoked. This percentage declined, and by 1964, at the time

of the first Surgeon General’s report detailing the health consequences of

smoking (US DHEW, 1964), the percentage of physicians who smoked had

decreased to around 30 percent (Garfinkel and Stellman, 1976). Smoking

prevalence among physicians continued to decline, and by the early 1980’s,

only 5 to 10 percent of physicians were smoking (Buechner et al., 1986;

Sachs, 1983). The most recent data come from an anonymous, self-report

survey conducted in 1989 to 1990, involving responses from 5,426 physicians (Hughes et al., 1992). In this survey, 51.1 percent of respondents

reported ever using tobacco, 13.7 percent reported tobacco use in the last

year, 10.6 percent reported use in the last month, and 6.3 percent labeled

themselves daily consumers. The reduction in smoking prevalence among

physicians resulted from a decrease in smoking uptake among new physicians and by the successful quitting of experienced physicians (US DHHS,

1989).

As the negative health consequences of smoking become widely known,

we would expect smoking uptake rates to change much more rapidly than

quitting behavior because it is easier not to start than to quit an addictive

behavior. In the United States, taking up smoking generally has occurred

between the ages of 12 and 25 (Pierce et al., 1991; US DHHS, 1989). Therefore, studies of smoking prevalence among medical students should indicate

quite accurately the proportion of new physicians who will smoke. The

Johns Hopkins Precursors Study and the Preventive Cardiology studies

provide data on smoking uptake among medical students.

From 1948 through 1964 at the Johns Hopkins Medical School

(Baltimore, Maryland), the behavior of medical students was analyzed by
Smoking and Tobacco Control Monograph No. 5

16

1950 1955 1960 1965 1970 1975 1980 1985 1990

0

20

40

60

80

100

Class (Year)

Current Smokers (Percentage)

Johns Hopkins

8 Medical Schools

No data

annual surveys, now known as the “Precursors Study” (M. Klag, personal

communication). Members of each admitted class were surveyed on several

categories of behavior, including current cigarette use. The average smoking

prevalence among medical students at Johns Hopkins Medical School was

65.4 percent for the years 1948 through 1951 (Figure 4), a rate only slightly

higher than the prevalence of smoking among physicians during these years.

However, by 1965 the prevalence for the medical students had dropped

below 40 percent. Presumably, if surveyed later as practicing physicians,

some would be found to have quit.

Throughout the 1980’s, the National Heart, Lung, and Blood Institute

provided a series of preventive cardiology awards to several investigators at

medical schools (Stone et al., 1990). As part of these awards, investigators

undertook cardiovascular risk surveys of medical school students. Dr. Tom

Pearson of Bassett Hospital (Cooperstown, New York) combined and

computerized data from eight medical schools (Johns Hopkins University,

Case Western Reserve University, Mt. Sinai, St. Louis University, State

University of New York at Rochester, University of Utah, George Washington

University, and the University of California at Irvine) (T. Pearson, personal

Figure 4

Smoking prevalence among medical students

Sources: Derived from unpublished data, Precursors Study and Preventive Cardiology Series.
17

Chapter 1

communication). In general, first- and fourth-year medical students from

the graduating classes of 1981 through 1987 were surveyed. In these medical

schools, from 1981 through 1987, the maximum prevalence was less than

3 percent in any year. These data seem to indicate that medical students

in the United States had become almost smoke-free by the early 1980’s.

Smoking prevalence among medical students can be put in context by

comparison with the smoking prevalence in 22- to 26-year-old individuals

in the population with 16 or more years of education, as determined from

the National Health Interview Surveys. In 1965, an estimated 40 percent

of the NHIS population in the age and education ranges given above were

current smokers, about the same percentages observed for the Johns Hopkins

medical students in that year. Prevalence declined steadily in the general

population over time, and by 1987 it was down to 14 percent (which is at

least 10 percentage points higher than smoking prevalence among medical

students in the Preventive Cardiology series). One explanation for the

difference between the change in the smoking behavior of medical students

and that of their peers is the radical change in social norms among aspiring

physicians with respect to the acceptability of smoking after publication of

the 1964 Surgeon General’s report.

PHYSICIANS’ ADVICE, Gritz (1988) has estimated that some 70 percent of the

AS REPORTED BY population visit a physician each year. In California in

PATIENTS 1990 (Burns and Pierce, 1992), 72.4 percent of the total

population visited a physician in the year prior to the survey. This included

66.8 percent of all current smokers. Indeed, 40.2 percent of current smokers

visited their physician on more than one occasion during that 12-month

period. Physicians have both the mandate and the opportunity to advise

smoking patients to quit; they are in the position to provide that advice at

low cost on a one-to-one basis to the majority of smokers each year.

Data Sources and Information on whether physicians had advised individual patients

Measures to quit smoking was obtained from three National Health Interview

Surveys (1974, 1976, and the 1987 Cancer Risk Factor Supplement) and the

1986 Adult Use of Tobacco Survey (AUTS). The three NHIS studies were

household in-person interview surveys with questions related to smoking

asked directly of the respondent (response rate more than 85 percent). Details

of the survey methodology were reported previously (NCHS, 1985 and 1987).

The 1986 AUTS survey was a random-digit-dialing telephone survey; within

an identified household, eligible respondents answered the questions themselves (US DHHS, 1986b). The response rate was 74 percent. Rates of physicians’ advice from the surveys, reported previously (Gilpin et al., 1992), are

summarized below.

In each survey year, ever-smokers were defined as those who had smoked

more than 100 cigarettes in their lifetime. Current smokers were defined by

the question, “Do you smoke cigarettes now?” Ever-smokers who answered

no to the question about current smoking were labeled “former smokers.”
Smoking and Tobacco Control Monograph No. 5

18

In the 1974 and 1976 surveys, respondents were asked, “Have you ever

been advised by a doctor to quit smoking?” In the 1986 survey, respondents

were asked, “Did any doctor ever advise you to quit smoking?” Finally, in

the 1987 survey the question was, “Has a doctor ever advised you to quit

smoking?” For this discussion, the sample of respondents analyzed included

current and former smokers, aged 20 or older at the time of interview, who

indicated whether or not they had received advice to quit from a physician.

When respondents were asked whether they had ever received advice to quit

smoking from a physician, no time interval was mentioned.

Increase in Three separate analyses of changes in reported advice with time

Reported Advice were performed. The first analysis considered former smokers,

the second focused on current smokers, and the third included both current

and former smokers and used information on the date of smoking cessation.

The analysis of current smokers alone should give a better picture of recent

advice patterns. Finally, in the third analysis, respondents who had been

former smokers the longest would generally have been more likely to be

advised at an earlier date than those who quit more recently or who are

current smokers, thus providing another indication of changes in physicians’

advice patterns.

Advice rates over time or over time since former smokers smoked were

compared with the χ2 test for trend. Figure 5 presents the overall percentages of current and former smokers who had been advised to quit smoking,

as reported in each survey year. These percentages have increased steadily

over the years (p < 10-8), especially in the last two survey years compared

with the first two. In 1974, only 26.4 percent of current smokers reported

receiving advice, and by 1987 the percentage had reached 50.9 percent.

Furthermore, the percentages of former smokers (by interval since they

smoked) and current smokers advised to quit smoking in the combined

1986 and 1987 surveys also show the trend for increased advice to quit

with time (p < 10-8) (Figure 6).

The trend to increased reporting of advice with time has been noted

previously within these same surveys and those for earlier years (US DHHS,

1990). For the 1964 AUTS survey, 15 percent of current smokers reported

receiving advice. By the 1966 AUTS survey, the percentage of smokers

reporting they received advice had reached 16.9 percent, and by the 1970

AUTS survey, it climbed to 21.8 percent (US DHHS, 1990).

Demographic To examine the relationship of demographic factors to the reported

Subgroups rates of advice among current smokers, the earlier 2 years, 1974 and

1976 (from NHIS), and the later 2 years, 1986 and 1987 (from AUTS and

NHIS, respectively), were combined. There are some important demographic

differences in who is likely to have received advice to quit smoking (Table 3).

In both periods, more female smokers than male smokers reported having

been advised to quit smoking (28.9 vs. 25.8 percent in the 1970’s, and 53.3 vs.

45.6 percent in the 1980’s).
19

Chapter 1

In both survey periods, a clear trend for age was seen: More advice is

reported with advancing age of the patient. However, in the later period

(1986 and 1987) this trend was less pronounced. This finding could result

from more frequent visits to the physician by older people, from an aging

of the population, or both (US DHHS, 1986a).

In both survey periods, white respondents reported receiving advice

more than did blacks (28.5 vs. 18.4 percent in the 1970’s, and 51.5 vs.

39.4 percent in the 1980’s). This indicates that physicians may not be

advising blacks to quit smoking as often or as strongly as they are advising

whites.

Smokers with more than a high school education reported receiving

advice more often than did those with less education, and all educational

levels showed the same increase with time. While the average age of the

population has been advancing in recent years, so has its level of education.

These changes may tend to offset one another and probably account for the

absence of a more substantial trend in reported advice relative to education

level.

Figure 5

Physician advice, as reported by current and former smokers

1974 1976 1986 1987

Survey Year

0

10

20

30

40

50

60

Percentage Reporting Advice

Former Smokers

Current Smokers

Sources: 1974, 1976, 1987 National Health Interview Surveys; 1986 Adult Use of Tobacco Survey.
Smoking and Tobacco Control Monograph No. 5

20

Differences in Physicians’ In 1986 and 1987, half of all current smokers reported

And Patients’ Reports that they had been advised to quit smoking by a physician. In seven studies that relied on physician self-report (including two

national surveys of family practitioners), the proportion of physicians

reporting regularly advising their smoking patients to quit ranged from

52 to 97 percent (Fortmann et al., 1985; Ockene et al., 1986; Orleans et al.,

1985; Rimer et al., 1986; Rosen et al., 1984; Valente et al., 1986; Wechsler

et al., 1983; Wells et al., 1986).

Several factors may account for the discrepancy in the advice rates

reported by patients and those reported by physicians. First, physicians

who do not respond to voluntary surveys about their practices for advising

patients to quit smoking may not routinely give such advice. Second, the

physicians seen most often by smokers may not be cardiopulmonary specialists and may not be as aware of the importance of advising patients to quit,

and therefore do not give their patients as much advice (Wells et al., 1986).

Third, physicians may be more likely to advise patients who have smokingrelated illnesses (Cummings et al., 1987; Ockene et al., 1987). Results from

Figure 6

Physician advice, by interval since patient last smoked

5-9

Years

10+

Years

1-4

Years

< 1

Year

Current

Smokers

Former Smokers

0

10

20

30

40

50

60

Percentage Reporting Advice

Sources: 1986 Adult Use of Tobacco Survey, 1987 National Health Interview Survey.
21

Chapter 1

a national survey of internists indicated that, although 82 percent of the

group reported counseling more than 75 percent of smokers with heart

disease, only 52 percent reported counseling more than 75 percent of all

patients who smoke (Wells et al., 1986). Finally, physicians may have given

advice that patients do not remember. A physician’s simple statement to a

patient, “You should quit smoking,” may not have the same impact as active

counseling or multiple messages (Kottke et al., 1988; Schwartz, 1987).

SUMMARY Although more smokers in recent years are receiving health professionals’

advice to quit smoking, many still are not being reached by this important

avenue. Physicians and dentists may hesitate to advise smoking patients to

quit because they perceive that such advice has little impact compared with

standard therapies for other ailments. Physicians and dentists need to

understand that the success of their efforts is not measured in how many

patients become ex-smokers in the year after advice is given. On that scale,

only about a 5-percent quit rate is to be expected (Cummings et al., 1987;

U.S. Preventive Services Task Force, 1989). Rather, advice will lead the

Table 3

Current smokers advised to quit, by time period and demographic characteristics

1974 to 1976 1986 to 1987

(n=16,033) (n=10,403) Ratio

Percentage (Standard Error)

Overall 27.3% (0.4) 49.7% (0.5) 1.8

Sex

Male 25.8 (0.5) 45.8 (0.7) 1.8

Female 28.9 (0.5) 53.3 (0.7) 1.8

Age

20 to 29 yr 19.4 (0.7) 41.9 (1.1) 2.2

30 to 44 26.7 (0.6) 49.6 (0.8) 1.9

45 to 64 33.0 (0.9) 55.1 (1.1) 1.7

≥ 65 33.4 (1.2) 54.5 (1.4) 1.6

Race

White 28.5 (0.4) 51.5 (0.5) 1.8

Black 18.4 (0.9) 39.4 (1.3) 2.1

Other 15.9 (3.1) 44.1 (3.0) 2.8

Education

< 12 yr 27.2 (0.6) 47.9 (1.0) 1.8

12 25.2 (0.6) 48.5 (0.8) 1.9

13 to 15 28.5 (0.6) 52.1 (0.9) 1.8

≥ 16 30.8 (1.3) 53.4 (1.5) 1.7

Sources: 1976, 1984, 1987 National Health Interview Surveys, 1986 Adult Use of Tobacco Survey.
Smoking and Tobacco Control Monograph No. 5

22

patient along a cyclical path to quitting. Smokers generally move through

stages of not thinking about quitting, then thinking about it, making a quit

attempt followed by relapse, and another period of no interest (Prochaska

and DiClemente, 1983). However, repeated advice to quit, together with

messages from other sources, will help reinforce the process so that eventually the smoker will make a successful attempt and become one of the

5 percent who quit.

REFERENCES

Buechner, J.S., Perry, D.K., Scott, H.D., et al.

Cigarette smoking behavior among Rhode Island

physicians, 1963-83. American Journal of Public

Health 76: 285-286, 1986.

Burns, D., Pierce, J.P. Tobacco Use in California 1990-

1991. Sacramento: California Department of

Health Services, 1992.

Cummings, K.M., Giovino, G., Sciandra, R.,

Koenigsberg, M., Emont, S.L. Physician advice to

quit smoking: Who gets it and who doesn’t.

American Journal of Preventive Medicine 3: 69-74,

1987.

Fiore, M.C., Novotny, T.E., Pierce, J.P., Giovino, G.A.,

Hatziandreu, E.J., Newcomb, P.A., Surawicz, T.S.,

Davis, R.M. Methods used to quit smoking in the

United States. Journal of the American Medical

Association 253: 2760-2765, 1990.

Fortmann, S.P., Sallis, J.F., Magnus, P.M., Farquhar,

J.W. Attitudes and practices of physicians

regarding hypertension and smoking: The

Stanford Five-City Project. Preventive Medicine 14:

70-80, 1985.

Garfinkel, L., Stellman, S.D. Cigarette smoking

among physicians, dentists and other health

professionals, 1959-1972. CA—A Cancer Journal for

Clinicians 26: 373-375, 1976.

Gilpin, E., Pierce, J., Goodman, J., Giovino, G., Berry,

C., Burns, D. Trends in physicians’ giving advice

to stop smoking, United States, 1974-87. Tobacco

Control 1: 1-36, 1992.

Gritz, E.R. Cigarette smoking: The need for action by

health professionals. CA—A Cancer Journal for

Clinicians 38: 194-212, 1988.

Hatziandreu, E.J., Pierce, J.P., Lefkopoulou, M., Fiore,

M.C., Mills, S., Novotny, T.E., Giovino, G., Davis,

R.M. Quitting smoking in the United States: Who

tries and who succeeds. Journal of the National

Cancer Institute 82: 1402-1406, 1990.

Hughes, P.H., Brandenberg, N., Baldwin, D.C., Storr,

C.L., Williams, K.M., Anthony, J.C., Sheehan, D.W.

Prevalence of substance use among U.S. physicians.

Journal of the American Medical Association 267:

2333-2339, 1992.

Kottke, T.E., Battista, R.N., DeFriese, G.H., Brekke,

M.L. Attributes of successful smoking cessation

interventions in medical practice: A meta-analysis

of 39 controlled trials. Journal of the American

Medical Association 259: 2882-2889, 1988.

Kottke, T.E., Brekke, M.L., Solberg, L.I., Hughes, J.R. A

randomized trial to increase smoking intervention

by physicians: Doctors Helping Smokers, round I.

Journal of the American Medical Association 261:

2101-2106, 1989.

National Center for Health Statistics. Current

Estimates from the Health Interview Survey. U.S.

Department of Health and Human Services, Ser. 10,

No. 166, 1987.

National Center for Health Statistics. The National

Health Interview Survey Design, 1973-84, and

Procedures 1975-1983. U.S. Department of Health

and Human Services. DHHS Publication No. (PHS)

85-1320, 1985.

Ockene, J.K., Hosmer, D.W., Williams, J.W., Goldberg,

R.J., Ockene, I.S., Biliouris, T., Dalen, J.E. The

relationship of patient characteristics to physician

delivery of advice to stop smoking. Journal of

General Internal Medicine 2: 337-340, 1987.

Ockene, J.K., Williams, J., Hosmer, D., Goldberg, R.J.,

Raia, T.J. A survey of physicians’ smoking

intervention practices. Presented at the Annual

Meeting of the Society for Behavioral Medicine, San

Francisco, California, March 1986.

Orleans, C.T., George, L.K., Houpt, J.L., Brodie, K.H.

Health promotion in primary care: A survey of U.S.

family practitioners. Preventive Medicine 14: 636-

647, 1985.

Pierce, J.P., Naquin, M., Gilpin, E., Giovino, G., Mills,

S., Marcus, S. Smoking initiation in the United

States: A role for worksite and college smoking

bans. Journal of the National Cancer Institute 83:

1009-1013, 1991.

Prochaska, J.O., DiClemente, C.C. Stages and

processes of self-change of smoking: Toward an

integrative model of change. Journal of Consulting

and Clinical Psychology 51(3): 390-395, 1983.

Rimer, B.K., Strecher, V.J., Keintz, M.K., Engstrom, P.F.

A survey of physicians’ views and practices of

patient education for smoking cessation. Preventive

Medicine 15: 92-98, 1986.
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Rosen, M.A., Logsdon, D.N., Demak, M.M.

Prevention and health promotion in primary care:

Baseline results on physicians from the Insure

project on life-cycle preventive health services.

Preventive Medicine 13: 535-548, 1984.

Sachs, D.P.L. Smoking habits of pulmonary

physicians. New England Journal of Medicine 309:

799, 1983.

Schwartz, J.L. Review and Evaluation of Smoking

Cessation Methods: The United States and

Canada, 1978-1985. U.S. Department of Health

and Human Services, Public Health Service,

National Institutes of Health, National Cancer

Institute, Division of Cancer Prevention and

Control. NIH Publication No. 87-2940, 1987.

Stone, E.J., Van Citters, R.L., Pearson, T.A. (Editors).

Preventive cardiology: Perspectives in

physician education. American Journal of Preventive

Medicine 6(Suppl.): 1-100, 1990.

U.S. Department of Health and Human Services. The

Health Benefits of Smoking Cessation: A Report of the

Surgeon General. U.S. Department of Health and

Human Services, Public Health Service, Centers for

Disease Control, Center for Chronic Disease

Prevention and Health Promotion, Office on

Smoking and Health. DHHS Publication No.

(CDC) 90-8416, 1990.

U.S. Department of Health and Human Services.

Health United States 1986 and Prevention

Profile. U.S. Department of Health and Human

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1986a.

U.S. Department of Health and Human Services.

Reducing the Health Consequences of Smoking:

25 Years of Progress. A Report of the Surgeon General.

U.S. Department of Health and Human Services,

Public Health Service, Centers for Disease Control,

Center for Chronic Disease Prevention and Health

Promotion, Office on Smoking and Health. DHHS

Publication No. (CDC) 89-8411, 1989.

U.S. Department of Health and Human Services.

Tobacco Use in 1986: Methods and Basic Tabulations

from Adult Use of Tobacco Survey. U.S. Department

of Health and Human Services, Public Health

Service, Centers for Disease Control, 1986b.

U.S. Department of Health, Education, and Welfare.

Smoking and Health: A Report of the Advisory

Committee to the Surgeon General of the Public Health

Service. U.S. Department of Health, Education, and

Welfare; Public Health Service. PHS Publication

No. 1103, 1964.

U.S. Preventive Services Task Force. Guidelines to

Clinical Preventive Service: An Assessment of the

Effectiveness of 169 Interventions. Report of the U.S.

Preventive Services Task Force. Baltimore: Williams

and Wilkins, 1989.

Valente, C.M., Sobal, J., Muncie, H.L., Levine, D.M.,

Antlitz, A.M. Health promotion: Physicians’

beliefs, attitudes and practices. American Journal of

Preventive Medicine 2: 82-88, 1986.

Wechsler, H., Levine, S., Idelson, R.K., Rohman, M.,

Taylor, J.O. The physician’s role in health

promotion: A survey of primary care practitioners.

New England Journal of Medicine 308: 97-100, 1983.

Wells, K.B., Lewis, C.E., Leuke, B., Schleiter, M.K.,

Brook, P.H. The practices of general and

subspecialty internists in counseling about smoking

and exercise. American Journal of Public Health 76:

1009-1013, 1986.
Smoking and Tobacco Control Monograph No. 5

24

The Health Professional’s

Responsibility in Smoking Cessation:

Strategies for Office and Community

John W. Richards, Jr., Thomas P. Houston, and Alan Blum

INTRODUCTION Achieving behavior change among individuals exposed to risks is

a complex task. The field of risk communication is an evolving science,

often poorly understood by both its practitioners and those who should be.

It seems evident, however, that providing information about a potential risk

is only the first of several steps in affecting behavior. Information, motivation, and sometimes legislation are needed to reduce personal and societal

risks. Seat belt campaigns that have culminated in automobile safety laws

for adults and children are a case in point.

The personal and professional role and responsibility of health professionals go beyond merely giving relevant information about smoking.

Needed are office-based and community efforts that can help motivate

patients and activate other health professionals to address more effectively

the single largest cause of illness and death in our society, smoking.

In reviewing categories of behavior change, Green and colleagues

(1988) identified three types of behavioral influence that apply to clinicians:

predisposing, enabling, and reinforcing factors. Knowledge and attitudes

toward health promotion and disease prevention, the health behavior of the

professional, confidence in counseling skills, and belief about their patients’

interest in such advice are the predisposing factors that can be both positive

and negative cues toward health promotion behavior. Factors that promote

or enable health promotion activities include a feeling of confidence about

performing preventive care services, reimbursement for these activities, and

an organized practice setting that facilitates preventive medicine. Reinforcing factors include positive feedback from patients, evidence of intermediate

results, peer support, and a perception that health promotion activities add

to the role of healer.

Many of these characteristics are not easily fulfilled in the case of

smoking cessation. Although many health professionals have adequate

knowledge about the pathophysiology of tobacco use and its adverse

consequences on health, most are not adequately trained in medical or

dental school, or during residency, to counsel patients about smoking

cessation (Horton, 1986). Likewise, although many patients desire health

promotion advice from their physicians, the physicians often do not fulfill

the patients’ expectations. In a study by Owen and Davies (1990), 67 percent

of smokers preferred receiving advice from a health professional over other
25

Chapter 1

means of assistance with smoking cessation. Physicians and dentists, however, are notoriously lax about advising patients to stop smoking. Only

about 45 percent of smokers report that a physician has ever advised them

to stop smoking (Anda et al., 1987; Davis, 1988).

Good news about physician counseling behavior comes from a survey

in which 98 percent of recently trained family physicians reported that they

counsel patients about smoking, even when no smoking-related disease is

present. Thirty percent of that group also said they believed they were

influential in their patients’ smoking cessation (Goldstein et al., 1987).

Many health professionals do not feel empowered to engage in smoking

cessation efforts because of reimbursement issues and the perception that

smoking cessation requires inordinate amounts of time. Green and coworkers’ identified reinforcing factors (Green et al., 1988) also may be perceived as blockers when physicians’ partners and peers do not support their

beliefs about smoking cessation, when feedback from patients is not as

readily apparent as with self-limiting or easily treated illnesses, or when

there is discouragement because of failure to achieve a 100-percent cure

among patients who smoke.

On the other hand, most physicians have adopted health behaviors that

are conducive to smoking cessation in practice. A 1987 study conducted by

the American Medical Association showed that only 9 percent of randomly

selected physicians were smokers (Harvey and Shubat, 1987). Because health

professionals have frequent contact with patients who smoke, there is opportunity for intervention. More than 70 percent of Americans see a physician

at least annually, and more than 60 percent see a dentist each year. Smokers

average 4.3 physician visits each year (Wetzler and Cruess, 1985), and even

a brief intervention by physicians can be successful in doubling the spontaneous quit rate of 2 to 4 percent (Ockene, 1987; Schwartz, 1987).

At this point, a brief review of the hazards of smoking and the benefits of

cessation is in order. Smoking’s effects on health constitute the single largest

cause of preventable disease and death in American society. The Office on

Smoking and Health has estimated that more than 430,000 Americans die

each year from diseases related to smoking (Centers for Disease Control,

1991). Nearly one of every five deaths in the United States is caused by

smoking; this represents more deaths than the combined total of deaths each

year from AIDS, automobile accidents, homicide, suicide, and illegal drugs.

The 1990 Surgeon General’s report (US DHHS, 1990) points out that

smoking is the leading cause of lung cancer among both men and women;

the risk of lung cancer is 22 times higher among male smokers and 12 times

higher among female smokers than nonsmokers. After smoking cessation,

the risk of lung cancer declines, so after about 10 years of abstinence, the risk

of lung cancer for the ex-smoker is between 30 and 50 percent of the risk for

those who have continued to smoke.
Smoking and Tobacco Control Monograph No. 5

26

Smokers have about two times the risk of nonsmokers of dying from

heart disease. Cessation reduces the excess risk by about 50 percent after

only 1 year. After 15 years of cessation, the risk is similar to that for persons

who have never smoked.

Stroke is the third leading cause of death in the United States. Stroke

prior to age 55 is twice as common among smokers as it is among nonsmokers. It is less clear how quickly stroke risks return to baseline for

persons who have stopped smoking—probably between 5 and 15 years.

Smoking is the major cause of chronic obstructive lung disease, the

fifth leading cause of death in the United States. Again, we see benefits in

cessation because the progression of chronic obstructive pulmonary disease

is reduced with abstinence from smoking. Cigarette smoking is one of the

major causes of peripheral artery disease and increases the mortality from

abdominal aortic aneurysm between two and five times.

Women have special risks from smoking besides lung cancer, now the

leading cancer killer among women. These include an increased risk of

cervical cancer and several complications of pregnancy, including bleeding

during pregnancy, premature rupture of membranes, preterm delivery,

placenta previa, abruptio placenta, and producing a baby with low birth

weight. Women who stop smoking before becoming pregnant or stop

smoking during the first trimester of pregnancy apparently reverse the risk

of low birth weight for the baby as well as reducing the other pregnancyassociated risks.

Recent data show also that smoking during pregnancy affects the growth

and development of young children, in both the physical and cognitive

areas. Stopping smoking early in pregnancy prevents these effects, just as

the in utero risks are reduced by smoking cessation (Sexton et al., 1990a and

1990b).

Both smoked and smokeless forms of tobacco have deleterious effects on

the soft and hard tissues of the oral cavity.

Because the facts about smoking and the benefits of cessation are known,

and 80 to 90 percent of patients want to stop smoking, it is incumbent on

physicians and dentists as community members to participate in smoking

cessation counseling. Clinicians are bestowed with an enormous mantle of

authority: Most smokers who express a preference want information about

smoking cessation from physicians in preference to other sources; and onehalf of smokers say they would try to quit if their dentist advised them to

quit. Physicians and dentists also have an ethical duty to prevent illness

and reduce the burden of disease and suffering.

Our patients do not wake up one morning and suddenly decide to

become smokers; rather, they are bombarded from an early age with messages and role models that encourage tobacco use. A health professional’s

approach to smoking cessation should therefore be a longitudinal strategy

involving a multitiered approach that includes the office, hospitals, schools,
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Chapter 1

civic organizations, and the mass media, in addition to the more traditional

individual patient encounter. What follows reflects trial and error by physicians and research efforts by members of Doctors Ought to Care, a physicianled group advocating smoking cessation strategies as an essential part of

every practice (Blum, 1980 and 1982). Moreover, there is growing evidence

that these techniques are effective.

IN THE PRAC- Most physicians’ and dentists’ offices are remarkably underused

TITIONER’S for smoking cessation, especially in light of the above-described

OFFICE devastation of health by tobacco use. The entire office staff must

work to create an environment conducive to nonsmoking behavior among

patients. The first step is to assume a patient’s perspective and tour the

office with the objective of creating an atmosphere that clearly conveys the

message that nonsmoking is the norm. Because the amount of time the

patient spends registering and waiting may be as long as the health care

encounter itself, every opportunity to encourage and support nonsmoking

behavior must be used throughout the office environment. The following

details what can be done in different office areas.

The Reception As part of the professional office, the reception area automatically

Area grants credibility and implies endorsement to whatever editorial or

commercial material it may contain. Health professionals are the target,

therefore, of publishers who are trying to get their magazines displayed in

patient care facilities. In fact, many magazines such as Better Homes and

Gardens, Working Woman, Family Circle, Woman’s Day, and People offer very

low “professional rates.” Each of these magazines contains an average of

10 cigarette advertisements per issue. These are often juxtaposed with health

articles, most of which are unrelated to the subject of tobacco (Houston,

1984). Indeed, Time, Newsweek, Sports Illustrated, Better Homes and Gardens,

U.S. News and World Report, Ladies Home Journal, and People—the most

frequently purchased magazines for doctor’s offices (Fischer, 1985)—have

many advertisements encouraging and glamorizing tobacco use. In addition,

most of them have deliberately avoided the subject of tobacco’s effects on

health (Richards, 1991).

It is absurd to display glamorous models in highly desirable settings

to promote cigarettes in a physician’s or dentist’s waiting room. Health

care professionals can send a message to patients and publishers alike by

canceling subscriptions to these publications and subscribing to publications

that do not promote tobacco (Richards, 1983; also see Appendix A). An

alternative technique is to call attention to the harmful and often untruthful

nature of these advertisements by stamping or pasting stickers on the advertisements with comments such as, “This ad is a rip-off” or “Your doctor does

not approve of this ad” (Figure 7). Moreover, a sign might be placed in the

reception area alerting patients to the reason specific reading material has

been provided. Of course, a sign should be displayed that informs patients

that the office is a smoke-free zone. Other signs in the office can invite

patients to inquire about smoking cessation and inform them that smoking

cessation activities are available.
Smoking and Tobacco Control Monograph No. 5

28

Figure 7

Sticker for waiting room magazines

Source: Doctors Ought to Care; copyright 1987; used with permission.

Other areas of the office, such as the restrooms, can be provided with

eye-catching posters and reading material that promote healthful behavior.

Even the ceilings of exam rooms are open for attention-getting posters or

messages. These would be supplements to the traditional use of time spent

in the exam room, when patients can read carefully selected materials.

Vital Signs In almost all practices, vital signs are noted prior to the patient-physician

encounter. Because tobacco use is the principal cause of premature morbidity

and mortality in this country, a column should be added to the vital signs

record and headed “tobacco” (Richards, 1991). A simple question—“Do you

use tobacco?”—should be asked as a part of checking vital signs. The utility

of this simple screening test is far greater than most screening used in practice.

When the response is positive, the physician or dentist has information that is

a powerful predictor of both acute and chronic disease in the patient and his

family. Moreover, it signifies to nonsmokers as well as to smoking patients

that tobacco use is a very important factor in health and that the health care

provider is concerned about smoking.

The Examination Whether the presenting complaint is acute or chronic, smoking

cessation can and should be a part of each visit. Tobacco use, once identified, should be placed on the problem list as a permanent problem. Just as a

physician routinely takes blood pressure readings for formerly hypertensive

individuals, the physician should continue to inquire about tobacco use even

after cessation is achieved. This reinforces patient efforts because physician

concern is often cited by patients as an important influence on smoking

behavior.

Identifying and using “teachable moments,” such as during or just after

an illness, can significantly increase chances for a successful intervention

by providing new motivating factors on which to build (Brunton, 1984).
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Chapter 1

However, it is not sufficient to wait for teachable moments: Experienced

physicians can and should create them.

To the alert physician or dentist, the presenting complaint will often

lead to smoking cessation opportunities. For example, a child with an ear

infection or even a cold offers a teachable moment to talk with parents about

their cigarette smoking. Prenatal visits, the intrapartum hospital stay, and

well-child visits provide the opportunity to discuss protecting children from

environmental tobacco smoke as well as to remind parents about their own

health risks. Routine dental appointments can become opportunities for

smokeless tobacco education, especially among adolescent boys. The school

sports physical, the camp physical, routine checkups for diabetic or asthmatic

patients—all should be used as teaching encounters about tobacco use.

During the examination itself, opportunities abound. Instead of a spot

on the wall for a patient to look at during the funduscopic exam, substitute

an attention-getting poster to make productive use of 30 seconds of direct

concentration. Casual comments while examining the mouth (“Still smoking, I see”) or while listening to the lungs (“Still smoking, I hear”) plant seeds

for change. However, asking the traditional question, “How much do you

smoke?,” may lead the patient to interpret that there is a safe level of

consumption, so the physician must be prepared with an appropriate

disclaimer to follow the patient’s response.

INDIVIDUALIZING To increase effectiveness, physicians and dentists should

INTERVENTIONS examine closely the basic reasons for patients’ smoking, keeping

in mind the techniques used to sell cigarettes and encourage consumption.

Most people, especially teenagers, choose cigarettes that advertisers promise

will make them look macho, mature, sexy, successful, or more acceptable to

their peers. Because cigarettes, if used, actually cause the opposite appearance,

the very same Madison Avenue images that promote buying and using

cigarettes can also be employed successfully by physicians to promote

unbuying or nonsmoking.

Smoking cessation is really no different from many other medical

interventions. However, with smoking cessation the average person who

stops smoking has tried several times over a prolonged period—sometimes

years—before becoming a successful nonsmoker. This can be frustrating for

the physician who is accustomed to achieving success with measurable

results in a matter of days.

For example, consider the urinary tract infection. The patient complains

of frequency, urgency, and dysuria. A culture is taken. Antibiotics are

selected and prescribed. The sensitivity confirms the correct choice. The

patient generally gets better quickly and is well in a week. If the patient

with a urinary tract infection were to come back in a week with continued

symptoms, no physician would say, “I’m sorry, but we tried an antibiotic;

unfortunately, it did not work. I guess you’ll have to suffer with this until

you figure out a way to get better. However, you might get pyelonephritis

and septicemia and die.”
Smoking and Tobacco Control Monograph No. 5

30

With smoking cessation, the practitioner does a “culture” by performing

a general assessment of the patient’s situation; determines the “sensitivity”

by asking the question, “What brand do you smoke?”; and then selects the

verbal “antibiotic” according to a combination of the above. If the first

verbal antibiotic for smoking cessation does not work, the clinician should

try another and then another, until success is achieved.

Just as a medical student is uncomfortable and apprehensive when using

antibiotics to treat his or her first patient with a urinary tract infection, the

same feelings are to be expected when first using various smoking cessation

techniques. With practice, however, using smoking interventions will

become as routine as treating a urinary tract infection.

One must remember that smoking cessation efforts, like other therapy,

must be individualized through consideration of agent (strategies that have

the best efficacy for a given situation), absorption and elimination (factors

that enhance or detract), dose (enough to be therapeutic, yet not toxic),

and timing (frequency and relation to other agents). Rather than a source

of frustration, each intervention should be considered a learning experience

for both the clinician and the patient. Realistic expectations are a must.

Achieving a smoking cessation rate of 25 percent of patients at 1 year might

seem disappointing for the physician accustomed to a 100-percent success

rate for treating urinary tract infections. However, one must keep in mind

that 25 percent would be an incredible success rate when contrasted with a

reported baseline rate of 2 to 4 percent per year. Clinicians would jump at

the chance to prescribe an antibiotic that is 100 percent more effective than

competing products. Practiced, thoughtful smoking cessation efforts can be

1,000 percent better than no intervention.

STRATEGIES FOR Selecting the proper words to discuss smoking with a patient

COUNSELING is every bit as important as selecting the proper pharmacologic

agents for other health problems. Unfortunately, little time in

Words training is devoted to developing this skill. Selecting the verbal

“drug of choice” is not difficult, however, once a proper culture and sensitivity

have been established.

In a recent article, Richards (1992) discussed 5 of the most important

questions for the physician to ask and 20 of the excuses most commonly

given by patients. Practice in these anticipated dialogues will better equip

the health care provider to deal with one-on-one smoking intervention

opportunities.

Money Money is a powerful motivator. A high school freshman might respond

to information that money saved by not buying cigarettes could be used to

purchase a stereo at the end of a year or a car after the junior year of school.

The young executive might be persuaded to give up a two-pack-per-day habit

if told that the same money placed in an 8-percent annuity might be worth

more than $1 million at retirement. In a similar fashion, a reward can be

paid for not smoking by taking the money one would have spent each day

on cigarettes and putting it in a “nonsmoking piggy bank.” This money can
31

Chapter 1

be deposited in the bank, put into an account for children, used to pay for

holidays or vacations, or, in a more immediate way, spent at the end of each

nonsmoking month on a gift for the new nonsmoker or the family. At

current prices, one pack per day comes to more than $50 per month, which

requires a pretax income of $70 to $100. A patient who quits smoking in

celebration of the birth of a child will have saved enough money over

18 years of abstinence to pay for the child’s college education.

Demarketing Turning the tables on Madison Avenue can be an easy and effective

strategy. A 15-year-old girl who smokes Virginia Slims (or another fashionimage brand) to appear sexy and independent might listen to information

about how smoking causes “zoo breath” and yellow teeth, and that kissing

a smoker is like “licking an ashtray.” It is unlikely that teenagers will listen

to statistics about possible deaths or disease in 30 or 40 years.

A 35- or 40-year-old woman might respond to the knowledge that

premature wrinkling of the face is a cosmetic side effect of smoking.

Both teenaged and young adult women might have second thoughts

when reminded that Philip Morris is exploiting women by making them

think that they have “come a long way,” when actually the company is

mocking women’s independence by telling them what to do and getting

them addicted to cigarettes.

The smoker of Now, True, Carlton, or other “low-tar” brands is concerned about health. Would the same person buy bread marketed as the

“lowest in poison” or a soup that has “only 3 milligrams arsenic”? Appealing

to health concerns and reinforcing the health benefits of cessation may be

most effective for this subcategory of smokers (Blum, 1979).

Another way to point out the illogic of smoking is to ask the patient who

refuses to stop smoking to switch to a brand inconsistent with the patient’s

desired image. For example, for the Marlboro-smoking truck driver, suggest

Virginia Slims or Eve. This often leads the smoker to smile and realize the

absurdity of smoking, which seems to break the ice and resistance to further

efforts. For the patient for whom no technique seems to work, despite many

attempts, a tactic to prolong the amount of time the patient considers the

doctor’s suggestions after leaving the office might be beneficial (for example,

giving pamphlets or handouts to enhance the patient’s absorption of the

message).

In all the above techniques and strategies, the physician or dentist

must take care to create an alliance with the patient against an enemy, that

is, the companies selling tobacco products. By pointing out the deceitful

marketing and unethical business practices of the cigarette industry and

the manufacturer of their brand in particular, patients, especially teens,

may become angry enough to stop purchasing their products. We must

never lose sight of the fact that our patients, the smokers, are victims of an

industry that has addicted them to nicotine. We must never look on the

smoker as the enemy or take sides against smokers in our efforts. Even

though many of our patients may not be able to stop smoking, we must

continue to treat them with compassion and kindness.
Smoking and Tobacco Control Monograph No. 5

32

The Quit Date Much has been written about establishing a quit date. Although

beneficial to most patients, if it appears so hard to quit that the patient has

to spend excessive time and effort getting ready, some may assume that it is

just too difficult to stop smoking and will never even try.

Asking, “Have you set a quit date?” is really a way of determining the

patient’s readiness to stop smoking. If the answer is “yes,” then follow with,

“When?” and “What is it about that date that makes it a good one?” This

will gather important additional motivating information for use in selecting

the verbal drug of choice. This may also rapidly identify blockers to be dealt

with or myths to be debunked.

If the patient has not already set a quit date, suggest setting one immediately. For patients who have tried to stop several times in the past, or for

those who have relapsed after significant periods of cessation, “Why not

today?” should be the next question. These patients may merely need a

new boost for their previous success, and a lengthy period of contemplation

before the stop date may actually allow them to put off the decision.

If the patient will not set a quit date, then explore the rationale with a

statement such as, “You’re an intelligent person. With all you know about

what smoking is doing to you and the fact that you will die about 18 years

earlier because of it, help me understand how you came to this decision.”

The patient’s answer will offer an enormous insight into his or her thinking

and motivation and will provide information for advising other patients as

well. More often than not, the patient’s rationale is based on inaccurate

information. Thus, it provides an opportunity to correct the myth, educate

the patient, and further encourage the smoker along the path toward

becoming a nonsmoker.

The Contingency Some clinicians use a written stop-smoking contract signed

Contract by both the patient and the physician after setting a quit date.

Some include the contract as a part of the medical record and ask the

patient to sign the agreement to stop smoking. Whether writing a personalized note on a prescription blank or the clinician’s letterhead, or

using specially designed contracts as may be found in smoking cessation

kits from a number of sources, something tangible for the patient to take

home may enhance the effectiveness of the cessation attempt (Taylor, 1985).

Such a contract also serves to communicate the important message that

medical or dental practice goes beyond dispensing medicine and repairing

damaged tissue.

Rewards Many physicians find rewards to be beneficial adjuncts for smoking

cessation activities. We previously mentioned monetary rewards, such

as putting the amount of money the patient would have spent on tobacco

during 1 year into an escrow account to be used for a long-term goal—

holiday gifts, a stereo, or a downpayment on a car. This can be broken down

into smaller increments as well, with daily contribution to a nonsmoking

fund. Other, nonmonetary rewards might mark the 1-day, -week, -month,

or -year anniversary and include a new hairstyle, a facial, a trip to a favorite
33

Chapter 1

park, or the guarantee of a day off from child care (which involves family

support). Creativity and engaging the patient in setting up a personalized

reward system are important.

Followup After the quit date, followup is essential to reinforcing the message of

smoking cessation to the patient. The physician or dentist should make

the followup contact through a brief office visit or a personal phone call

within a week or so of the quit date. If time constraints or schedules will

not permit, the office staff may be just as useful in making these contacts.

The perspective of Solberg and colleagues (1990) on the team approach to

smoking cessation in the family physician’s office is most instructive. At

the followup visit, or if a future encounter reveals that the patient has relapsed by smoking one or more cigarettes, the physician or dentist must

take care not to make the patient feel even more guilty about the relapse.

Many patients will assume that, because they have resumed smoking

(even if it is at a much lower level), they have failed and cannot be helped.

Rather, the relapse should be discussed in depth so that the patient can

understand the circumstances under which smoking was resumed and

create contingencies to address the situation that triggered the relapse.

By building on what was learned during the smoking cessation effort,

the patient should be encouraged to stop smoking again. Anticipatory

guidance and warning the patient about tempting situations (being with

smokers, attending parties, drinking alcohol—especially at bars) will assist

the patient in dodging these bullets. A careful smoking history with a

patient’s smoking diary and recording the stimuli and situation associated

with lighting up can be quite helpful to the clinician in this regard.

COMMUNITY From auto races to rock concerts to athletic events, even community

AWARENESS charity fundraising events, the promotion of tobacco products appears

AND ACTION in the guise of corporate sponsorship. These events are intended to

create social acceptance and complacency among users and non-users alike.

The enormous economic power of the tobacco industry through sponsorship, taxes, and advertising revenues can make local prevention efforts very

unpopular. Health professionals should be aware of, but not deterred by,

those who either do not recognize the long-term health consequences that

sponsorship of these events represents or who consider economic gain more

important than health. Every physician and dentist is a potential smoking

cessation specialist and should take advantage of opportunities to participate

or take the lead in nontraditional activities in tobacco control.

Does everyone really know about the hazards of smoking? One need

only consider the outcry by chain-smoking homeowners about radon

vapors, by puffing parents over asbestos in the classroom ceilings, or

by the news media over cyanide-tainted grapes, or the irony of tobaccocompany-sponsored boat races to raise money for cerebral palsy before

realizing that, although much is known, very little is perceived or believed.

Surveys of relative risk in our society make it clear that the general public

thinks tobacco smoking is much less dangerous than health professionals

know it to be.
Smoking and Tobacco Control Monograph No. 5

34

A letter to the newspaper editor or to the local sponsors of an event that

uses tobacco products in association with sports or fitness can often prompt

a turndown of tobacco company sponsorship. The letter can highlight the

conflict between tobacco sponsorship and the health of the community’s

children and others attending the event.

Physicians and others concerned about health can make “house calls”

to encourage good health; for example, protesting the Virginia Slims tennis

tournament or comparable events by picketing while wearing white coat and

stethoscope and holding placards (Figure 8). Other tactics include holding a

health press conference at the event or volunteering for media talk shows

(Richards et al., 1988). The credibility enjoyed by dentists and physicians

in the community goes far beyond that of tobacco promoters. By using

local media, the service club speaking circuit, volunteer agencies, and even

solicitation among patients, corporations and bureaucrats can be mobilized

and motivated to take up a call to ensure a smoke-free environment for

all citizens. The prohealth community should not overlook bus benches,

T-shirts, bumper stickers, notebook stickers for schoolchildren, and buttons

as vehicles for antismoking messages (for example, the shirt in Figure 9).

Smoking cessation and tobacco control must become an integral part

of clinical practice. The office should be an oasis of health-promoting ideas

Figure 8

Physicians picketing at the Virginia Slims tennis tournament in New Orleans

Source: Doctors Ought to Care; used with permission.
35

Chapter 1

Figure 9

T-shirt bearing an antismoking message

and messages for patients about the risks of smoking and the benefits of

cessation. Beyond the traditional messages, however, the practitioner must

accurately present the facts and statistics and change smokers’ perceptions

about the mystique of smoking. Practitioners must remember that smokers

have been victimized by an industry that makes enormous profits from ill

health, and they must create an alliance with patients against the tobacco

industry. Health professionals bear a burden of responsibility about informing, educating, motivating, and working toward behavior change in their

patients. To do less shortchanges patients and places practitioners in the

unenviable situation of merely treating the resultant illness and comforting

the families of those who have died prematurely.

Finally, we must not be afraid to go beyond the traditional activities that

health professionals are expected to do and step outside the bounds of the

individual doctor-patient relationship into the community. Participating

with the local press, appearing on radio and television talk shows, going to

civic clubs and churches, and organizing protests at tobacco-sponsored

events all have their place in community and medical activism. The importance of these activities cannot be overstated, given the enormous burden

of morbidity and mortality caused by smoking and the obvious benefits of

cessation and the prevention of smoking initiation.

Source: Doctors Ought to Care; used with permission.
Smoking and Tobacco Control Monograph No. 5

36

In many ways, the tobacco industry uses the community as a vector of

the disease of nicotine addiction. Marketing pressures and social acceptance

of smoking, exposure to environmental tobacco smoke, and the complacency

of government, corporations, and even the medical community with respect

to tobacco mandate action by the practitioner.

Individual clinicians can and do make a difference in community

smoking control and individual smoking cessation. These two efforts are

synergistic. The increased numbers of individuals who stop smoking add to

the growing social unacceptability of smoking. Conversely, as community

movements for smoking control gain momentum, individuals will become

more motivated to seek advice on smoking cessation from physicians and

dentists. To accomplish these joint tasks, we must first arm ourselves with

the necessary skills, knowledge, and attitudes, then fully integrate smoking

cessation counseling into everyday practice and work toward reducing the

threat from the number one cause of morbidity and mortality.

Every physician and dentist can, should, and must become a smoking

cessation expert. If we do not, who will?

REFERENCES

Anda, R.F., Remington, P.L., Sienko, D.G., Davis, R.M.

Are physicians advising smokers to quit? The

patient’s perspective. Journal of the American

Medical Association 257: 1916-1919, 1987.

Blum, A. The family physician and health

promotion: Do-gooding or really doing well?

Canadian Family Physician 28: 1613-1620, 1982.

Blum, A. Medicine vs. Madison Avenue: Fighting

smoke with smoke. Journal of the American

Medical Association 283: 739-740, 1980.

Blum, A. Would you buy bread lowest in

carcinogens? Advertising Age, October 29, 1979,

p. 86.

Brunton, S.A. Physicians as patient teachers. Journal

of Western Medicine 141(6): 857-859, 1984.

Centers for Disease Control. Smoking-attributable

mortality and years of potential life lost: United

States, 1988. Morbidity and Mortality Weekly Report

49(4): 62-71, 1991.

Davis, R. Uniting physicians against smoking: The

need for a coordinated national strategy. Journal of

the American Medical Association 259: 2900-2901,

1988.

Fischer, P. Inappropriate magazines for the waiting

room. New York State Journal of Medicine 85(7): 465-

466, 1985.

Goldstein, B., Fischer, P.M., Richards, J.W., Goldstein,

A., Shank, J.C. Smoking counseling practices of

recently trained family physicians. Journal of

Family Practice 24(2): 195-197, 1987.

Green, L.W., Eriksen, M.P., Schor, E.L. Preventive

practices by physicians: Behavioral determinants

and potential interventions. American Journal of

Preventive Medicine 4(Suppl.): 101-107, 1988.

Harvey, L., Shubat, S. AMA Surveys of Physician and

Public Opinion on Health Care Issues, 1987.

Chicago: American Medical Association, 1987.

Horton, J. Education programs on smoking

prevention and smoking cessation for students and

housestaff in U.S. medical schools. Cancer Detection

and Prevention 9: 417-420, 1986.

Houston, T.P. Priorities in health promotion.

Postgraduate Medicine 76(5): 223-230, 1984.

Ockene, J.K. Smoking intervention: The expanding

role of the physician. American Journal of Public

Health 77: 782-783, 1987.

Owen, N., Davies, M.J. Smokers’ preference for

assistance with cessation. Preventive Medicine 19:

424-431, 1990.

Richards, J.W. Cancer screening in the office.

American Family Physician 43: 1528, 1991.

Richards, J.W. A positive health strategy for the office

waiting room. New York State Journal of Medicine

83(13): 1358-1360, 1983.

Richards, J.W. Words as therapy: Smoking cessation.

Journal of Family Medicine 31(6): 687-692, 1992.

Richards, J.W., Blum, A., Houston, T., Fischer, P.

DOC: A primer for social/health activism. In:

Smoking and Health 1987. New York: Excerpta

Medica, 1988, pp. 373-375.

Schwartz, J.L. Review and Evaluation of Smoking

Cessation Methods: The United States and Canada,

1987-1985. U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, National Cancer Institute, Division of

Cancer Prevention and Control. NIH Publication

No. 87-2940, 1987.
37

Chapter 1

Sexton, M., Fox, N.L., Hebel, J.R. Prenatal exposure to

tobacco: I. Effects on physical growth to age three.

International Journal of Epidemiology 19: 66-71,

1990a.

Sexton, M., Fox, N.L., Hebel, J.R. Prenatal exposure to

tobacco: II. Effects on cognitive functioning at age

three. International Journal of Epidemiology 19: 72-

77, 1990b.

Solberg, L.I., Maxwell, P.L., Kottke, T.E., Gepner, G.J.,

Brekke, M.L. A systematic primary care office-based

smoking cessation program. Journal of Family

Practice 30: 647-654, 1990.

Taylor, R.B. Health promotion in clinical practice

(seminar monograph). Portland, OR: Oregon

Health Sciences University, 1985.

U.S. Department of Health and Human Services. The

Health Benefits of Smoking Cessation: A Report of the

Surgeon General. U.S. Department of Health and

Human Services, Public Health Service, Centers for

Disease Control, Center for Chronic Disease

Prevention and Health Promotion, Office on

Smoking and Health. DHHS Publication No.

(CDC) 90-8416, 1990.

Wetzler, H.P., Cruess, D.F. Self-reported physical

health practices and health care utilization:

Findings from the National Health Interview

Survey. American Journal of Public Health 75: 1329-

1330, 1985.
Smoking and Tobacco Control Monograph No. 5

38

Source: Medical news and perspectives: Magazines without tobacco advertising. Journal of the American Medical

Association 226(22): 3099-3102, 1991.

FOR ADULTS

Accent on Living

Adirondack Life

Air & Space

Alaska Magazine

American Baby

American Health

American Heritage

American History Illustrated

American Square Dance

Americas

Animal Kingdom

Antique Automobile

Arizona Highways

Arthritis Today

Artist’s Magazine

Audubon

Aviation Week & Space

Technology

Backpacker

Bicycling

Business Week

Byte

Cars & Parts

Cat Fancy

Child

Christian Herald

Common Cause Magazine

Complete Woman

Consumer Reports

Cooking Light

Country Journal

Craftworks for the Home

Crafts

Cyclist

Dance Magazine

Diabetes Forecast

Dog Fancy

Down Beat

Down East Magazine

Elks Magazine

Exceptional Children

Exceptional Parent

Farm Journal

Final Frontier

Fishing Facts

Florida Sportsman

Flying

Flying Models

Freshwater & Marine Aquarium

The Futurist

Garbage

Garden

Golf Illustrated

Good Housekeeping

Good Old Days

Guideposts

Hadassah Magazine

Harvard Business Review

Harvard Lampoon

Harvard Medical School

Health Letter

Health

Health News & Review

Hippocrates

Historic Preservation

Home Office Computing

Horn Book Magazine

Horse Illustrated

Horticulture

Income Opportunities

Instructor

International Travel News

Isaac Asimov’s Science

Fiction

Itinerary

Journal of Irreproducible

Results

Kaleidoscope

The Lion

MacUser

MacWorld

MAD Magazine

Maine Fish & Wildlife

Maine Life Magazine

Mature Outlook

Mayo Clinic Health Letter

Men’s Fitness

Men’s Health

Midwest Living

Model Railroader

Modern Maturity

Montana Magazine

Mother Earth News

Mother Jones

Ms.

Muscle & Fitness

Nation

National Gardening

National Geographic

National Parks

National Wildlife

Natural History

The New Yorker

North American Review

Nutrition Action Healthletter

Oceans

Old House Journal

Organic Gardening

Parenting

Parents Magazine

PC Magazine

PC World

Personal Computing

Petersen’s Hunting

Petersen’s Photographic

Popular Communications

Popular Photography

Popular Woodworking

Prevention

Railfan and Railroad

Reader’s Digest

Runner’s World

Sail

Salt, Inc.

Satellite Orbit

Saturday Evening Post

Science

Science News

The Sciences

Scientific American

Sea Frontiers

Shape

Sierra

Single Parent

16 Magazine

Skin Diver Magazine

Smithsonian

Society

Southern Accents

Sports Afield

Stork

Sunset Magazine

Theatre Crafts

Threads

Travel Holiday

Travel & Leisure

Twins

APPENDIX A

Magazines Without Tobacco Advertising
39

Chapter 1

Sassy

Sesame Street

Seventeen

Teen

3-2-1 Contact

YM

Workbasket

Workbench

World Monitor

Writer’s Digest

Yankee

Zoogoer

Utah Holiday

Vegetarian Times

Venture Magazine

Vermont Life

Vibrant Life

Video Review

Walking Magazine

FOR ADULTS (continued)

The Washington Monthly

Weight Watchers Magazine

West Coast Review of Books

Western Outdoors

Westways

Wildlife Conservation

Women’s Sports & Fitness

FOR CHILDREN

AND TEENS

Big Bopper

Black Beat

Bop

Boy’s Life

Cricket

Highlights for Children

Humpty Dumpty

Jack and Jill

Kid City

Ladybug

Ranger Rick’s

Right On!
Smoking and Tobacco Control Monograph No. 5

40
41

Chapter 2

Chapter 2

Recruitment and Training of

Practicing Physicians, Dentists,

And Their Office Staffs

CONTENTS Introduction

Stuart J. Cohen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Effects of Training Family Physicians in a

Comprehensive Smoking Cessation Intervention

Elizabeth A. Lindsay and Douglas M. Wilson . . . . . . . . . . . . . . . . . . . . . 48

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Phase I Project (1984-1987) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Phase II Project (1987-1989). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Doctors Helping Smokers: Development of a

Clinic-Based Smoking Intervention System

Thomas E. Kottke, Leif I. Solberg, Milo L. Brekke,

Shirley A. Conn, Patricia Maxwell, and Mark J. Brekke . . . . . . . . . . . . . . 69

Background: Doctors Helping Smokers . . . . . . . . . . . . . . . . . . . . . . 69

A Meta-Analysis of Controlled Trials . . . . . . . . . . . . . . . . . . . . . . . . 71

Nokomis Clinic Intervention Program. . . . . . . . . . . . . . . . . . . . . . . 72

Doctors Helping Smokers, Round III . . . . . . . . . . . . . . . . . . . . . . . . 75

Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Prompting Smoking Cessation in Family Practice

William C. Wadland, John R. Hughes, and Roger H. Secker-Walker . . . . 92

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Recruitment in a Primary Care Trial . . . . . . . . . . . . . . . . . . . . . . . . 92

Training on Brief Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Summary of Pilot Trial Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Future Pharmacological Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Smoking and Tobacco Control Monograph No. 5

42

Smoking Cessation in Primary Care Practice:

Summary of Results From the Quit for Life Project

Steven R. Cummings, Thomas J. Coates, Mort J. Stein,

Neil D. Swan, and the Quit for Life Research Group . . . . . . . . . . . . . . . . 102

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Surveys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Other Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Physician and Dentist Interventions

For Smoking Cessation

Stuart J. Cohen, George K. Stookey, and Sue A. Kelly . . . . . . . . . . . . . . . 113

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Physician Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Dentist Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Differences Between Dental and Medical Programs . . . . . . . . . . . . . 141

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

The Tobacco Reduction and

Cancer Control (TRACC) Program:

Team Approaches to Counseling in

Medical and Dental Settings

Jack F. Hollis, Thomas M. Vogt, Victor Stevens,

Anthony Biglan, Herbert Severson, and Edward Lichtenstein . . . . . . . . . 143

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Nurse-Assisted Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144

Intervention With Hospital Patients . . . . . . . . . . . . . . . . . . . . . . . . 151

ST Intervention for Dental Patients . . . . . . . . . . . . . . . . . . . . . . . . . 156

Smoking Cessation Among Adolescents . . . . . . . . . . . . . . . . . . . . . 162

Summary and Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Appendixes

A. Screening Form for Study on Assessing

Patient’s Health Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

B. Study on Physician Advice for

Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

C. Entry Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

D. Medical Screening Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

E. Generic Reminder Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

F. Reminder Sheet for Gum Group . . . . . . . . . . . . . . . . . . . . . . . . 176

G. Reminder Sheet for No-Gum Group . . . . . . . . . . . . . . . . . . . . . 177

H. Physician Data: Initial Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

I. Exit Questionnaire #1 (All Patients) . . . . . . . . . . . . . . . . . . . . . 179

J. Exit Questionnaire #2 (No-Gum Group). . . . . . . . . . . . . . . . . . 181

K. Exit Questionnaire #3 (Nicotine Gum Group) . . . . . . . . . . . . 182
43

Chapter 2

L. One- to Two-Week Followup for Smoking

Cessation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

M. Six-Month Followup for Smoking

Cessation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

N. Followup Questionnaire on the

Use of Nicotine Gum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Smoking and Tobacco Control Monograph No. 5

44
45

Chapter 2

Recruitment and Training of

Practicing Physicians, Dentists,

And Their Office Staffs

Editor: Stuart J. Cohen

INTRODUCTION This chapter contains a description of a series of research studies that

involved the recruitment and training of practicing physicians, dentists, and

their office staffs. The first section, by Drs. Lindsay and Wilson, describes the

educational programs used to train community-based family physicians in

Ontario, Canada, to help their patients stop smoking. Using the results of

their experience with the first group of trainees, the investigators developed a

more advanced and clinically effective 4-hour training program to assist a new

cohort of community-based family physicians in helping their patients stop

smoking. Of note in these investigations were the direct comparison of the

performance and effectiveness of trained and untrained physicians, and an

effort to assess the benefit of rescheduling patients for followup visits related

to smoking.

In the second paper, Dr. Kottke and his colleagues describe the programs

and results from a series of investigations in the Doctors Helping Smokers

project, which involved more than 150 primary care physicians in Minnesota.

The project emphasized the system for recruiting physicians and the establishment of a clinic environment system involving all office staff in the smoking

cessation program. The clinical settings involved in the Doctors Helping

Smokers project ranged from small private practices to large medical clinics.

For the latter settings, the intensity of project support averaged 6 site visits,

24 telephone calls, and 6 mailings to help initiate the clinic smoking cessation

program and sustain it for 18 months or longer.

In the chapter’s third section, Drs. Wadland, Hughes, and Secker-Walker

review the recruitment of smokers from a five-physician family practice in

rural Vermont and from a six-physician academic general internal medicine

practice. Their project attempted to assess the additional impact resulting

from a prescription for nicotine gum on patients’ efforts and success in quitting smoking and in their confidence in their physicians’ advice. Of interest

in the project was a 2- to 3-hour training program to help physicians in

delivering smoking cessation advice and instruction in the proper use of

nicotine gum.

The fourth paper, by Dr. Cummings and associates, describes the various

studies and surveys involved in the Quit for Life project. The Quit for Life

group conducted two randomized controlled trials to see if their program

to train physicians in counseling patients about smoking cessation and to

augment the training with involvement of their office staffs would result in
Smoking and Tobacco Control Monograph No. 5

46

greater smoking cessation among the patients of physicians in the training

program than among the patients of physicians who did not participate.

The cohorts of physicians consisted of 81 internists from the Kaiser Permanente

Medical Group of Northern California and 44 private-practice internists and

family practitioners. Three 1-hour training sessions were held; they included

videotapes to demonstrate smoking cessation counseling, role-playing, and

positive feedback. The correct use of nicotine gum and the benefit of followup

visits were emphasized. Of note in the discussion are the problems of recruiting

private-practice physicians to participate and of obtaining office staff support

for implementing an office-based cessation program.

The fifth paper, by Drs. Cohen and Stookey and Ms. Kelly, describes parallel

studies involving two cohorts of primary care physicians and two cohorts of

private-practice dentists from Indiana. The first cohort of physicians involved

residents in internal medicine and faculty general internists and their patients

from the outpatient medicine clinic of a city/county teaching hospital. The

second group of physicians were general internists and family physicians drawn

from five sites of a large, freestanding HMO. Both cohorts of dentists were

limited to private general dental practitioners and periodontists who primarily

treated adult patients on a regular basis. The goal of the project was to develop,

validate, and evaluate practical methods to help clinicians be more effective in

helping their patients stop smoking. Of special interest was the impact of chart

reminders and/or nicotine gum on the counseling provided by clinicians and

on their patients’ smoking cessation.

The final section describes the Tobacco Reduction and Cancer Control

(TRACC) program developed by Dr. Hollis and his colleagues in Oregon and

involving the clinical facilities of Kaiser Permanente. TRACC used a team

approach to counseling smokers in a variety of situations and settings, including nurse-assisted smoking counseling for outpatient settings, smoking interventions for hospital patients, smokeless tobacco intervention for dental

patients, and smoking cessation among adolescents. Some unique features

of the TRACC program were the use of a videotape to teach smokers steps for

quitting successfully and establishment of a centralized system to identify

smokers and their quit dates so that supportive followup calls could be made

by trained phone callers.

Collectively, the studies described here indicate that within the context

of a 4-hour workshop, physicians and other health providers can be trained

to be more effective in counseling their patients who smoke. Moreover, smoking cessation efforts in these projects appeared more likely to be successful

when office systems were in place that involved the office staffs in the programs. Components of a successful office support system appear to include

• A way to readily identify patients who smoke and to highlight that

information for the clinician;
47

Chapter 2

• A method of triage so that the patients who are most ready to make

an effort to stop smoking get more intensive counseling; and

• A followup procedure to support patients in their efforts to quit

smoking.
Smoking and Tobacco Control Monograph No. 5

48

1 This research was supported by NIH grant no. CA-38334, by a Canadian National Research and

Development Program Scholar Award to J.A. Best, and by Ontario Ministry of Health Research

grant no. 01922.

2 McMaster University, Hamilton, Ontario, and University of Waterloo, Waterloo, Ontario.

Effects of Training Family

Physicians in a Comprehensive

Smoking Cessation Intervention1

Elizabeth A. Lindsay and Douglas M. Wilson

INTRODUCTION The McMaster/Waterloo2 family practice studies were carried

out between 1984 and 1989. The phase I study measured the impact on

patient smoking cessation of a continuing education event with supporting

educational materials and an office cueing system. Through the phase I

studies, we learned that the physicians who were not provided training but

were given a reminder system in their offices appeared to offer advice as

effectively as trained physicians, because as many patients of untrained

physicians expressed their intention to stop smoking: 82.2 percent of

patients in the untrained group and 77.4 percent of patients in the trained

group stated that they intended to quit after the physicians addressed the

issue with them. It is noteworthy that the patients in this study did not

have to make a commitment to stop smoking. Motivation to stop smoking

was not part of the eligibility criteria.

Untrained physicians did not perform key elements of the intervention

taught to trained physicians, such as setting stop-smoking dates, providing

take-home material, and offering followup support; patients of untrained

physicians reported being much less successful with smoking cessation at

2 months (6.6 percent) than those of trained physicians (16.5 percent).

The 1-year cessation rates in the trained group were lower than the reported

2-month results but maintained statistical significance over the control

condition. Following this successful outcome, the goal of the phase II study

was to assess specific components of the experimental intervention tested in

phase I. Because of the time and financial implications of offering long-term

followup, we chose to compare the impact of short-term intervention (two

visits) with a longer program offered by physicians.

In all of this work, the educational programs and resource materials enabled

the physicians to intervene confidently in a systematic manner with their

smoking patients. We found that physicians perceived the intervention to be

helpful to them, that their compliance in delivering the specific elements of
49

Chapter 2

the intervention was at least 80 percent for each of the key elements, and

that patients appreciated and responded well to their physicians’ offer to help.

Among the patients in the phase II study—who all had expressed an interest

in stopping smoking—the 1-year, validated cessation rates averaged 13 to

14 percent. The long-term followup did not increase cessation significantly

over the two-visit followup. However, we have strong evidence that many of

the patients who were not intended to receive long-term followup actually did

receive it through a natural sequence of followup appointments for other

conditions.

This introduction is intended for program planners and educators who

are responsible for providing education for physicians, residents, or the staffs

who work with them. Recommendations for providing effective training in

smoking cessation are presented here. The recommendations are grounded in

the research described in this chapter and others in this monograph, but they

also reflect our experience as workshop leaders in 20 states and 4 provinces in

the United States and Canada.

Integration A review of recent physician intervention research projects leads us to

Into Practice conclude that making a measurable difference in the number of patients

who have stopped smoking at the end of 1 year requires (1) an office system

that will remind physicians to address the smoking issue and (2) the capacity

to deliver an efficacious cessation intervention. A physician must be highly

committed to the smoking issue to invest the time and energy required to

set up a practice with a reminder system and to develop skills in effective

counseling about smoking cessation. An educational planner must understand

that the level of commitment to this issue, as well as knowledge and skills, will

vary widely in a community of physicians; therefore, the objectives and format

of educational sessions should vary as well.

Because there is a wide range of commitment and interest in smoking

cessation among physicians and their office staffs, it is important that physicians know what they need to do to obtain different levels of impact. They may

decide to limit their involvement in this issue to brief advice to stop smoking

to all smoking patients, and others may decide to offer visits to patients that will

focus on smoking cessation. Other physicians may choose to offer a long-term

program that includes followup visits. For physicians to make choices about

their level of involvement, they need to know the increases in cessation they

can expect with increasing levels of intervention. We find that, among trained

physicians, the level of involvement is an individual decision and depends on

many factors. Educational planners can facilitate these decisions by what they

include in their training sessions.

Clear Objectives To help physicians be more effective, it will be important to set

realistic objectives for specific educational programs. There will be a number

of factors to consider as objectives are set; for example, time availability is a

strong determinant of what can be accomplished. We find that several hours

are needed to teach physicians how to set up their offices and how to deliver
Smoking and Tobacco Control Monograph No. 5

50

an efficacious intervention. In addition, to ensure that an office cueing system

is set up, a personal visit to physicians’ offices is often necessary. This comprehensive approach may be impractical in many continuing medical education

situations. (See Chapter 5 for examples of how this can be accomplished.)

Therefore, it is clear why it is important to teach physicians these skills while

they are still in training.

Learning needs of the audience should be put together with time availability to determine what the objectives will be for a specific educational

event. It will be important to consider the learners’ level of motivation, their

present skill level, and what is the most important material to be covered.

For example, 30 minutes with a highly motivated physician might best be

spent on helping the physician to be clear about what to do with a 10-minute

office visit with a patient. In an hour with an audience that has gathered for

a purpose unrelated to smoking cessation, the content might focus more on

motivation for why smoking cessation is a good use of physician time. This

type of audience will also need to hear a summary of an approach with practical tips that will demonstrate how to intervene effectively.

Features of The content of an educational presentation should cover the following

The Program elements: (1) motivational material, including scientific evidence, that

will increase physicians’ commitment to integrating effective smoking

cessation interventions into their practice; (2) background material that

will increase participants’ understanding of smoking behavior, addiction,

and behavior change; (3) the content and skills for delivering an effective

intervention with patients; (4) knowledge and resources for creating a smokefree office and an office system that cues and supports the intervention with

patients; and (5) a description of the variety of roles that are possible for the

physician as an influential figure in the community.

Areas of Emphasis Physicians want to know what they should do with the brief time

available to them. It is important to give specific structure to the patient visits

and clearly defined content to cover. Our research to date has demonstrated

that physicians are generally good at offering advice to stop smoking and

indicating why patients should stop. Therefore, in our workshops we often

move quickly through that aspect of an intervention and focus more on less

familiar aspects of the intervention, such as the importance of setting a stopsmoking date, providing guidance for proper use of nicotine gum, advising

patients on how to deal with withdrawal symptoms, and issues related to

followup, such as weight gain and dealing with relapse.

How to deal with followup is confusing to some physicians. Our

suggestion is to offer followup to any patient who is attempting to stop

smoking. This can take the form of further visits or phone calls, the offer

of which indicates continuing support that is perceived as important by

patients. The research findings on the effect of this offer are mixed. We

know that only some patients will attend followup visits and that those

patients are more highly motivated than those who do not attend. We also
51

Chapter 2

know that followup sometimes is provided as part of future visits that are

unrelated to smoking cessation. We believe that it is important for physicians

and their health care teams to know how to deal with followup issues and to

provide an opportunity for those patients who want this help to be able to

obtain it easily.

Educational Methods We have found a combination of demonstration and practice

with supportive print resources leads to high physician compliance with our

approach to smoking intervention. It is this combination that requires more

time than is available in a 1-hour presentation.

Physicians who have participated in this educational model rated the

event highly in evaluations and often mentioned specifically the importance

of having an opportunity to practice the intervention and use the support

materials at the training session. Because the physicians have chosen to

attend a workshop, they are probably not representative of the general

population of physicians; however, their comments provide direction for

the ideal model.

Flow of the Session For both 1-hour and longer sessions, it is important to involve

participants and ask them to speak from their own experience. We have found

it particularly helpful to ask physicians, very early in the session, what they

have found to be obstacles to providing effective smoking cessation advice to

their patients. We note these issues on a flipchart and assure participants

that we will try to address all of the issues during the session.

There is an increasing use of technology at continuing medical education

events that engages participants by asking key questions about the content

to be covered in the session. Through the use of touchpads and computerized

compilation of responses, answers are displayed on the screen within 30 seconds. This technique actively involves participants in the session and enables

presenters to know the knowledge levels and practices of the audience.

The flow of the session should reflect the motivation and knowledge level

of participants. Generally, we move from general background to the specific

detail of what to do. The flow is also congruent with the sequence of the

intervention. It is sensible to discuss how to address the smoking issue with

patients, what to do with a followup visit, and then focus on specific difficult

issues. Unfortunately, the introductory material sometimes takes longer than

is intended and there is insufficient time for the important followup issues.

This latter material is what physicians often need to know, and we suggest

organizers take steps to ensure that time is carefully monitored.

A Range of Given the wide range of motivation to learn about smoking cessation,

Learning it is appropriate to offer different levels of learning opportunities to

Opportunities meet the needs and the practical considerations in most medical

communities. (Chapter 5 demonstrates how this is being accomplished in

the Community Intervention Trial for Smoking Cessation [COMMIT].)
Smoking and Tobacco Control Monograph No. 5

52

The effort spent in marketing educational events will be an important

determinant of attendance. We have learned, through a survey of physicians

in 11 communities across the United States and Canada, that physicians

believe they are addressing cessation with most smoking patients and that

they feel adequately prepared to address the issue. If this is generally the

case, it is probable that physicians will not see the need to attend a continuing

medical education session on smoking cessation. We also know that they

overreport the frequency of their interventions and that most do not include

the ingredients we have found to be important for successful cessation. It will

be important to help physicians assess accurately what they need to know

about delivering an efficacious intervention and realize that they can make

a significant impact by applying the intervention consistently.

The scheduling and the setting for CME events will be important

determinants of who and how many will attend. In our research projects,

when full attendance of participating physicians was critical, we offered

several choices for attendance and chose the time for events after asking for

“most convenient times” from potential participants. These choices should

be determined by an analysis of your local customs and needs. It is always

important to provide a comfortable learning environment and appropriate

refreshments, and we have found that CME credits and financial incentives

also can affect attendance.

Who Should Teach The leaders at educational sessions must have a depth of

knowledge about smoking cessation so they can describe simply and clearly

what physicians need to do in their brief time with patients. We have found

that a team of a family physician and a behavioral scientist works very well,

but the professional background of the leaders may be less important than

their ability to deliver clear instructions, respond well to learner concerns,

and help physicians see that smoking cessation is an effective use of their

time.

Health Care Teams Smoking cessation interventions may be greatly enhanced by

involvement of a receptionist, an office nurse, or other team member. In

some cases, reimbursement considerations as well as interest and skills of a

team member make this a feasible model.

It will rarely be enough to simply tell physicians how they can integrate

their team in the smoking cessation initiatives. Other staff members need

to attend training or receive training in their office environment. Any office

system must be simple and nonintrusive to the regular work of the practice,

and there must be a perceived payoff for putting the system in place. It may,

therefore, be important to include a mechanism for keeping track of successful

stop-smoking attempts to demonstrate the effect of their efforts.
53

Chapter 2

PHASE I The goals of the McMaster/Waterloo Family Practice Smoking Cessation

PROJECT Project were as follows: (1) to develop a smoking cessation intervention

(1984-1987) that could be delivered by community physicians within the context of

regular office practice; (2) to design and deliver a continuing education

McMaster/ session that increased the motivation, knowledge, and skills of the study

Waterloo physicians; (3) to create the print and audiovisual materials that would

Project enable the effective delivery of the training session and the patient intervention; (4) to test the intervention package by means of a randomized controlled

trial in which the physician was the unit of randomization; (5) to carry out both

process and outcome evaluations to increase our understanding of physician

compliance with the recommended changes in practices, the smoking cessation

process, and the impact on patient behavior; and (6) to assess the role of the

offer of further followup after two visits (phase II project).

Physician and Eighty-three community family physicians and 1,942 smoking patients

Patient participated in this trial. We had invited 460 family physicians pracRecruitment ticing within a 40-mile radius of McMaster University to participate.

Their names were obtained from an Ontario Medical Association listing that

includes the majority of family physicians in the area. One hundred two physicians responded positively, but 12 withdrew or, because of distance, were set

aside for future studies, prior to randomization. The remaining 90 physicians,

who represented 75 practices, were randomly allocated, by practice, to the three

treatment groups; 7 physicians withdrew from the study after randomization.

Comparison of characteristics of the physician dropouts and the study physicians (70 practices) revealed no significant differences that we feel would bias

the composition of the experimental groups.

Patients entered the study when they visited their physician for a routine

office appointment. We tried to recruit the most representative sample of

smoking patients by asking all smokers to participate. Receptionists in all

three groups recruited the study participants according to a standard protocol

that started at the beginning of each family practice session by asking all

patients if they were smokers. Receptionists asked each eligible smoker (not

pregnant or breastfeeding, over age 16, and smoking at least one cigarette

each day) to participate until a maximum of two smokers each day agreed

to complete the questionnaire. The consent letter provided with the questionnaire asked patients to agree to be followed and emphasized that they were not

agreeing to try to stop smoking.

The experimental variation in condition began when the patient went in

to see the physician. In condition 1 (usual care), the physicians were not to

know which of their patients had agreed to participate in the study. If it was

part of their usual practice to address the smoking issue with patients, they did

so. We gave no instructions to patients about whether they should mention

their agreement to participate to their physician, and we had no way of

assessing whether they did.
Smoking and Tobacco Control Monograph No. 5

54

In condition 2 (cued only), the physicians were cued by a project document

indicating the patient’s agreement to participate. These physicians were

instructed to advise the patient to quit smoking and offer nicotine gum as an

aid to quitting. There were no further instructions given to these physicians.

In condition 3 (trained and cued), physicians had attended a training

session to develop the knowledge and skills for delivering the intervention.

A project flowsheet cued these physicians as to which patients were in the

study and also helped them to remember the ingredients of the intervention.

In addition, self-help materials were provided for distribution to patients.

Materials and The continuing medical education protocol was set up to enhance

Training learning through attention to a comfortable setting and provision

Techniques of time for the group to visit informally before the session began.

Introduction material provided a context in which the intervention

Training Program for smoking cessation could be seen as a worthwhile and appropriate

activity for physicians. The protocol included (1) premailed background material that included several recent reprints from medical journals,

(2) a 3- to 4-hour training session, and (3) materials that guided and reminded

physicians of the maneuver taught in the training session.

Training Session The purposes of the session were to increase (1) knowledge and understanding of the contents of the intervention, with particular emphasis

on the rationale for and proper prescribing of nicotine gum; (2) skills for challenging smokers about quitting, negotiating a decision about quitting, and

setting a quit date, as well as offering supportive followup visits; and (3) a

positive attitude toward the importance of the physician’s role in smoking

cessation and toward implementing the intervention. The session began with

an overview of the research project, including a brief discussion of the smoking

cessation process, the literature on physician-delivered interventions, and a

description of proper use of nicotine gum.

The experimental intervention included three types of visits. To teach

the content and skills for these visits, the training session followed a looplike format, in keeping with learning principles that support the need for

information, demonstration, and practice. First, we described the protocol

through slides and verbal instructions; then a physician-patient interaction

was demonstrated on videotape, and participants experienced guided practice

with surrogate patients. Through this sequence of description, demonstration,

and practice, participants learned the procedures for a challenge visit, a quit-date

visit, and supportive followup visits.

Intervention Taught The full intervention, including six potential contacts, would be

carried out over a 2-month period.

The first visit. When a patient agreed to participate, the receptionist

attached project materials to the patient chart. The materials reminded the

physician that the patient was a smoker and guided the discussion about

smoking cessation. After the regularly scheduled office visit, the physician
55

Chapter 2

spent an additional 5 to 7 minutes with the patient, discussing the importance

of stopping smoking and the advantages of quitting in terms of the individual’s

personal health and current symptoms related to smoking. The following were

key parts of this discussion: (1) gathering a smoking history, such as the

number of years of smoking and the quantity smoked each day, and (2) getting

a sense of the patient’s willingness to try quitting. It was also important to

challenge the patient to make a clear decision about quitting and to set a date

to stop smoking within the next month, when the patient would come back

to see the physician.

During the initial visit, the physician informed the person about nicotinebearing chewing gum as an aid to quitting and provided the patient with selfhelp materials. Before leaving the office, the patient set up an appointment

for a quit-date visit and, if feasible, appointments for the four followup visits.

The patient also received a document that resembled a contract, indicating

his or her decision to try to stop smoking and dates of future appointments.

Physicians did not receive reimbursement for this first visit, but the Ontario

Health Insurance Plan reimbursed them for subsequent visits.

Quit-date visit. At the 10-minute quit-date visit, the physician reinforced

and supported the patient’s reasons for wanting to stop smoking, and the

patient was to stop at that visit. For those patients who chose to use the gum,

the physician explained its proper use while the patient tried a piece. Patients

paid for the nicotine gum. In the training for this visit, we emphasized the

importance of encouragement and building the patient’s confidence. See

Figure 1 for the patient chart that guided the content for this visit.

Supportive followup visits. The content of these four brief followup visits over

the next 2 months varied, depending on the stage of the cessation process and

the personal issues brought by the patient to each visit. Physicians assessed this

stage by simply asking how the patient was doing with the smoking cessation

program. A flowsheet for each patient provided guidelines for monitoring and

supporting techniques. We encouraged physicians to listen carefully to the

issues raised by the patient and to offer advice that was personal and supportive.

Print and audiovisual materials. For the purposes of training, we developed

a slide presentation and demonstration videotapes. For the office maneuver,

we developed a flowsheet for patient visits, a patient contract, and patient

self-help “Tip Sheets.” The patient materials were adapted from one-page

summaries that were developed by the Stanford Cardiovascular Risk Reduction

project for use with refrigerator magnets.

Results The primary definition of successful cessation was self-reported sustained

abstinence for 3 months prior to biochemically validated cessation after

Definition of 1 year. However, we also included self-reported attempts to stop smoking

Outcomes and self-reported 2-month cessation.
Smoking and Tobacco Control Monograph No. 5

56

Figure 1

Patient chart, quit-date visit and followup

Quit Day Post Quit Day Post Quit Day 1 Month 2 Month

DATE:

General well-being

Average daily use of cigarettes

over the past week

Commitment to quitting

(low, medium, high)

Confidence to succeed

(low, medium, high)

Concerns about quitting

Any strategies for getting 

ready?

Average daily use of Nicorette

over the past week

Any side effects of Nicorette —

Do you like the gum?

Any withdrawal symptoms after

stopping cigarettes?

How often do you feel like 

smoking?

How strong is this craving?

(low, medium, high)

Does the gum help you cope

with this craving?

Have you noticed any weight 

gain?

Is this a problem?

Need information?

Do you spend a lot of time

around other smokers?

Are you feeling support from 

others at home or at work?

Cigarette symptoms, e.g., cough

Patient Name:

Major 

reasons for

quitting

Health

Other

PATIENT FLOW SHEET
57

Chapter 2

Patient Response Patients’ intentions to stop smoking with or without gum were

recorded at the time of the initial visit. Of those who stated an

intention to try to quit (approximately 80 percent), a significantly higher

proportion of patients in the trained and cued group (71 percent) than in the

cued-only group (61 percent) chose to stop smoking and to use nicotine gum.

Gum use for greater than 2 weeks was less than 25 percent for both groups

(Wilson et al., 1988). (See Tables 1 and 2.) Approximately 65 percent of

patients in the trained and cued group returned for at least one followup

visit. The 1-year cessation rate increased with the number of followup visits

attended (Wilson et al., 1988).

On the 2-month questionnaire, 38.1 percent of the usual-care patients,

62.8 percent of the cued-only group, and 76.7 percent of the trained and

cued group reported attempting to stop smoking for at least 24 hours.

Successful cessation was reported by 3.8 percent in usual care, 6.6 percent

of the cued-only group, and 16.5 percent of the trained and cued group

(Table 3). Our primary definition of successful cessation was self-reported

sustained abstinence for 3 months prior to biochemically validated cessation

after 1 year. Validated 3-month sustained cessation rates at 1-year followup,

adjusted for covariates, were 4.4 percent for usual care, 6.1 percent for the

cued-only group, and 8.8 percent in the trained and cued group (Table 3).

The criterion for validation of smoking cessation was a saliva cotinine

value of 0.057 μmol/L or lower, or a saliva thiocyanate level of 1,724 μmol/L

or lower if the patient was still chewing nicotine gum. Approximately 92 percent of patients who reported they were not smoking were validated. Those

not reached were classified as smokers. Of the patients who reported themselves as ex-smokers for at least 1 week and submitted to cotinine validation,

25 percent did not qualify as nonsmokers according to the validation criteria.

Another 8 percent of those who reported themselves as nonsmokers would not

submit to validation and thus were classified as smokers (Lindsay et al., 1989).

Physician Practices Counseling performance was measured by means of exit telephone

interviews with a random 15 percent of patients and rated audiotapes

of physician counseling with simulated patients. Physicians in the trained

group were more likely than untrained physicians to use procedures they were

trained to include, such as offering advice, inviting patients back for followup,

setting stop-smoking dates, and providing take-home materials (Lindsay et al.,

1989; Wilson et al., 1988).

Physicians who were cued to offer nicotine gum (both cued-only and

trained and cued) offered nicotine gum at nearly the same frequency, whereas

the usual-care physicians offered gum much less frequently (Wilson et al.,

1988). Cueing and training each had highly significant effects on counseling

performance, as demonstrated by the significant variations in performance

between experimental conditions. Performance, as measured by exit interview

scores, was associated with all short-term outcomes; however, in our first

analysis of performance, the rated simulation performance scores were not.
Smoking and Tobacco Control Monograph No. 5

58

Table 1

Patient’s recall of office visit with physiciana

Percentage of Yes Responses

Usual Cued Trained

Care Only and Cued Chi-

(n=90) (n=94) (n=96) Squareb p

Did Doctor Say

Anything About

Patient’s Smoking? 31.1% 70.2% 85.4% 61.96 < 0.001

Suggested Quitting 24.4 64.0 84.4 59.72 < 0.001

Offered Help 12.2 61.7 84.5 106.93 < 0.001

Suggested

Gum Method 8.9 58.5 62.5 38.15 < 0.001

Set Quit Date 2.2 11.7 54.2 80.84 < 0.001

Doctor Wants To

See Again 4.4 22.3 83.3 137.22 < 0.001

Gave Reading

Materials 2.0 17.0 80.2 144.07 < 0.001

a Gathered through open-ended questions asked within 3 days.

b Chi-square based on differences among the three groups.

Table 2

Stated intention to try to stop smoking in untrained (gum-only) and trained (gum-plus)

groups and patient attendance at followup visits (gum-plus)

Attended Attended

Try To at Least Four or

Do Not Stop Try To One Five Unsure

Want To Without Stop With Followup Followup or No

Total Quit Gum Gum Visit a,b Visitsb Data

 n n (%) n (%) n (%) n (%) n (%) n (%)

Gum Only 726 108 (14.9) 171 (23.6) 425 (58.7) ND ND 21 (2.9)

Gum Plus 606 74 (12.1) 86 (14.2) 383 (63.2) 390 (64.3) 129 (21.3) 63 (10.4)

a Includes those attending a quit-date visit.

b ND, no data available.
59

Chapter 2

No performance indicator that we measured through exit interviews or

simulated visits predicted long-term outcomes (J.A. Best and colleagues,

unpublished data).

We were not satisfied with our first analysis of the audiotaped simulated

visits, so a cooperating investigator conducted an innovative analytic procedure adapted from judging of technical and artistic merit in figure skating

(Burgess, 1989). This analysis of 35 audiotapes of untrained and trained

physicians to assess content and style of the delivery of a smoking intervention once again demonstrated a highly significant effect of physician training

on the content of the intervention and on 2-month cessation rates. The

analysis also revealed one measure of style, degree of empathy, and predicted

enhanced 2-month cessation (Burgess, 1989).

Conclusions The research demonstrated that physicians will attend a half-day continuing education workshop to enhance their skills in smoking intervention. We

found that the physicians integrated the maneuver into their practices but

often needed the research staff to ensure that the project smoking cessation

materials were used appropriately. When the materials were used with patient

charts, physicians performed the intervention according to their training.

Untrained physicians who were cued by project materials to address cessation

with smoking patients performed several aspects of the intervention with the

same frequency as trained physicians. Patients agreed to try to stop smoking

as frequently in both groups, and similar numbers chose to use nicotine gum

to try to stop smoking. Significantly fewer patients of physicians in the

untrained groups reported trying to quit smoking for 24 hours. The trained

group helped patients set a stop-smoking date, provided take-home materials,

Table 3

Smoking cessation attempts and proportion of ex-smokers in each of the

treatment groups, as indicated in patient charts and 2-month questionnaire

Adjusted

Not Sustained

Physician Smoking 3-Month

Discussed at 2 Cessation

Smoking Patient Tried To Months Rates at

Total With Intends Quit for (Self- 1 Year

n Patientsa To Quita 24 Hoursb Report)b (Validated)b,c

Usual Care 601 ND ND 36.4% 3.8% 4.4%

Gum Only 726 98.0% 82.2% 60.7 6.6 6.1

Gum Plus 606 90.8 77.4 71.9 16.5 8.8

a ND, no data available.

b p < 0.05.

c Analysis of covariance adjusted for differences at baseline.
Smoking and Tobacco Control Monograph No. 5

60

and offered followup support much more frequently than the untrained

physicians. The trained, gum-plus group had much higher 2-month cessation

rates than the other two groups, but the difference, although retaining statistical significance, was much smaller at the end of 1 year.

The influence of a physician intervention decreases with time. This is an

expected finding, as the patient’s daily social environment and other factors

are likely to increase in relative influence as time passes after the physician

intervention. We need to develop complementary interventions that will

improve maintenance of the early effects of physician interventions.

Side Studies We conducted a series of interviews over 1 year with patients whose

physicians invited them to try to stop smoking (Willms et al., 1990

Patients of and 1991). The physicians in this study were trained in the same

Trained way as those in the main trial, but they were selected from a different

Physicians community, distant from the main trial center. The interviews were

designed to assess, from the patients’ point of view, which were the most

important components of the intervention. The interviews were transcribed

and interpreted through application of a systematic approach for qualitative

research methods (including ethnographic methods).

This research indicated that the most significant component of the

physicians’ intervention was the kind of support given. We describe the

results of this study with the terms “interventionistic” and “personalistic.”

Although both aspects were important, patients emphasized the importance

of the personalistic components. These activities include aspects of the

physicians’ work that are nurturing, egalitarian, and mutually communicative.

It appears from this work that it is important for physicians to speak with

biomedical authority, because our evidence suggests that patients expect a

certain amount of that content and because there is need for emphasis on

creating more organization- and clinic-based supports (Willms et al., 1991).

Nicotine Gum Another side study of the main trial assessed the intervention package

As an Adjunct tested in the main trial with and without the offer of nicotine gum

(Gilbert et al., 1989). A separate sample of 12 community physicians

selected previously for the main trial and set aside because of distance from

the main center attended a 4-hour training session during which the maneuver

was demonstrated and practiced. We taught physicians how to deliver the

intervention both with and without the offer of nicotine gum. Receptionists

were instructed to recruit the first two smokers visiting the practice each day.

Patients (n=223) were randomized to receive the same intervention, but either

including the offer of nicotine gum or without the offer of nicotine gum.

One-year smoking cessation was validated by cotinine saliva analysis.

The validated 3-month sustained abstinence rates at 1 year were 8.1 and

9.8 percent in the gum and no-gum groups, respectively. The 95-percent

confidence interval for this difference was -9.3 to 6.4 percent.
61

Chapter 2

PHASE II PROJECT

(1987-1989)

Developing a More

Effective Intervention

Structuring

The Visits

There was no evidence from this study that smoking cessation rates

were enhanced by the offer of 2-mg nicotine-bearing gum, when added to a

comprehensive intervention offered to all smokers in primary care. Insufficient

power may be partially responsible for our findings; however, the trend in the

findings does not support the additional usefulness of nicotine-bearing gum.

It is also of interest that the other side study (described above)—which also

tracked cessation rates for those offered and not offered gum—showed that

cessation rates were higher but not statistically significant in the no-gum group.

Physicians in the phase I study found that the time they needed

for talking to patients, when added to a regular visit, was quite

disruptive to their practices. Therefore, we shortened the first

visit to include only the following:

• An offer to patients to be part of the McMaster Family Smoking Cessation

Program;

• Questions to patients about their interest in stopping smoking and the

completion of a questionnaire;

• A clear statement of concern and support from the physician; and

• A request to come back and talk further about stopping.

Physicians offered patients an opportunity to come back for a separate visit to

discuss their approach to cessation. At this second visit, a random selection of

half of the patients were invited to come back for further followup.

Consideration of what is known about the cessation process can guide

the selection of times that appear to be most appropriate to provide further

physician support visits. These considerations led to the following recommendations for timing of the four followup visits:

• Close to the quit date (encouragement to get off to a good start, ensure

proper use of gum, if appropriate);

• Seven to ten days after stopping (provide help with withdrawal symptoms);

• One month after stopping (patient may be able to give other lifestyle issues

attention); and

• Two to three months after stopping (most relapses occur in first 3 months;

the patient is learning to be a nonsmoker and is adapting to the

nonsmoking culture).

The need for these visits and their timing are individually determined.

Therefore, as with many aspects of the Family Practice Smoking Cessation

Program, physicians offered opportunities for followup but let individual

patient needs determine timing and content.
Smoking and Tobacco Control Monograph No. 5

62

First return visit. If patients returned to discuss their smoking, physicians

took a history of their smoking behavior, including information about previous attempts to stop smoking and what was helpful or not helpful in those

attempts. Other key questions as well as a take-home questionnaire helped

patients think about the reasons they smoked and why they wanted to stop.

The ethnographic work in the first study suggested that patients appreciated

a personal approach from their physicians that communicated a clear interest

in individual concerns and advice that was relevant to their experience

(Willms et al., 1991).

Assistance offered by the physician. The revised intervention recommended

that physicians suggest several strategies for getting ready to stop smoking,

including setting a stop-smoking date. The self-help materials available for

each patient provided many tips on how to prepare, such as anticipating

the discomfort of withdrawal symptoms. During the first week or two after

cessation, an inability to handle withdrawal symptoms often undermines

a smoker’s good intentions. Guidelines recommended that physicians ask

patients about previous experience with withdrawal and plan for how to

deal with potential problems. This was in keeping with another finding

from the ethnographic work, which indicated that patients expected and

appreciated physicians focusing on the physiological aspects of the cessation

process, especially regarding feeling better and becoming “healthier.” The

offer of nicotine gum with instructions for proper use was a part of this intervention, but because of the limitations of the evidence of its effectiveness in

the previous study, physicians were advised to offer gum to smokers who

seemed to be physically addicted to nicotine or who had previously made

several unsuccessful attempts to stop smoking.

Office system for cueing and monitoring the intervention. A systematic

approach to cueing and monitoring smokers was built into the Family Practice

Smoking Cessation Program. The physician’s office staff flagged all smokers’

charts and appended flowsheets to guide the intervention in patient charts

for the physician’s attention.

Development of Our previous study demonstrated that the training workshop provided

Training Session to physicians led to changes in practice and ultimately led to higher

And Resources smoking cessation rates among patients (Wilson et al., 1988). Review

of continuing education intervention research indicates that physicians

rarely change clinical practices through simple acquisition of knowledge

(Fowler et al., 1989).

Through the first Family Practice Smoking Cessation Program, we learned

that physicians without special training appeared to perform some of the

elements of the intervention equally as well as the trained physicians (Lindsay

et al., 1989). We found that physicians in both groups were almost equally

successful at motivating patients to try to stop smoking and that they were

equally persuasive about the use of nicotine gum. There were large differences
63

Chapter 2

in performance in the areas of setting stop-smoking dates, offering followup,

and providing self-help materials to patients; and we also detected small

differences in physician style in talking to patients (Burgess, 1989).

Less than half of the patients in the phase I study took advantage of the

physicians’ offer of followup visits. Little training time was spent on the

followup visits, and physicians reported feeling least prepared for the followup

element of the intervention. Because the focus of the present study was on the

effect of followup and because of these weaknesses in the first study, a higher

proportion (approximately 50 percent) of the content of the training was

dedicated to content and process of the followup visits.

The training session followed the loop format used successfully in our

prior work, which provided information, demonstration, and practice with

feedback. By repeating this sequence for at least two types of visits, workshop

participants had an opportunity to develop their skills in applying the

intervention.

Teaching about style as well as content. Patients told us that physician style

was important in their approach to smoking cessation. However, we were

unable to quantify the characteristics of more successful approaches in the

first study. The work of Ockene and colleagues (1990), in which a patientcentered intervention is taught to residents, emphasized the importance

of asking questions and providing feedback to patients about their feelings.

There is evidence in other areas of patient care that believing one is understood and receiving feedback about how the physician perceives the patient’s

feelings are related to both satisfaction and compliance by patients. The

training included discussion of these style issues as well as a video demonstration of recommended interpersonal skills. These issues were reinforced

through study materials provided for use during the patient visits.

Focus on key followup issues. The guidelines for the four followup visits

were based on the cessation process and consideration of the amount of time

physicians were likely to spend in these visits. Three key content issues and

five style issues were the focus for followup visit training. Patients’ interests

and needs guided the content. The guidelines provided suggestions for how

physicians could support patients in planning for and adapting to their new

lifestyle as nonsmokers. The training session provided information on weight

control, preventing and coping with relapse, and one method of relaxation to

cope with stressful situations.

Study Design This study tested the impact on smoking cessation of the offer and

And Participants provision of several followup visits compared with attendance at one

followup visit among patients who wanted to stop smoking.

Forty-one community family physicians agreed to participate in the study.

They were recruited from the Hamilton, Ontario, area and were eligible if they

agreed to attend the training session and provide administrative assistance
Smoking and Tobacco Control Monograph No. 5

64

through their office staff. Undoubtedly, these physicians were more interested

than the average physician in providing smoking cessation assistance to their

patients.

All of the physicians participated in a 4-hour training session designed to

develop their ability to deliver two cessation interventions: one that included

followup continuing for several months and one that did not. Six hundred

forty-seven smoking patients participated and were randomly allocated to

one of the two conditions.

Implementation Patients entered the study when they visited their physician for a

regular office visit. The intention in this study was to attract people who were

interested in stopping smoking. To qualify, patients had to smoke at least

one cigarette every day (or most days), be 16 years of age or older, and not be

pregnant or breastfeeding. Receptionists provided a copy of the consent form

and the questionnaire to patients. Signs were posted in the offices to inform

patients about the availability of the program.

Physicians spoke to consenting patients about their interest in stopping

smoking. If patients expressed an interest in stopping, physicians invited

them to return for a more in-depth discussion and development of a plan.

When patients returned, receptionists provided physicians with the next in a

sequence of numbered envelopes along with the patient chart. The materials

for the two interventions were printed in different colors and were prepacked

in envelopes that were placed in a random sequence determined by a computerized program and were numbered accordingly.

At the return visit, all patients were to receive the same intervention up to

the point of the offer of further followup visits. In one group, the physicians

completed their intervention at this visit. In the other group, the physicians

offered to see patients four times over a 2- to 3-month period.

Process Measures Pretest questionnaires were completed to provide physician and

And Baseline patient characteristics. Interviews with patients, within 2 weeks

Characteristics of the quit-date visit and at 6 months after, provided information

about patient perceptions about the visits with their physician and about

their experience with attempting to stop smoking. The primary outcome

in this study was sustained 1-year validated cessation rates, although we also

provided 6-month self-reported data.

Results All physicians participating in the study attended the training

session. Through exit interviews, patients reported what physicians

Patient Reports of included in the smoking cessation visit and their perceptions of its

Physician Behavior usefulness. At least 75 percent of the patients rated their physicians

as very helpful, encouraging, and understanding. Patients who

received the offer of followup rated their physicians as more helpful and

encouraging than the ratings by patients who did not receive this offer

(Gilbert et al., 1992). More than 90 percent of the time, physicians included

advice about health risks, helped patients set a quit date, gave patients a stop-
65

Chapter 2

smoking contract, offered the use of nicotine gum, and provided self-help

materials and reasons for the patient to stop smoking (Gilbert et al., 1992).

More than 80 percent of patients said their physicians discussed weight

control, withdrawal symptoms, the role of planning and exercise, the importance of social support, and the role of spouses, as well as giving some attention

to stress management. These first return visits averaged 16.5 minutes.

Patients’ Perceptions At the 6-month interview, we asked patients what aspects of the

stop-smoking program had been the most helpful. At 6 months,

physician advice and support were rated as the most helpful elements by

patients in both groups; setting a quit date, having printed materials, and using

nicotine gum were also rated highly. The usefulness of the contract and

followup were rated lower.

Smoking Cessation Although there were significant differences in self-reported cessation

between the two experimental groups at 2 months and at 1 year, when

the rates were validated at 1 year the differences lost statistical significance. We

found considerable crossover had occurred between the two groups; that is, the

group that was not to receive long-term followup often actually did receive it

when they returned to their physician for other problems, and the long-term

followup group often did not return for their followup visits. This blurring of

the difference between the two groups makes interpretation of results difficult.

Elements of Successful We also looked at the relationship between what elements of

Cessation the intervention patients considered helpful or not helpful and

whether they succeeded in stopping smoking. At the 6-month

interview, patients rated the degree of helpfulness of various parts of the

intervention. Physician advice and support were rated as the most helpful

ingredients and followup visits as the least helpful. However, when we look at

cessation rates at 6 months, we find that the patients who found the quit date,

contract, and followup most helpful were also those with the highest cessation

rates. This raises the question: Do patients who are highly motivated to stop

smoking take advantage of all aspects of the program and therefore rate the

components higher, or do the program components actually lead to higher

cessation rates?

Approximately one-quarter of the patients at the 6-month interview rated

nicotine gum as helpful. When asked at 1 year to describe their use of nicotine

gum, slightly more than one-quarter of the patients (28 percent) reported using

the gum for longer than 2 weeks. The cessation rate at 6 months for patients

who rated the gum important was 27.3 percent.

Discussion The purpose of this study was to determine the importance of long-term

followup in relation to successful smoking cessation, to gather process data

regarding the feasibility of incorporating this maneuver into regular office

routines, and to determine the perceived relative importance of other

ingredients of the intervention.
Smoking and Tobacco Control Monograph No. 5

66

Cessation Rates The cessation rates in this study compare favorably with those in other

studies. The 13- to 14-percent 1-year validated rate is similar to the rates

for more motivated patients in our previous study and is in the same range as

the results of other studies that have tested maneuvers of similar intensity. It

is important for physicians to know that if they offer a smoking-specific visit

to smoking patients, approximately 60 percent of those patients who have

expressed an interest in stopping smoking will return, and the one visit will

produce cessation rates in this range. It also appears that those patients who

return for further visits are more successful in stopping smoking than those

who do not return. Although we have not demonstrated the effectiveness of

followup, the higher cessation rates will mean both physicians and patients

may perceive this time as useful.

Structure of We found that physicians who attended the 4-hour training session set up

The Visits their offices to accommodate the intervention, used the resource materials,

and complied with the intervention. The brief introduction visit did not

disrupt practice and the return visit focused on smoking, allowing physicians

to take a smoking history, set quit dates, give instructions for gum use, and

address other questions raised by patients. Although these visits were demonstrated in the training to be 8 to 10 minutes long, physicians estimated that

they averaged 16.5 minutes. The visits were paid for by the provincial health

insurance.

It appears that physicians offered patients long-term followup as indicated

in the randomization process, but only 69 percent of those randomly offered

followup attended more than one further visit. We discovered through chart

audits that long-term followup happens naturally as patients return for future

visits for other reasons (Gilbert et al., 1992). This natural followup within

the no-followup group may explain why we found no differences in 1-year

cessation rates. We should point out that the average duration of a scheduled

followup visit was slightly more than 12 minutes. It is very unlikely that

discussion about smoking on unscheduled followup was this long. However,

we conclude that setting up smoking-specific followup visits after one smokingfocused visit may not be necessary for most people, as long as physicians are

keeping good records and remember to check on progress at these other visits.

Personalized Advice Project records and patient interviews indicate that physicians

And Support followed the recommended protocol and were perceived to be

encouraging, understanding, and helpful. Patients reported that

physician advice and support were the most important aspects of the intervention. This evidence validates the survey data that have indicated that

patients do appreciate and value their physicians’ interest in their smoking.

Our data also indicate a high level of patient satisfaction with this particular

maneuver; that is, patients gave high ratings of importance to their physicians’

support in their cessation attempts.
67

Chapter 2

Lindsay, E.A., Wilson, D.A., Best, J.A., Willms, D.G.,

Singer, J., Gilbert, J.R., Taylor, D.W., Hannah, W.J.,

Vayda, E. A randomized trial of physician training

for smoking cessation. American Journal of Health

Promotion 3: 11-18, 1989.

Ockene, J.K., Ockene, I.S., Kabat-Zinn, J., Green, H.L.,

Frid, D. Teaching risk-factor counseling skills to

medical students, house staff, and fellows. American

Journal of Preventive Medicine 6(Suppl.): 35-42, 1990.

Willms, D.G., Best, J.A., Taylor, D.W., Gilbert, J.R.,

Wilson, D.M., Lindsay, E.A., Singer, J. A systematic

approach for using qualitative methods in primary

prevention research: A focus on smoking. Medical

Anthropology Quarterly 4(4): 391-409, 1990.

Willms, D.G., Best, J.A., Wilson, D.M., Gilbert, J.R.,

Taylor, D.W., Lindsay, E.A., Singer, J., Johnson, N.A.

Patients’ perspectives of physician-delivered

smoking cessation interventions. American Journal

of Preventive Medicine 7(2): 95-100, 1991.

Burgess, S.C. Understanding physician-delivered

smoking cessation counseling: An analysis of

counseling style and content to predict outcome

(Master of Science thesis). University of Waterloo,

Ontario, Canada, 1989.

Fowler, G., Mant, D., Fuller, A., Jones, L. The “Help

Your Patient Stop” initiative: Evaluation of

smoking prevalence and dissemination of WHO/

UICC guidelines in U.K. general practice. Lancet

1(8649): 1253-1255, 1989.

Gilbert, J.R., Wilson, D.M., Best, J.A., Taylor, D.W.,

Lindsay, E.A., Singer, J., Willms, D.G. Smoking

cessation in primary care: A randomized controlled

trial of nicotine-bearing chewing gum. Journal of

Family Practice 28(1): 49-55, 1989.

Gilbert, J.R., Wilson, D., Singer, J., Lindsay, E.A.,

Willms, D.G., Best, J.A., Taylor, D.W. A family

physician smoking cessation program: An

evaluation of the role of followup visits. American

Journal of Preventive Medicine 8(2): 91-95, 1992.

Quit Date, Our data demonstrate that most patients did set a stop-smoking date,

Contracts, Gum but the effectiveness of the strategy was not tested in this study. In

retrospect, only 140 indicated that the quit date was helpful, but 33

percent of those who found it helpful were successful at 6 months. As to the

use of the contract and the nicotine gum, it appears that some individuals find

each of these techniques helpful. This trial did not attempt to study those

who selected these elements of the intervention.

Followup Visits This study focused on the impact of physicians offering longer term

followup, and we did search for differences between those who attended

followup and those who did not. There is an overlap of the characteristics

of those most likely to stop smoking and those who attended followup that

confounds our ability to understand whether there are, in fact, differences.

The primary overlapping characteristic is that those who are lighter smokers

attended followup and also were more likely to be successful. This finding

may be a little surprising, because one might expect the more addicted smoker

to seek more medical assistance. Older, more educated patients with fewer

friends who smoke tended to take advantage of followup visits. We might

speculate that the more isolated smoker might seek ongoing support from his

or her family physician.

Conclusion Physicians who attended training and used the program resources

integrated the intervention into their practice fully when patients expressed

an interest in participating. We do not know whether study physicians

applied the intervention to patients not in the study or continued to use

the resources after the study ended. Provision of a visit dedicated to smoking

cessation produced substantial cessation rates, and the offer of subsequent

smoking-specific followup visits did not increase those rates significantly.

REFERENCES
Smoking and Tobacco Control Monograph No. 5

68

Wilson, D.M., Taylor, D.W., Gilbert, J.R., Best, J.A.,

Lindsay, E.A., Willms, D.G., Singer, J. A randomized

trial of a family physician intervention for smoking

cessation. Journal of the American Medical Association

260(11): 1570-1574, 1988.
69

Chapter 2

3 Supported in part by National Institutes of Health grant no. CA-38361 and by Blue Plus Health

Plan.

Doctors Helping Smokers:

Development of a Clinic-Based

Smoking Intervention System3

Thomas E. Kottke, Leif I. Solberg, Milo L. Brekke,

Shirley A. Conn, Patricia Maxwell, and Mark J. Brekke

BACKGROUND: As with the other NCI-sponsored physician and dentist interDOCTORS HELPING vention trials, the goal of Doctors Helping Smokers was to

SMOKERS determine how physicians might promote smoking cessation

effectively among their patients. A decade before the Doctors Helping Smokers

proposal was written, Russell and coworkers (1979) had already documented

that a physician could make a small but significant impact on smoking cessation rates simply by advising patients to quit smoking and giving them a

smoking cessation brochure. Additionally, the Multiple Risk Factor Intervention Trial had demonstrated impressive efficacy with its smoking intervention

(Multiple Risk Factor Intervention Trial Research Group, 1982), and the

Minnesota Heart Health Program had developed state-of-the-art self-help

materials that could also be used in a one-to-one counseling session.

Because the first author had received a National Heart, Lung, and Blood

Institute Preventive Cardiology Academic Award in 1981, we had already

begun to work with primary care physicians at the time that we were preparing

the Doctors Helping Smokers grant application. By analyzing the organizational context of angioplasty, the treatment of hypertension, advice to quit

smoking, and advice to eat a low-fat diet, we identified nine factors that we

believed must be considered in the implementation of any program (Kottke

et al., 1987) (Table 4). This experience led us to formulate the problem of

developing physician-based smoking interventions as a systems problem

rather than a problem of selecting a single best solution from among a field

of candidates (Kottke et al., 1990a).

We also recognized that any intervention must satisfy two conditions if

it is to be effective—it must be efficacious (change patient outcomes when it

is applied) and it must be acceptable to both the professional delivering the

intervention and the patient who is the target of the intervention. We elected

to focus Doctors Helping Smokers on the task of developing a solution to the

problem that physicians tended not to use smoking interventions that were

already available and of documented efficacy.
Smoking and Tobacco Control Monograph No. 5

70

The proposal’s original hypothesis was that physicians who attended

a 6-hour training workshop and were supplied with the self-help booklet

developed by the Minnesota Heart Health Program would so appreciate the

negative health effects of smoking and be so convinced of the efficacy of

their intervention that they would increase markedly the rates at which they

gave advice to quit smoking. It was also hypothesized that this increase in

physician activity would, in turn, lead to increases in patient smoking

cessation rates.

As a test of recruitment strategies, physicians were recruited through

one of three variations in a direct mail program. This recruitment program

demonstrated that none of these direct mail interventions could recruit

physicians at a rate that would have much impact on the patient or physician

population. Regardless of the content of the particular mailing to a physician,

only 10 percent of physicians responded, and 7 percent or fewer were willing

and able to participate in the trial (Kottke et al., 1990c). Other investigators

in this field have reported the same experience (Cummings et al., 1989a;

McPhee et al., 1989; Wilson et al., 1988).

Rounds I and II of Doctors Helping Smokers asked the participating

physicians to identify every smoker in their practices and ask them to quit

smoking (Kottke et al., 1989). As part of the evaluation of our intervention,

Table 4

Checklist for implementation of systematic smoking intervention protocols in medical practice

Knowledge of Relevance Have we assured that the physician understands that his or her patients will

benefit from a cue to stop smoking?

Skills Have we given the physician the skills to advise the patient to stop smoking

and help the patient develop problem-solving and maintenance skills?

Adequate Return Have we designed a program that will either pay for itself or effectively serve

as a practice-builder for the physician?

Organization Have we designed an organization that will cue the physician to ask the

patient to address smoking and to support the physician when he or she

receives a request for help?

Perceived Effectiveness Have we demonstrated to the physician that asking the patient to stop

smoking increases the probability that the patient eventually will quit?

Perceived Patient Demand Have we demonstrated to the physician that his or her patients want advice

and help to stop smoking?

Perceived Legitimacy Have we demonstrated to the physician that asking patients to stop smoking

is a legitimate professional behavior?

Confidence Have we given the physician the confidence to ask patients to stop smoking?

Commitment Have we imparted to the physician the commitment to ask patients to quit

smoking?
71

Chapter 2

patients of those physicians were interviewed by telephone soon after their

clinic visits and again a year later. Several findings emerged from this study:

• Even physicians who had promised to ask every smoker to quit smoking

were unable to accomplish this task in more than 60 to 70 percent of

cases.

• The proportion of patients who would agree to quit smoking when

asked by a physician (approximately 30 percent) was far smaller than

the proportion who would try to quit smoking during the subsequent

year (approximately 50 percent).

• Quit attempts were frequently followed by rapid relapse. One-quarter

of the patients who reported that they had quit smoking for at least 24

hours relapsed within 2 days, half relapsed within a week, and 65 percent

relapsed within a month. If a patient was able to remain abstinent for

180 days, the probability of relapse within the next 180 days was low.

• Two factors had to be favorable if a smoker was going to quit smoking:

the desire to quit smoking (in this case measured by the patient’s

response, on a 1 to 10 scale, to the question “How much do you want

to quit smoking?”) and the ability to deal with dependency on cigarettes

(in this case measured by the length of time, after first rising, that the

patient smoked his or her first cigarette). The desire to quit smoking was

a necessary precursor of a quit attempt and was stimulated when the

patient’s spouse, significant others, or physician expressed a desire for

the patient to quit smoking. However, even when the patient had a high

desire to quit smoking, the probability of sustained abstinence was low if

the patient smoked soon after first rising in the morning (Venters et al.,

1990).

• The major source of disagreement between the physician and many

patients was not whether patients should quit smoking but, rather,

exactly how and when.

• Physicians disliked exhorting patients to quit smoking and would justify

with multiple reasons why they did not perform that task. Conversely,

physicians enjoyed assisting patients who wanted to follow their

recommendations.

• Ongoing support from a physician reduced the probability that a patient

who had stopped smoking would relapse.

A META-ANALYSIS To better understand the source of apparent contradictions in

OF CONTROLLED the smoking cessation trial literature, Kottke organized a metaTRIALS analysis of 39 controlled trials that might possibly be delivered

in a physician’s office (Kottke et al., 1988). The same general pattern was

observed for studies that reported their results after 6 months of followup

and studies that reported their results after 12 months of followup. The fact
Smoking and Tobacco Control Monograph No. 5

72

that the intervention effects were uniformly stronger after 6 months of

followup than after 12 months indicated that intervention effects decayed

over time. No single intervention strategy was particularly more effective

than all others. Success was associated with the following:

• Patient exposure to more than one intervention modality;

• Length of time that the subject was in contact with the program;

• Number of times that the subject was in contact with the program;

• Use of both physicians and nonphysicians; and

• Use of both group and face-to-face programs.

It was predicted from multivariate modeling that a program featuring two

intervention modalities with six reinforcing sessions over a period of 1 year

would produce a 43-percent success rate. This analysis demonstrated that the

smoking cessation process has more characteristics of behavioral shaping

(Skinner, 1959) than of health beliefs (Becker and Maiman, 1975).

NOKOMIS CLINIC During round I, we came to appreciate that physicians wanted to

INTERVENTION know precisely how to organize their practices to systematically

PROGRAM provide smoking cessation advice; hypothetical situations did not

convince most physicians that they should attempt an innovation in their

own practices. We therefore used the storefront clinic directed by one of us

to develop, test, and document whether our team-based smoking interventions

produced success. This project demonstrated the following:

• Most smokers were willing to discuss smoking cessation, but only a few

smokers could be recruited into formal programs.

• Just as a successful research program requires both testable hypotheses

and a system to test them, the delivery of clinical smoking interventions

required a system to deliver the intervention (Table 5).

• A clinical smoking intervention program could be described as containing five necessary components—identification of all smokers through

a screening and labeling program, reminders to the physician, a brief

message to quit smoking delivered by the physician, self-help materials,

and followup (Table 6).

• The smoking intervention clinic environment program could be

defined as consisting of seven necessary elements—policy establishment,

coordination, an implementation plan, orientation and training,

resources, audit, and maintenance (Table 7).

• When these conditions were implemented, almost 90 percent of smokers

could be identified and almost the same proportion could be given a

smoking cessation message at every encounter.
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Chapter 2

Table 5

Parallel components of supporting environments for testing the efficacy of interventions and

delivering efficacious interventions as clinical programs

Research Environment Clinical Environment

● Subject identification ● Identification of patients who smoke

● Standardized intervention ● Cessation message and application of patient-specific

aids from a menu of efficacious interventions

● Data entry form ● Progress record

● Observation for effect of intervention ● Followup with patients

● Removal of environmental confounders ● Smoke-free clinic

● Official agreement to sponsor research ● Clinic endorsement

● Research personnel recruitment ● Necessary supporting staff

● Principal investigator ● Physician in charge

● Research assistants ● Clinical assistants/nurses

● Project coordinator ● Staff member in charge

● Manipulation protocol ● Physician role defined

● Manual of operations for research assistants ● Staff role defined

● Orientation and training ● Orientation and training

● Funding ● Cost-benefit adequacy

● Evaluation ● Evaluation

● Feedback ● Feedback

● Morale maintenance ● Spirit-building within team of providers

Table 6

Basic elements of patient-provider interaction for effective intervention

Screening and Labeling ● Routinely identifies at least all adult patients as to use or non-use of tobacco.

● Labels charts for user or non-user status.

● Re-screens users at each office visit for current usage.

Physician Reminders ● Reminds physicians at each visit of user status and current usage.

● Reminds physicians of previous tobacco-related encounter attitudes

and plans.

Physician Message ● Physician message during each visit that is brief, clear, supportive, and

specific (negotiates specific plans, assistance, and followup).

Assistance ● Self-help guides, education, and counseling available to those who want or

need them.

Followup ● Supportive communication (re-visit, phone call, or mail) near a promised quit

date and after quitting.

● Review of previous plans at all visits.
Smoking and Tobacco Control Monograph No. 5

74

Table 7

Supporting elements needed to ensure application of the intervention

Policy Establishment Clinic management clearly and specifically states the goal and

timeframe of action. It names the individuals with authority to carry out

the plan.

Coordination Both a physician coordinator and a staff coordinator are identified to

implement the policy. In large clinics, a committee or task force is

desirable to support the coordinators.

Implementation Plan A written plan is devised that identifies how each intervention element

is to be performed, including the role definitions, job descriptions,

financial aspects scheduling, and a timetable for startup.

Orientation and Training Every physician and staff person affected by the plan is informed of it,

given an opportunity to feel involved, and trained in the tasks that will

be required of them.

Resources All the materials needed are devised or obtained and distributed.

Referral arrangements are identified (as needed).

Audit Establishes a way to periodically assess both the end results and the

process for both the overall clinic and for individual physicians and

staff members.

Maintenance Keeps the system going and improves its performance through a

combination of feedback and audit information, spirit-building

information and events, and repeat orientations and training as needed

for both old and new clinic members.

• Not only was the program acceptable to smokers, but also they appreciated the assistance. Fewer than 5 percent of the smokers reported feeling

that it was not appropriate for the clinic to ask its patients to stop

smoking. Almost 80 percent reported that the program seemed to be

about right, about 10 percent said it was too much, and 10 percent said

it was too little. Three-quarters agreed that they were more satisfied with

their overall care at the clinic because of the stop-smoking efforts there;

one-quarter said that they would recommend the Nokomis Clinic to

others because of those efforts.

Whereas the interventions used in round I and round II failed to produce

sustained smoking cessation, the Nokomis Clinic project intervention system

produced 1-year cessation rates of about 20 percent (Solberg et al., 1990). This

project demonstrated that through development of a supportive environment

and involvement of the entire clinic work unit in the smoking intervention

effort, an effective and efficacious intervention effort could be incorporated

into a busy family practice clinic, and it could be sustained there for more

than 4 years.
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Chapter 2

When fully incorporated into an office practice, the smoking intervention

system developed at the Nokomis Clinic would have the following features:

• Each adult patient would be categorized as a smoker or a nonsmoker

and each medical record would be labeled accordingly.

• At every visit, each smoker would be asked about current tobacco use

and be asked by the physician to quit smoking.

• The clinic would implement an intervention program that could

respond to the particular needs of the individual smoker.

• A smoking cessation progress record would be kept for each smoker

and used as a reminder to raise the topic as well as a simple way for

physicians to review past actions and to arrange future assistance and

followup.

• Self-help materials would be readily provided to interested smokers.

• The clinic would implement a process to assure that the progress of

each smoker be followed and that quitters be reinforced for abstinence

immediately after quit dates or as they visited the clinic for other

reasons.

This smoking intervention system became the basis of the American

Academy of Family Physicians Smoking Intervention Kit (AAFP Stop Smoking

Program, 1987a and 1987b), and it provided much of the philosophical

background for the National Cancer Institute publication, How To Help Your

Patients Stop Smoking (Glynn and Manley, 1990). It also became the

intervention program suggested to the clinics in the round III trial.

DOCTORS HELPING For round III, Doctors Helping Smokers collaborated with

SMOKERS, ROUND III Blue Cross/Blue Shield of Minnesota through its managed

care plans, Blue Plus and HMO Midwest. Blue Cross/Blue Shield contracts

with independent primary care practices in Minnesota through Blue Plus,

and in Wisconsin through HMO Midwest, to provide health services to the

individuals covered by these plans. In none of these medical practices do

managed care patients make up more than 15 percent of all patients seen

by the practice.

The target clinics of the round III intervention were all 11 Minnesota clinic

organizations that provided service to enrollees living outside the MinneapolisSt. Paul metropolitan area but within a 2-hour drive of Minneapolis-St. Paul.

At the beginning of the study, 126 primary care physicians were practicing in

these clinics in 31 sites. Two sites closed during the period of the study.

The clinics in the control group were 10 clinic organizations in western

Wisconsin that held contracts to provide services to individuals covered by the

managed care contracts of Blue Cross/Blue Shield of Minnesota. These clinic
Smoking and Tobacco Control Monograph No. 5

76

organizations were somewhat smaller than the intervention group clinics;

they averaged 7.7 primary care physicians per clinic and 1.5 sites per clinic.

The Patients When enrolling in Blue Plus or HMO Midwest, each enrollee is required

to name a clinic that will be responsible for his or her primary care. (Because

many individuals work in Minnesota while living in Wisconsin, it is not

unusual for an individual covered by Blue Plus to name a Wisconsin clinic

for primary care.) Blue Cross/Blue Shield has the names, addresses, and

insurance claims of these enrollees and could survey them without the

involvement of the physicians in either the intervention group or the

control group clinics. This group of enrollees was used to evaluate the

round III intervention.

In contrast to other programs that have tested smoking interventions

in clinics (Cummings et al., 1989a; McPhee et al., 1989; Russell et al., 1979;

Wilson et al., 1988), participating physicians consisted of an entire population,

not volunteers from a population, and at no time did Doctors Helping Smokers

provide salary support for any clinic employee, place a study employee in a

clinic for the purpose of providing patient care, or have a Doctors Helping

Smokers employee routinely monitor physician and staff activity.

Physician The failure of rounds I and II to attract more than a small minority of

Recruitment physicians to give smoking cessation advice led us to develop a markedly

different recruitment strategy for round III of Doctors Helping Smokers. While

rounds I and II used direct mail contact with the individual physician, as

described above, round III was based on developing a relationship with entire

clinic groups over a period of time. Table 8 summarizes the differences between the recruitment strategies for the first two rounds and for round III of

Doctors Helping Smokers. A letter was the initial contact for both, but the

sponsoring organizations for round I did not have day-to-day interaction with

the clinics as did the sponsors of round III. The initial response required of

the physician in round I was the mailing of a postcard; aside from a reminder

letter or two, Doctors Helping Smokers had no plausible explanation for

attempting further contact with the physician if this card was not mailed.

The letter in round III only advised the physician of the nature of an upcoming telephone call.

The second contact in both rounds I and II was a telephone call. However,

the purpose of the telephone call in round I was to confirm that the physician

was willing and able to participate in the randomized trial. In round III, the

purpose of the telephone call was to ask the physician to name a date when

the Doctors Helping Smokers team could visit the clinic to explain the study.

The physician had to agree only to stay at the clinic over the lunch hour to

meet with the Doctors Helping Smokers investigators.

The first face-to-face contact (third of all contacts) in round I occurred only

if the physician attended the workshop. The first face-to-face contact (third of

all contacts) with round III physicians was in their own clinics; they had to
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Chapter 2

Table 8

Summary of recruitment process for Doctors Helping Smokers

Rounds I and II Round III

Initial Contact Mail Mail

Organizational No day-to-day contact Day-to-day contact about

Relationship about clinical matters clinical matters

Initial Response Required Mail postcard No response required

of Physician

Second Contact Telephone Telephone

Second Response Agree to come to Agree to stay at clinic to

Required of Physician workshop and have lunch with Doctors

participate in trial Helping Smokers team

Third Contact Face-to-face at nonclinic Face-to-face in physician’s

site if in workshop group; own clinic

mail contact otherwise

Third Response Required Carry out trial in own office Agree to ongoing negotiation

of Physician of specific activities with

Doctors Helping Smokers

team

agree only to continue discussions with the Doctors Helping Smokers team

about potential intervention strategies they might be willing to adopt for

their clinical practices.

Using a philosophy similar to what later was called “the social learning

model of consultation” (Brown and Schulte, 1987), which was based on

Bandura’s social learning theory (Bandura, 1977), we used the following

recruitment process in round III: One of the Doctors Helping Smokers

investigators contacted the medical director of each intervention group

clinic with an introductory letter. The letter explained the study without

asking for any commitment. We followed the letter with a telephone call

to the medical director to arrange a site visit. The purpose of this visit was

primarily informational but included four goals:

• To personally introduce the Doctors Helping Smokers investigators and

the Doctors Helping Smokers agenda to the clinic physicians and

administrators;

• To describe the commitment of Blue Plus to clinic-based smoking

cessation interventions;

• To reach a consensus that smoking should be treated to the extent that

it would not disrupt other clinic operations; and
Smoking and Tobacco Control Monograph No. 5

78

• To ensure that the effort would be a true collaborative effort,

— The physicians in each clinic would agree to consider implementing

the Doctors Helping Smokers program, but individual physicians or

the entire group would be free to start or stop at any time without a

requirement to justify the action to Doctors Helping Smokers.

— The clinic personnel would be seen as contributing depth of

knowledge about the personnel, organization, and patient preferences

at that particular clinic: Doctors Helping Smokers would be seen as

contributing breadth of knowledge and special expertise about smoking intervention techniques and activities based on experience at

multiple sites.

— Doctors Helping Smokers would provide a recommended approach

and provide intervention and training materials, training programs,

audits, feedback, and consultation at the desire of the clinic.

— Doctors Helping Smokers would advocate only interventions of

documented feasibility.

To avoid having the physicians hold back for fear of being trapped into

undesired or nonproductive commitments, the Doctors Helping Smokers

team explicitly told each clinic that they did not need to even start the

project unless they wished to and that they would be free to stop at any time.

Complimentary workshops, in which physicians, nurses, administrators,

and other clinic personnel received instruction and exchanged experiences

with each other, were provided three times a year at Blue Plus headquarters.

The workshops were usually organized into three components. First, a national

expert (e.g., Ronald Davis, M.D.; Stuart Cohen, Ed.D.; Thomas Glynn, Ph.D.)

was brought in to discuss smoking intervention from a national perspective;

this gave the attendee a sense of interacting in an important, high-level,

national process. Second, the Doctors Helping Smokers investigators would

discuss their new procedures and findings; this allowed the investigators

to transfer information to attendees and give them a sense that they were essential participants in the local program. Finally, the individual attendees would

present their own activities; this created a sense of commitment and competence

in the attendees and allowed them to learn from each other’s experiences.

Newsletters were mailed bimonthly to all key personnel at the clinics, and

the two nurse-educators employed by Doctors Helping Smokers telephoned or

visited each clinic site at regular intervals to provide help with problem-solving,

to assess program progress, and to provide feedback and reinforcement. The

newsletters provided information about the project to those who were not

currently involved and provided information and a sense of belonging to office

personnel who had become active in Doctors Helping Smokers. The site visits

were essential for recruitment of the clinic personnel and to reinforce their
79

Chapter 2

commitment to the project. The site visits served particularly to signify to

the clinic personnel that they were important to the project as individuals

and that the project staff valued their contribution highly.

The Patient The clinics could adopt any patient intervention program that they

Intervention wished. However, we strongly advocated the above-described program

Program developed at Nokomis Clinic. Rather than trying to recruit smokers

into formal cessation programs, the patient intervention program designed

for Doctors Helping Smokers was based on consistent and repeated advice to

the smoker to quit smoking. The entire clinic was involved, and the clinic’s

task was defined as working with patients who wanted help rather than trying

to convince resistant patients to quit smoking.

The Clinic The goal of the clinic environment program was to provide the physiEnvironment cians and medical staff with an environment that made it easier to give

Program the advice than not to give it. It was also the intent of the program to

reinforce clinic staff members when they gave smoking cessation advice. In

designing the system, the investigators looked to the organization of surgical

operating rooms, coronary care units, hypertension treatment programs, and

other successful interdisciplinary medical systems as models to be emulated.

In the specific case of a clinical smoking intervention program, we

postulated that a supportive environment would have to include 14 elements

(Solberg et al., 1990):

• A smoke-free clinic;

• Formal clinic endorsement of the program;

• Staff support;

• Physician support;

• A physician coordinator;

• A staff coordinator;

• Definition of the physician’s role and responsibility;

• Definition of staff roles and responsibilities;

• An orientation program;

• Cost-benefit adequacy;

• Program evaluation;

• A system to feed results back to the physicians and staff;

• A spirit-building program; and

• A program to market and advertise the program.
Smoking and Tobacco Control Monograph No. 5

80

The purpose of a smoke-free clinic was to avoid giving the patient conflicting messages about the importance of being a nonsmoker. A clinic was

considered smoke-free if patients, physicians, and employees were prohibited

from smoking in all clinic buildings and on clinic grounds.

We believed that clinic endorsement of the program was essential if the

clinic was to be committed to the program. Clinic endorsement was considered present if the clinic management had developed systems and procedures

to incorporate smoking interventions into the daily clinic routine and had

announced the formation of a smoking intervention program.

Staff support was considered present if staff members encouraged each

other to perform the program well; if there was no negativity or sabotage by

staff members; if nurses, medical records personnel, and receptionists were all

involved and supportive of the program; and if personnel wore symbols (pins

and T-shirts) associated with the program.

Physician support was considered present if the physicians were positive

about the program and encouraged each other to participate in the program;

if no physicians were negative about the program or sabotaged the program;

if physicians exhibited leadership to their employees; and if physicians wore

symbols of the program.

Many observers of innovation and product development have observed

that new products languish if they don’t have a “product champion,” and

all successful medical programs—for example, operating rooms, coronary

care units, and emergency rooms—have both a physician coordinator and a

staff coordinator. The physician coordinator was expected to be the “product

champion” for the smoking intervention program. The physician coordinator

was expected to meet with the staff on a regular basis, discuss the program

at the physicians’ meetings, and take supportive action when required.

The staff coordinator was expected to champion the product among the

employees and to bring the employees’ problems to the attention of the

physician coordinator.

The physician role was to give a brief smoking cessation message, to ask

the patient if he or she were willing to set a quit date, to give the patient selfhelp materials, to reinforce those who had quit smoking, and to document the

encounter on the smoker progress record. The staff role included identifying

smokers, documenting the patient’s history of tobacco use, and carrying out

the activities identified by the Nokomis Clinic project.

The physicians and staff could not be expected to participate in the

program if they did not understand what was expected of them. Therefore,

the purpose of the orientation program was to train the physicians and staff who

worked in the clinic at the beginning of the project and train new physicians

and staff as they were hired by the clinic. The orientation program was also

expected to follow up with physicians and staff as required by special

circumstances.
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Chapter 2

Programs that do not have adequate cost-benefit ratios can be expected to

disappear in times that the clinic is in a crisis. Therefore, it was a goal to have

the smoking program benefit the clinic financially and benefit the staff emotionally. Benefits had to exceed costs in terms of fiscal return, production

of health to the patient, and emotional reward to the staff. Cost-benefit

adequacy also was considered to require a method to recover the program

costs, definition of service charges, billing and receipt of payments, and

administrator satisfaction that the program was not an undue financial

burden on the clinic.

Preventive medicine programs like the smoking intervention program

tend to give only negative feedback. Smokers who are resistant to the smoking

cessation message create a stronger impression than those who quit smoking

because they were given advice to quit. Therefore a formal program evaluation,

feedback system, and spirit-building program were considered necessary to demonstrate that the program was being carried out and that it was successful. Program evaluation required the development of a plan to evaluate whether the

patients were being identified as smokers or nonsmokers, whether the charts

were being labeled, whether patients were being given a smoking cessation

message, whether patient progress was being documented, whether patients

were quitting smoking, and whether patients were getting positive reinforcement for quitting. It was expected that both individual and group performance

of these tasks was to be evaluated.

The feedback component of the program was expected to present program

results to the clinic management, physicians, and staff groups at regular intervals. It was also expected that feedback be provided to individual physicians

and staff.

The goal of the spirit-building component of the intervention was to

reinforce the positive aspects of the intervention for the clinic as a group and

for individuals in the clinic. The spirit-building component was also expected

to create incentives for participating in the program.

Physicians respond to patient demand for services, so it would be ideal

if patients would ask for smoking cessation assistance. If the program is to

be sought by the patients, it must be advertised and marketed to the patient

community. The marketing and advertising component of the program was

expected to generate demand for the program among the patient population

and community. Also, it was expected to prime the smoker so that he or she

expected to be asked about smoking when coming to the clinic for other

reasons.

Round III Results All medical directors in the 11 intervention clinics agreed to an

initial meeting with a Doctors Helping Smokers/Blue Plus physician

Clinic Recruitment and the nurse-educator. The presence of the nurse-educator at this

meeting reinforced our intentions to use a team approach, and it

introduced her as the individual who would be making the site visits. At some
Smoking and Tobacco Control Monograph No. 5

82

of the initial meetings, only the medical director represented the clinic. At

some of the clinics, a few additional physicians joined the medical director,

and at others, nearly the entire medical staff was present. Although only

6 of the 126 primary care physicians (5 percent) attended the first workshop

and only 13 physicians (10 percent of the total) attended any workshop, all

11 clinic groups were represented by at least some clinic personnel at the first

training workshop. The members of the Doctors Helping Smokers intervention team made 177 site visits, 759 telephone calls, and 175 mailings to the

intervention clinics between May 1, 1987, and October 31, 1988. This was

an average of 5.7 site visits, 24.0 telephone calls, and 5.6 mailings per practice

site.

Approximately 6 months after the initial contact with the clinics

participating in round III, an audit of the Doctors Helping Smokers patient

encounter records demonstrated that 68 percent of the primary care physicians

were completing the Doctors Helping Smokers records for at least some of their

patients. On the survey that was mailed at the same time that the medical

records were audited, more than 90 percent reported that they had heard of a

systematic program in their clinic to identify and help patients who smoked

(Kottke et al., 1990c) (Table 9). None expressed a belief that their clinic

should not be involved with such a program, and 69 percent reported using

the program with their patients who smoked. One-third of the physicians

reported that the program had helped them deal with the problem of smoking

among their patients. Fewer than 10 percent of the physicians reported that

they had been very much involved with developing the program.

Eighteen months after initial contact, physicians in 25 of the 31 sites

were participating in the implementation of a smoking intervention system

similar to, or exactly the same as, the Doctors Helping Smokers program. All

11 clinic systems were represented by at least one active site. Although 2 sites

had closed, physicians in 24 of the remaining 29 sites were participating in

the implementation of a smoking intervention system similar to, or exactly

the same as, the Doctors Helping Smokers program. Five sites never started

any component of the Doctors Helping Smokers program.

One of the investigators conducted site visits during February, March, and

April 1989 to assess the level of implementation at each of the other 24 sites.

Although the rates of implementation varied for the different components of

the patient intervention program, between 40 and 50 percent of the 29 clinic

sites showed very little evidence of implementing the program (Kottke et al.,

1992). About one-quarter of the 29 sites systematically identified smokers

and noted the smoking intervention encounter at every visit. Fewer than

20 percent of the 29 sites kept complete smoker progress records, but almost

half of the sites had implemented a cessation intervention plan and a patient

followup plan. Three-quarters of the 29 sites made self-help materials available

for their patients.
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Chapter 2

Table 9

Self-reported participation in round IIIa

Physician has heard of Doctors Helping Smokers.

Yes = 79 percent No = 5 percent Uncertain = 2 percent

Physician believes clinic should be involved with Doctors Helping Smokers.

Very much = 53 percent Quite a bit = 21 percent Somewhat = 10 percent

Not at all = 0 percent Not answered = 2 percent

Physician uses the program with patients who smoke.

Now and in past = 59 percent Past only = 2 percent Never = 25 percent

The extent to which physician identifies patients who smoke and offers them help

to stop smoking:

All patients = 26 percent Most patients = 46 percent

Some patients = 13 percent No patients = 1 percent

Program has helped physician to deal with patients who smoke.

Yes = 30 percent Uncertain = 28 percent No = 5 percent

No experience = 24 percent

Physician reports being involved in development of program.

Very much = 8 percent Quite a bit = 8 percent Somewhat = 36 percent

Not at all = 34 percent

a 105 of the 122 primary care physicians returned the survey. The response to each variable plus the

14-percent nonresponse rate totals 100 percent.

Clinic Environment Between one-quarter and one-third of the 29 clinic sites showed

Program little or no evidence of adopting the clinic environment program.

About 15 percent of the 29 sites adopted all aspects of the clinic

environment program. Adoption of individual components varied from a

high of 80 percent for a smoke-free clinic to a low of 14 percent for formal

endorsement of the program, evaluation of the program, adoption of a spiritbuilding program, and development of a marketing program.

The reasons for not adopting the clinic environment program differ for

each site, and the investigators have not yet been able to develop a mathematical model that explains the reasons for adoption or nonadoption by each of

the sites. We believe that four major factors contributed to the problem of

nonadoption: (1) the instability of the regional medical environment at the

time of the study, (2) the investigators’ inability to visit the clinics more

frequently to provide them with help and reinforcement, (3) the investigators’

inability to reimburse clinics for even the modest extra effort required by each

of the physicians, and (4) the generally held attitude that giving smoking

cessation advice is optional in clinical practice.
Smoking and Tobacco Control Monograph No. 5

84

Patient Although only 10 percent of physicians ever attended a workshop, the

Experience inclusion of office staff as part of the intervention team and the use of

site visits created avenues of communication with the clinics that could

be used to foster adoption of the Doctors Helping Smokers intervention.

Therefore, round III changed the experience of patients who attended the

intervention group clinics during the intervention period (Kottke et al.,

1992). For those who had visited their clinic in the 6 months prior to the

preintervention survey, the proportion reporting that tobacco use had been

brought up by the physician or clinic staff was equally low (about 22 percent)

for both cohorts (Table 10). The two cohorts did, however, report significantly

different experiences during the intervention. The mean proportion of

patients who reported on the postintervention survey that someone asked

them if they smoked was about 14 percentage points higher for the

intervention clinics than for the control clinics (p < 0.05). The mean

proportion of patients who reported on the preintervention survey that no one

had asked if they smoked at their last clinic visit, and subsequently reported

on the postintervention survey that someone had asked if they smoked when

they last visited the clinic, was also higher for intervention group clinics in

comparison to control group clinics (p < 0.05).

The mean proportion who reported on the postintervention survey that

they had been asked if they smoked when they last visited the clinic, and who

reported on the preintervention survey that no one had asked if they smoked,

was about 8 percentage points higher for the intervention cohort than for the

control cohort (p < 0.05). The mean proportion of patients who reported on

the postintervention survey that their doctor had advised them to stop smoking was about 14 percentage points higher for intervention group clinics than

for control group clinics (p < 0.05).

The difference in the mean proportion reporting that the smoking cessation advice was helpful when given was about 50 percent higher for the

intervention group cohort than for the control group cohort, and the rate

at which specific help was offered was nearly twice as high for respondents

in the intervention group cohort than for respondents in the control group

cohort. Because of the small sample sizes, these differences only approached

statistical significance (p < 0.10).

In comparison to patients of control group clinics, patients of intervention

group clinics who were not smoking at their last visit were more than twice as

likely to report that someone had commended or complimented them at their

last visit for not smoking and were almost three times as likely to report that

their doctor had commended or complimented them at their last visit for not

smoking (both p < 0.05). About twice as many of the members of the intervention cohort reported that they felt helped by the clinic or doctor in some

way to remain an ex-smoker. Because of the small sample sizes, the difference

in this rate for the two cohorts was not statistically significant.
85

Chapter 2

Table 10

Activities of the control and intervention clinics, as reported by regular smokersa

Controlb Interventionb

(Number of Clinics Analyzed) (8) (10)

Prior to the Intervention

Tobacco use was brought up by a

physician or staff at any visit in

the 6 months prior to intervention. 22.9%±11.2 21.9%±9.6 0.84

At the Last Clinic Visit During the

Intervention Period

Someone asked whether the patient

used tobacco. 26.0±12.2 39.8±12.3 < 0.05

Patient was asked if he/she used

tobacco when he/she hadn’t been

asked before the intervention. 20.4±6.9 28.7±8.5 < 0.05

The doctor advised the patient to

quit smoking if he/she was still

smoking at the last clinic visit. 26.4±14.6 40.5±12.1 < 0.05

The patient considered advice

helpful if given. 16.4±9.0 23.9±8.0 < 0.10

The patient was offered specific

help if he/she expressed interest

in quitting. 13.4±11.1 22.8±11.5 < 0.10

If the Patient Was Not Smoking

at Last Clinic Visit

Someone commended or

complimented the patient

for not smoking. 11.3±11.8 28.2±19.9 < 0.05

The doctor commended or

complimented the patient for

not smoking. 9.5±11.4 25.9±19.8 < 0.05

The patient felt helped in some

way to remain an ex-smoker. 6.6±9.8 13.0±16.9 0.33

a Regular smokers were those who smoked one or more cigarettes every day for the 7 days prior to the

preintervention survey.

b Column entries are percentages of patients responding affirmatively.

LESSONS LEARNED Through an iterative cycle of hypothesis formulation, program

development, hypothesis testing, and hypothesis reformulation as suggested

by Argyris et al. (1985), Doctors Helping Smokers was able to develop a clinicbased intervention that increased the rate at which smoking patients received

advice to quit when they sought care from a group of nonvolunteer medical

clinics. We feel that the following observations are the most important lessons

to be learned from this study.
Smoking and Tobacco Control Monograph No. 5

86

Requirements for The success of recruitment in round III is predicted by the literature

Recruitment on the relationship between social contacts and successful recruitment. Green (1970) found that perceived expectations of the subPositive, Ongoing ject’s friends is an important modifier of behavior, and Rogers (1983)

Relationship noted that innovations are most likely to diffuse when individuals

are alike in personal and social characteristics. Gerlach and Hine

(1970) found in their studies of Black Power and Pentecostal organizations

that recruitment predictably takes place through preexisting, significant social

relationships of positive affect; mass media are rarely the source of recruitment.

In their studies, the type of relationship (brother, spouse, parent, fellow church

member, neighbor, patron, peer) was a less important predictor of recruitment

than either the frequency of interaction between recruiter and potential member

or the affect of the relationship (positive or negative) with the potential convert.

Recruitment was always achieved by those with whom the relationship had

been very positive; negative relationships, even between kin supposedly

important to each other, did not result in recruitment.

Face-to-Face Factsheets, letters, brochures, articles, and other mass media only provide

Interaction information (Gerlach and Hine, 1970). Rogers (1983) has found that without regard to the type of innovation, only 5 to 10 percent of individuals

will respond to information in the absence of peer group support. The responders represent members of two groups: information seekers, who wish

to find out more about the activities being promoted, and individuals who are

already active and are seeking reinforcement. The implication is that mailed

materials can provide support for the already active or information for those

not active, but any differences among mailed materials will result only in

minor differences in recruitment rates.

Repeated Contacts The Doctors Helping Smokers experience is consistent with Rogers’

observation that adoption of innovation requires ongoing contact

between the change agents and the adopter. Rogers (1983) noted that the

requirement of more than 20 contacts per year between an early adopter and

a change agent is not atypical if an innovation is to be diffused. Without a

similar level of investment, apparently one cannot expect adoption even if

recruitment is initially successful. The 177 site visits, 759 telephone calls,

and 175 mailings from Doctors Helping Smokers to the clinic sites between

May 1, 1987, and October 31, 1988, were inadequate to produce full adoption.

Entire Work Unit Although similar proportions of physicians attended workshops in all

three rounds, round III resulted in recruitment of 10 times as many

physicians because the recruitment effort was directed toward the entire clinic

and took place in the clinic. Doctors Helping Smokers is not the only trial

where it was observed that recruiting whole work units was far more successful

than recruiting individual physicians (Cummings et al., 1989a).

An effective program involves recruiting the entire unit, because peers and

employees who are not part of a new program will be working against it if they

do not understand how it contributes to the mission of the clinic. The surgeon
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Chapter 2

Charles H. Mayo, the sociologist Eliot Freidson, and others have all appreciated

the impact that the organizational base of the medicine work unit has on the

ability to complete a desired task (Freidson, 1970; Mayo, 1988; McDonald et

al., 1984).

Behavior Shaping A model that assumes that patient behavior is primarily motivated

by attempts to avoid disease makes patient behavior appear irrational.

The vast majority of smokers acknowledge that smoking is a health hazard,

that quitting smoking would benefit their health, and that they would like to

quit smoking. Even so, they claim that they are unable to stop smoking for

extended periods of time.

The data from the meta-analysis (Kottke et al., 1988) and from Doctors

Helping Smokers (Kottke et al., 1989, 1990c, and 1992) demonstrate that

smoking and smoking cessation behavior is rational if it is viewed as a process

of behavior shaping (Skinner, 1959) or social learning (Bandura, 1977).

Patients give priority to achieving goals that are more immediate than the

maintenance of physical health into the far future. The smoker may feel that

smoking increases the probability of attaining these short-term goals. It is up

to the smoking intervention program to help the patient learn ways to achieve

short-term goals without smoking and to come to believe that smoking interferes with the attainment of short-term goals.

Desire and Our experience with transdermal nicotine patches is consistent with the

Ability To Quit observation that a way of countering the factors of habit and addiction

and a way of maintaining a high desire to quit smoking must be present

if a smoker is to remain abstinent. Almost 80 percent of patients on the active

patch, compared with 40 percent on the placebo, quit smoking while on the

patch, but the long-term success of the two groups was identical (Hurt et al.,

1990). The nicotine patch offered the smokers a way to deal with the addiction but could not maintain their desire to abstain from smoking. The desire

to quit smoking, independent of habituation or addiction, is a product of

the social environment and must be continuously reinforced by the social

environment and support system.

Physician and If viewed from a “rational” perspective, failure to adopt a smoking

Staff Behavior intervention of documented efficacy is an enigma: Addressing matters

that affect a patient’s health is a physician’s responsibility. Physicians

believe that smoking is among the most harmful of the behaviors that their

patients can practice (Orleans et al., 1985; Wechsler et al., 1983), and more

than half of American smokers try to quit each year. Why, then, is it so

remarkably difficult to get physicians to give smoking cessation interventions

to their patients (Cummings et al., 1989a; Kottke et al., 1990c; McPhee et al.,

1989; Wilson et al., 1988)? Why do patients continue to report that their

physicians still do not routinely give them advice to stop (Anda et al., 1987)?

And, why do physicians not adopt smoking cessation interventions that have

been documented to be both efficacious and cost-effective (Cohen et al., 1989;
Smoking and Tobacco Control Monograph No. 5

88

Cummings et al., 1989b; Kottke et al., 1989; Ockene et al., 1991; Strecher

et al., 1991)? From the perspective of the health belief model (Becker and

Maiman, 1975), physician behavior is as irrational as patient behavior.

However, physicians are not typically irrational and, viewed from another

perspective, their behavior is not mysterious. American medicine is driven

primarily by patient expression of demand for service, not unexpressed patient

need for service (Kottke et al., 1990b). Viewed in this context, physicians can

truly want their patients to quit smoking but fail to act because they expect

their patients to follow the convention used for almost all medical encounters:

They expect their patients to broach the subject of smoking cessation as a

signal that they want and will accept help with the problem.

Although physicians enjoy special status in society (Freidson, 1986), it

appears that their behavior is determined by the same factors that determine

patient behavior. The physician never has adequate time to complete all

possible tasks, and some rewards can be increased only at the cost of other

rewards. Time spent talking with patients about smoking means time not

spent seeing patients who are presenting undiagnosed symptoms and signs.

The physician’s diagnosing conditions tends to increase patient satisfaction;

trying to convince patients to stop smoking tends to upset and anger patients.

Behavior shaping predicts that, given a choice, physicians would tend to

choose the behavior that is emotionally reinforcing, making diagnoses, over

the behavior that is emotionally punishing, advising people to quit smoking.

The observation that physician performance at the task of asking patients if

they smoke and advising them to quit tends to decay over time (Ewart et al.,

1983) corroborates this explanation.

Mutual Acceptability Patient-physician interaction takes the form, almost exclusively,

Of the Encounter of a patient seeking out a physician and asking for help through

the making of a “chief complaint.” The physician responds by

telling the patient if and how he or she is willing to provide help. It is the

exceptional situation in which the physician acts against the will of the

patient. These situations are limited to incarceration when the patient is

mentally incompetent, notification of contacts when the patient poses an

infective threat to the community, and pediatric immunization. In the first,

the physician must obtain a court order to act. In the second, the private

physician almost always lets the public health officials take over responsibility

for care. On the basis of this observation, we can expect that physicians will

always try to avoid conflict with the patient and take action only if it is in

response to a patient request or is likely to be accepted by the patient.

In the case of advice to quit smoking, if the physician is expected to take

action, that action must be defined as advice to the patient to quit smoking.

There is little reason to believe that physicians will ever adopt the practice of

routinely attempting to convince their patients to quit smoking. Even if the

physician is not considered obligated to convince the patient to stop smoking,
89

Chapter 2

it is appropriate to obligate the physician to carry out six smoking intervention

tasks (Kottke et al., 1990b): (1) understand why people smoke and how

they quit; (2) identify patients who smoke; (3) advise those patients to quit;

(4) enable them to stop smoking by prescribing services or by imparting them

with the knowledge, skills, and confidence to stop; (5) help those patients

to maintain abstinence by providing positive reinforcement both in the

examining room and in the community; and (6) establish, support, and

maintain a system to facilitate tasks 2 through 5.

CONCLUSIONS On the basis of the empirical evidence gathered in Doctors Helping

Smokers, we have markedly reformulated the way in which we see the smoker,

the physician, and the environment in which they interact:

• The smoker, rather than being an individual lacking in knowledge about

the harmful effects of smoking who would quit if he or she were aware

of these facts, almost always knows about the harmful effects, usually

would like to quit, has a 40-percent probability of trying to quit in a

given year, but is unlikely to remain abstinent after any single attempt.

• The physician, rather than being an autonomous individual who would

try to convince the smoker to quit if he or she were aware of the harmful

effects of smoking, is an individual who is highly aware of the harmful

effects of smoking but operates under a number of misconceptions

about how to help smokers quit, lacks the resources to identify the

smokers who want to quit and provide them with help, and experiences

intense competition for his or her time and attention.

• The environment, designed to help the physician meet the demands of

the patient for acute care, currently offers little support to the physician

who would like to help patients stop smoking.

We therefore designed an interdisciplinary clinic-based program that

(1) identified all smokers but focused on providing help to the smokers who

wanted to quit smoking, were trying to quit smoking, or who had recently

quit smoking; (2) conceived of the physician as an individual who is highly

dependent on office staff for support and, therefore, involved the entire office

staff in the effort to identify smokers, advise them to quit, and provide them

with the help they might want or need in the smoking cessation effort; and

(3) provided a clinic environment that cued the staff to act and reinforced

them when they did act. Through the Doctors Helping Smokers program,

we have demonstrated, in a group of nonvolunteer clinics, that at least some

clinics can be recruited to adopt the program described above and that this

adoption, even at incomplete levels, results in significant increases in the

rates at which smokers are identified, advised to quit, and reinforced in their

quit attempts.
Smoking and Tobacco Control Monograph No. 5

90

ACKNOWLEDGMENTS The authors wish to thank the Minnesota Academy of Family Physicians and

the health care professionals who participated in this study.

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Strecher, V.J., O’Malley, M.S., Villagra, V.G., Campbell,

E.E., Gonzalez, J.J., Irons, T.G., Kenney, R.D., Turner,

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Wechsler, H., Levine, S., Idelson, R.K., Rohman, M.,

Taylor, J.O. The physician’s role in health promotion: A survey of primary care practitioners. New

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Wilson, D.M., Taylor, D.W., Gilbert, J.R., Best, J.A.,

Lindsay, E.A., Willms, D.G., Singer, J. A randomized

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the American Medical Association 248: 1465-1477,

1982.

Ockene, J.K., Kristeller, J., Goldberg, R., Amick, T.L.,

Pekow, P.S., Hosmer, D., Quirk, M., Kalan, K.

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Russell, M.A.H., Wilson, C., Taylor, C., Baker, C.D.

The effect of general practitioners’ advice against

smoking. British Medical Journal 2: 231-235, 1979.

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Smoking and Tobacco Control Monograph No. 5

92

Prompting Smoking Cessation

In Family Practice

William C. Wadland, John R. Hughes, and Roger H. Secker-Walker

INTRODUCTION The primary aims of this project were to determine the effect of

a prescription for nicotine gum when added to brief physician advice and

followup on (1) smoking cessation, (2) quit attempts, (3) intentions to quit,

(4) self-efficacy about the ability to quit, and (5) confidence in physician

advice. The study design was a randomized clinical trial where adult smokers

receiving routine health care from their family physician were assigned to

either the group receiving physician advice against smoking and followup

(advice alone) or the group receiving physician advice against smoking and

followup plus a prescription for nicotine gum (advice plus gum). Subjects

were expected to fill the prescription at their own expense. Verification of

smoking cessation was done at 6 months by self-report, observer report, and

carbon monoxide (CO) monitoring. The intentions to quit, self-efficacy,

and confidence in physician advice were measured by brief questions given

before and after the physician visit. The secondary aims were to describe

and compare the rates of recruitment between two intervention sites. As a

pilot project, the study generated information useful for further clinical trials

on smoking cessation in primary care medicine. Because of the varied success

of nicotine replacement therapy in general medical practice, there is a need

to assess alternative pharmacological measures for smoking cessation in the

same setting.

RECRUITMENT IN Physicians in two primary care practices in Chittenden County,

A PRIMARY CARE Vermont, agreed to participate in this pilot project on smoking

TRIAL cessation. The first practice (site 1) was a private family practice

with 5 physicians (aged 35 to 62) and about 15,000 patients, including

children. The clinic is located in a semirural town near Burlington. At this

site, the study was conducted during 34 working days from February through

April 1987.

The second practice (site 2) was an academic general internal medicine

practice with 6 physicians (aged 32 to 58) and about 16,000 patients, not

including children. The practice was located in the University Health Center

in Burlington. Site 2 had a history of research efforts related to smoking

cessation and adult comprehensive care (Bronson and Omeara, 1986). The

study described here was carried out during 53 working days from July

through October 1987.

All adult patients entering the practices for routine, nonemergency care,

including new and return appointments, received a screening questionnaire to

identify health risks (see Appendix A at the end of this chapter). The screening

form asked all potential subjects about their age, gender, and general health
93

Chapter 2

risks, including smoking. Because both smokers and nonsmokers completed

the screening form, it allowed for gathering of information on both groups

without embarrassing smokers by being the only group completing forms.

The screening of potential subjects was done either by the practice receptionists at the first site or by trained study coordinators at the first and second sites.

All study forms were color-coded to make filing easy for the coordinators.

At the private-practice site, 576 adult patients were screened, of whom

128 (22 percent) were smokers (Figure 2). Among the 128 adult smokers

screened, 54 percent consented to enter the study (see consent form,

Appendix B). Among those who consented, 11 smokers (9 percent) failed

to meet the inclusion criteria, as determined by an entry questionnaire and a

medical screening form (Appendixes C and D). The forms were color-coded

for easy reference. A total of 58 smokers (45 percent of those eligible) enrolled

in the clinical trial.

Initially at site 1, the receptionists screened 287 patients over 21 days,

or 13.7 patients per day; whereas the study coordinators screened 267 patients

over 13 days, or 20.5 patients per day. The receptionists received only a

brief orientation to the project. They were instructed to hand out forms to

interested smokers and refer them to the coordinators for more instruction.

The rate of enrollment was 1.7 patients per day.

At site 2, the screening form was offered to 2,050 adult patients, of whom

358 (17.5 percent) refused to read it, and 1,692 (82.5 percent) completed it.

Of those completing the form, 274 (16.2 percent) were smokers. Site 2 had

already done a study on smoking cessation (Bronson and Omeara, 1986) that

may have affected the overall prevalence of smokers in the practice. Among

the smokers screened, 19 percent consented to enter the study. A total of

38 smokers (14 percent of those eligible) enrolled in the trial. The rate of

enrollment was 0.7 subjects per day.

It was hypothesized that the impersonal nature of handing out a consent

form discouraged enrollment. To test this hypothesis at site 2, 104 interested

patients were randomly assigned to have the study coordinators either actively

read the informed consent form to them or to have subjects read the consent

form on their own. The actively informed group had 51 patients, of whom

27 consented (53 percent). The self-informed group had 53 patients, of whom

25 consented (47 percent). The difference between the two methods of

gaining consent was not found to be significant.

The conclusions of tracking recruitment in this clinical trial on smoking

cessation in two general medical practices were as follows: (1) the rate of

enrollment was 3.3 times as great in the private practice as in the academic

practice (45 vs. 14 percent); (2) trained coordinators were better recruiters than

practice receptionists; and (3) having the study personnel actively involved in

obtaining informed consent did not improve recruitment. This study has been

described in more detail by Wadland and colleagues (1990).
Smoking and Tobacco Control Monograph No. 5

94

Figure 2

Comparative depiction of recruitment to a smoking cessation trial at two sites

* Refusal to general screening was monitored only at site 2.

Source: Wadland et al., 1990; used with permission of the authors.

TRAINING ON As part of the current trial, participating physicians attended a 2- to

BRIEF ADVICE 3-hour workshop training them to (1) elicit a health problem that

is a reason for smoking cessation; (2) state the reversibility of the problem;

(3) provide a previously tested cessation booklet, “Quit and Win”; (4) give a

prescription for nicotine gum and instructions on its proper use; (5) ask for

a commitment to quit smoking; (6) ask for a quit date; (7) make an appointment for followup at 1 to 2 weeks after the quit date; and (8) congratulate

the patient for trying to quit. The physicians received continuing medical

education credit and refreshments for attending the session, which was

held in their offices after patient care hours. Prior to the session, they had

received a packet of information explaining the study rationale, review

articles on nicotine replacement therapy, expected time commitment of

the physician and practice personnel, and payment for participation—

Offered

Screening Form

358 1,692

2,050

Screened

1,418 274

Refused

Screening

Smokers

222 52

Consented

(19%)

14 36

Refused

(81%)

Nonsmokers

0

Called

in Early

(0%)

Enrolled

(14%)

Excluded

(5%)

Site 2*

(percentage of smokers)

576

Screened

448 128

Smokers

42 69

Consented

(54%)

11 58

Refused

(33%)

Nonsmokers

17

Called

in Early

(13%)

Enrolled

(45%)

Excluded

(9%)

Site 1

(percentage of smokers)

*Refusal to general screening was monitored only at site 2.
95

Chapter 2

$10 per subject receiving physician advice against smoking. The physicians

were invited to comment on the study protocol and to make suggestions for

applying it in their practices.

Common scenarios were role-played. For example, a patient wants to

quit because of frequent coughing and easily sets a quit date. Another patient

has no real reason to quit and is not sure of committing to an exact date to

quit. A third patient wants to quit but is not sure of the date. A fourth patient

really likes smoking and believes it is a personal right. Physicians watched the

project directors play out such scenarios, and then they role-played themselves.

Finally, the physicians viewed a slide-tape show on nicotine gum and its proper

use. There was ample time for questions and answers.

During the course of the study, the office coordinators provided qualified

subjects with an envelope containing different instructions to the physicians,

based on the randomization schedule. After the physicians dealt with the

primary reason for each visit, they reviewed the degree of smoking dependency,

provided by the entry questionnaire (Appendix C). The entry form included

information on the type of cigarettes smoked, average number of cigarettes per

day, and Fagerstrom tolerance questions for assessing the degree of dependency.

All subjects received generic advice suggesting reasons to quit and stating the

reversibility of symptoms. A generic reminder sheet was used to prompt

physicians (see Appendix E).

The physicians then opened a randomization envelope that stated whether

the patient was to receive a prescription for nicotine (gum group) or further

advice only (no-gum group). Reminder sheets for the gum group (Appendix F)

and no-gum group (Appendix G) were provided, depending on the assignment.

Subjects in both groups were asked for a commitment to quit and a quit date,

and they were offered followup by appointment or phone. To equalize the

duration of contacts, patients in the no-gum group, instead of receiving instructions on the gum, were asked about their biggest fear related to quitting and

received further coping tips and advice about weight control with smoking

cessation. Both groups received about 5 to 10 minutes of physician advice.

To verify that they provided advice, the physicians completed a form documenting each patient’s quit date (Appendix H). All patients completed an exit

questionnaire (Appendix I) verifying the content of the physician advice. All

patients answered postadvice questions on intentions to quit, self-efficacy, and

confidence in the physician advice. The no-gum group completed a separate

exit form to verify the physician advice content (Appendix J). The gum group

completed a similar form, verifying that a prescription and instructions for

nicotine gum were provided (Appendix K). All subjects were offered a followup

visit in 1 to 2 weeks after quitting.

At 1 to 2 weeks after the physician visit, all subjects received by mail a

questionnaire (Appendix L) that served as a reminder to subjects and as a log

of quit attempts and cessation. At 6 months, subjects received a questionnaire
Smoking and Tobacco Control Monograph No. 5

96

(Appendix M) asking similar questions to document quit attempts and cessation. All subjects who did not complete the forms were called by telephone.

Family observers were asked to verify cessation in those who stated that

they had quit. A followup questionnaire on gum use (Appendix N) asked

about filling and using the prescription. All subjects stating they had quit

at 6 months were invited to receive $25 for verifying cessation with a CO

breath test.

SUMMARY OF After recruitment and screening, 94 subjects entered the clinical

PILOT TRIAL trial. There were no significant differences between sites with respect

RESULTS to sociodemographic variables, rates of quitting, or quit attempts.

Observer verification was always in agreement with subject reporting.

At the 6-month followup, there was information on 43 subjects in relation

to smoking cessation. The results are in Table 11. The numbers were small,

and there was clearly no significant difference.

The quit attempts were reported by subjects answering the questions in

Table 12 at 2 weeks and at 6 months. There was no significant difference

between the groups in quit attempts. This may be the result of small numbers,

as the mean number of quit attempts was greater in the gum group.

There were no differences in change from before to after the interventions

between the gum and no-gum groups with respect to their intentions to quit,

self-efficacy about the ability to quit, and confidence in the physician’s advice.

Table 11

Cessation at 6-month followup

Quit Not Quit

Gum Group 2 20

No-Gum Group 4 17

Table 12

Quit attempts

Did Patient Make How Many

Quit Attempt? Quit Attempts?

Yes No Mean S.D.

Gum Group 21 11 3.35 6.37

No-Gum Group 19 15 1.78 0.94
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Chapter 2

The gum and no-gum groups were combined in the analysis of preintervention

and postintervention changes in intentions to quit and self-efficacy. Concerning prechange and postchange on the intention-to-quit question (“Do you

intend to quit?”), 22 subjects reported no change, 3 subjects reported decreased intention to quit, and 40 reported greater intention to quit (Wilcoxon

signed-rank test, p < 0.001). Concerning prechange and postchange in the

self-efficacy question (“Will you succeed if you try?”), 33 subjects reported no

change, 4 subjects reported lower self-efficacy, and 24 subjects reported higher

self-efficacy (Wilcoxon signed-rank test, p < 0.001). These results are encouraging in suggesting that even brief physician advice on smoking cessation will

enhance intentions to quit and self-efficacy.

The initial sample size and power calculation to complete the project

called for 219 subjects per treatment arm to show a 10-percent difference

(10 percent in the no-gum group and 20 percent in the gum group) in quit

rate with a power of 80 percent and an α of 5 percent. It was estimated that

at least 600 subjects were required for the entire study to allow for refusal

and loss to followup. With the recruitment data from this pilot project, a

more accurate prediction of the total cost and scope of the project can be

made. Using only private practices with 4 to 5 physicians and a population

base of 12,000 to 15,000 patients, and assuming 1.5 true subjects enrolled per

day, it would take 10 similar practices 40 days, or about 2 months, to accrue

600 subjects.

RECOMMENDATIONS The experience of this project provides an opportunity to

share suggestions for other investigators based on what did not work, what

worked, and what could be done differently.

The following approaches did not work:

• Using untrained receptionists for recruitment of subjects; and

• Reading the informed consent to subjects (made no difference in

recruitment).

The following approaches did work:

• Having trained research coordinators at the practice site and using a

generic screening form enhanced recruitment of subjects.

• Color-coding physician and research assistant prompts was helpful.

• Training sessions of physicians at the practice site enhanced study

interest.

• Giving feedback to individual physicians seemed to enhance their

motivation to continue the study.
Smoking and Tobacco Control Monograph No. 5

98

The following approaches are suggested for future studies:

• Include the practice personnel in the practice orientation and training

sessions about the project.

• Choose sites that have not had prior smoking cessation studies that may

have decreased the interest and prevalence of potential subjects.

• Include more sites and longer study periods to enhance sample size.

FUTURE The success of nicotine gum replacement in general medical practice has

PHARMA- been marginal at best. Several prior studies (see Table 13) have reported

COLOGICAL improved quit rates (from 1 to 7 percent better) with the use of nicotine

THERAPY gum versus placebo (Hughes et al., 1989; Fagerstrom, 1988). Studies have

been criticized for sample sizes inadequate to detect differences of less than

10 percent. However, a 10-percent difference may be necessary for physicians

to sustain an interest in the use of nicotine replacement therapy. Clearly, the

effect of nicotine chewing gum is far greater in combination with group therapy

in heavily dependent smokers (Tonneson et al., 1988). Many general physicians

who tried nicotine replacement therapy with brief advice against smoking are

now seeing a number of return smokers who failed nicotine gum therapy.

Failed smokers and their physicians are expressing frustration and looking for

options. Referring patients to costly behavioral treatment programs is an

option, but fewer than 7 percent of those referred actually attend (Hughes et al.,

1989). Because more than 70 percent of all smokers see their physician every

2 years, the rationale for a simple, effective pharmacological aid to physician’s

advice against smoking remains attractive (Pederson, 1984). There is less

patient effort and cost and better availability than with psychological

treatment.

Physicians should be discouraged from using some pharmacological

measures. Silver salts combined with tobacco smoke cause unpleasant metallic

tastes and appear ineffective. Sedatives to relieve anxiety have not been effective. Pentobarbital and alcohol do not decrease smoking, and they increase it

in abusers of those substances. Diazepam abates the first 24 hours of withdrawal and craving only. Meprobamate shows quit rates similar to no-drug

and inferior to placebo treatment. Antidepressants show some promise, but

the side-effects profile may be prohibitive. Stimulants such as amphetamines

increase smoking. Beta-blockers show no decrease in craving and no long-term

quit rates. Narcotic agonists such as naloxone have showed increased smoking

and mixed results. Over-the-counter medications such as lobeline have questionable efficacy, in light of poor study designs (Jarvik and Henningfield, 1988).

Though it is not an approved indication for the drug, physicians are

using transdermal clonidine in treatment failures with nicotine replacement.

Transdermal clonidine is available for the treatment of hypertension and is

well tolerated with minimal side effects. There is no need to taper off of
99

Chapter 2

Table 13

Long-term abstinence in randomized trials of nicotine gum with brief advice

Percentage Abstinenta

6 months 1 year

Setting n Nicotine Control Nicotine Control

Nicotine Gum vs. No Gum

British Thoracic Society (1983) Pulmonary clinic 777 - - 10% 9%

Campbell et al. (1987) General practice 573 - - 3 1

Fagerstrom (1984) General practice 145 - - 25b,c 9e

Gilbert et al. (1989) General practice 223 - - 6 7

Harackiewicz et al. (1988) University health

center 151 - - 13 15

Page et al. (1986) General practice 289 12c,d 8 --

Russell et al. (1983) General practice 1,354 - - 9c 4e

Shaughnessey et al. (1987) General practice 99 - - 10 20

Sutton and Hallett (1987) Worksite 270 - - 9 2e

Sutton and Hallett (1988) Worksite 161 - - 9 2

Wilson et al. (1988) General practice 1,933 - - 9 4

Nicotine Gum vs. Placebo

British Thoracic Society (1983) Pulmonary clinic 802 - - 10 11

Campbell et al. (1987) General practice 836 - - 3 2

Fortmann et al. (1988) Public health clinic 600 30b 22e 22b 18

Hughes et al. (1989) General practice 315 29 19 10 7

Jamrozik et al. (1984) General practice 200 10b 8 --

a Percentage continuously abstinent and biochemically verified except as noted.

b Point prevalence rather than continuous abstinence.

c Biochemically verified in only a subset of claimed abstainers.

d No biochemical verification.

e p < 0.05 by chi-square test.

transdermal clonidine as there is with oral clonidine, where abrupt withdrawal

can provoke hypertensive rebound. Clonidine, an α2-antagonist, blocks firing

in the locus ceruleus, which is the major controller of sympathetic activity in

the brain. It has been used to counter symptoms of withdrawal from alcohol

and morphine. Most studies on the use of clonidine in smoking cessation

have been limited to oral use, short-term followup, and withdrawal effects

(Davison et al., 1988; Franks et al., 1989; Glassman et al., 1984 and 1988;

Ornish et al., 1988; Sees and Clark, 1988). There is a growing need for longterm efficacy and safety trials in involving transdermal clonidine as an aid to
Smoking and Tobacco Control Monograph No. 5

100

smoking cessation in general medical practice. Some creative study designs

may consider combinations of pharmacological therapy such as transdermal

clonidine with nicotine gum.

Transdermal nicotine replacement may be an attractive alternative for

smoking cessation in general medical practice. The transdermal approach

improves compliance dramatically and produces more stable blood levels of

nicotine than does nicotine chewing gum. Initial reports (McNabb et al.,

1982) of short-term success with extensive behavioral therapy are encouraging

(Buchkremer et al., 1989; Rose et al., 1985). A preliminary study in general

medical practice by Abelin and cowokers (1989) demonstrated 3-month

abstinence rates of 36 percent for the nicotine group versus 23 percent for the

placebo. There is a definite need to test the long-term efficacy and safety of

transdermal nicotine replacement therapy in general medical practice. Mixed

study designs using nicotine gum and transdermal nicotine in selective

smokers may prove most effective.

Other possible nicotine replacement therapies include nicotine aerosols,

inhalers, and nasal sprays; however, social acceptability and potential abuse

limit their efficacy. With the advent of transdermal nicotine, future studies on

smoking cessation in general medical practice are necessary and the prospect

seems promising.

REFERENCES

Abelin, T., Buehler, A., Müller, P., Vesanen, K., Imhof,

P.R. Controlled trial of transdermal nicotine patch

in tobacco withdrawal (comment). Lancet 1(8628):

7-10, 1989.

British Thoracic Society. Comparison of four methods

of smoking withdrawal in patients with smokingrelated diseases: Report by a subcommittee of the

Research Committee of the British Thoracic Society.

British Medical Journal 286: 595-597, 1983.

Bronson, D., Omeara, K. The impact of shared

medical records on smoking awareness and

behavior in ambulatory care. Journal of General

Internal Medicine 1: 34-37, 1986.

Buchkremer, G., Bents, H., Horstmann, M., Opitz, K.,

Tölle, R. Combination of behavioral smoking

cessation with transdermal nicotine substitution.

Addictive Behaviors 14: 229-238, 1989.

Campbell, I.A., Lyons, E., Prescott, R.J. Stopping

smoking: Do nicotine chewing gum and postal

encouragement add to doctors’ advice? Practitioner

231: 114-117, 1987.

Davison, R., Kaplan, K., Fintel, D., Parker, D.,

Anderson, L., Haring, O. The effect of clonidine on

the cessation of cigarette smoking. Clinical

Pharmacology and Therapy 44: 265-267, 1988.

Fagerstrom, K.O. Effect of nicotine chewing gum and

followup appointments in physician-based smoking

cessation. Preventive Medicine 13: 517-527, 1984.

Fagerstrom, K.O. Efficacy of nicotine chewing gum:

A review. In: Nicotine Replacement: A Critical

Evaluation (Progress in Clinical Biological Research

Series, volume 261), O.F. Pomerleau and C.S. Pomerleau (Editors). New York: Alan R. Liss,

1988, pp. 109-128.

Fortmann, S.P., Killen, J.D., Telch, M.J., Newman, B.

Minimal contact treatment for smoking cessation.

Journal of the American Medical Association 260:

1575-1580, 1988.

Franks, P., Harp, J., Bell, B. Randomized, controlled

trial of clonidine for smoking cessation in a primary

care setting. Journal of the American Medical

Association 262: 3011-3013, 1989.

Gilbert, J.R., Wilson, D.M., Best, J.A., Taylor, D.W.,

Lindsay, E.A., Singer, J., Willms, D.G. Smoking

cessation in primary care: A randomized controlled

trial of nicotine-bearing chewing gum. Journal of

Family Practice 28(1): 49-55, 1989.

Glassman, A.H., Jackson, W.K., Walsh, B.T., Roose, S.P.,

Rosenfeld, B. Cigarette craving, smoking withdrawal,

and clonidine. Science 226: 864-866, 1984.

Glassman, A.H., Stetner, F., Walsh, T., Raizman, P.,

Fleiss, J., Cooper, T., Covey, L. Heavy smokers,

smoking cessation, and clonidine. Journal of the

American Medical Association 259: 2863-2866, 1988.
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Harackiewicz, J.M., Blair, L.W., Sansone, C., Epstein,

J.A., Stuchell, R.N. Nicotine gum and self-help

manuals in smoking cessation: An evaluation in a

medical context. Addictive Behaviors 13: 319-330,

1988.

Hughes, J.R., Gust, S., Keenan, R., Fenwick, J., Healey,

M. Nicotine vs. placebo gum in general medical

practice. Journal of the American Medical Association

261: 1300-1305, 1989.

Jamrozik, K., Fowler, G., Vessey, M., Wald, N. Placebo

controlled trial of nicotine chewing gum in general

practice. British Medical Journal 289: 794-797, 1984.

Jarvik, M., Henningfield, J.E. Pharmacological

treatment of tobacco dependence. Pharmacology,

Biochemistry and Behavior 30: 279-294, 1988.

McNabb, M.E., Ebert, R.V., McCusker, K. Plasma

nicotine levels produced by chewing nicotine gum.

Journal of the American Medical Association 248(7):

865-868, 1982.

Ornish, S., Zisook, S., McAdams, L. Effects of

transdermal clonidine treatment on withdrawal

symptoms associated with smoking cessation.

Archives of Internal Medicine 148: 2027-2031, 1988.

Page, A.R., Walters, D.J., Schlegel, R.P., Best, J.A.

Smoking cessation in family practice: The effects of

advice and nicotine chewing gum prescription.

Addictive Behaviors 11: 443-446, 1986.

Pederson, L.L. Role of physicians in smoking

cessation. In: The Health Consequences of Smoking:

Chronic Obstructive Lung Disease. A Report of the

Surgeon General. U.S. Department of Health and

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Smoking and Health. DHHS Publication No. (PHS)

84-50205, 1984.

Rose, J.E., Herskovic, J.E., Trilling, Y., Jarvik, M.

Transdermal nicotine reduces cigarette craving and

nicotine preference. Clinical Pharmacology and

Therapy 38: 450-456, 1985.

Russell, M.A., Merriman, R., Stapleton, J., Taylor, W.

Effect of nicotine chewing gum as an adjunct to

general practitioner’s advice against smoking.

British Medical Journal 287(6407): 1782-1785, 1983.

Sees, K., Clark, H.W. Use of clonidine in nicotine

withdrawal. Journal of Psychoactive Drugs 20: 263-

268, 1988.

Shaughnessy, A.F., Davis, R.E., Reeder, C.E. Nicotine

chewing gum: Effectiveness and the influence of

patient education in a family practice. Journal of

Family Practice 25: 266-269, 1987.

Sutton, S., Hallett, R. Randomized trials of brief

individual treatment for smoking using nicotine

gum in a workplace setting. American Journal of

Public Health 77: 1210-1211, 1987.

Sutton, S., Hallett, R. Smoking intervention in the

workplace using videotapes and nicotine chewing

gum. Preventive Medicine 17: 48-59, 1988.

Tonnesen, P., Fryd, V., Hansen, J., Gunnersen, A.B.,

Forchammer, H., Stockner, M. Effect of nicotine

chewing gum in combination with group counseling on the cessation of smoking. New England

Journal of Medicine 318: 15-18, 1988.

Wadland, W.C., Hughes, J.R., Secker-Walker, R.H.

Recruitment in a primary care trial on smoking

cessation. Family Medicine 22: 201-204, 1990.

Wilson, D.M., Taylor, D.W., Gilbert, J.R., Best, J.A.,

Lindsay, E.A., Willms, D.G., Singer, J. A randomized

trial of a family physician intervention for smoking

cessation. Journal of the American Medical Association

260(11): 1570-1574, 1988.
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102

Smoking Cessation in Primary

Care Practice: Summary of Results

From the Quit for Life Project

Steven R. Cummings, Thomas J. Coates, Mort J. Stein,

Neil D. Swan, and the Quit for Life Research Group

INTRODUCTION Most American physicians believe that cigarette smoking is an

important threat to health and that efforts to encourage smoking patients to

quit the habit should have a high priority in the practice of medicine. Physicians are generally aware that cigarette smoking is the single most important

avoidable cause of premature death and disability in the United States (US

DHEW, 1979). Because some 70 percent of smokers visit a physician each

year, patients could be influenced to quit smoking by the physician’s counseling or other smoking cessation strategies (Ockene, 1987). Most physicians,

however, report that they feel poorly prepared to counsel smoking patients to

stop, and only a few say they believe their smoking cessation efforts to be very

successful (Cummings et al., 1989d; Ockene et al., 1988; Wechsler et al., 1983).

The literature suggests that physicians can effectively help their patients

to quit smoking by routinely asking whether patients smoke, counseling and

otherwise motivating patients to quit, helping smokers to commit themselves

by establishing a date on which they will stop smoking, getting the patients’

further commitment by persuading them to return for a followup office visit,

and providing self-help materials and support from the physician’s office staff

(Orleans, 1985; US DHHS, 1986). Physicians rarely use any of these strategies

(Cummings et al., 1989d), however, and the value of training physicians to use

these approaches had not previously been tested in a rigorous randomized

trial.

We tested the value of these approaches in two groups: (1) internists in a

large hospital-based health maintenance organization and (2) internists and

family practitioners in private practice. We also conducted surveys of physicians and dentists to describe their current attitudes and practices about

smoking cessation, analyzed the cost-effectiveness of counseling about smoking cessation, and, as an underpinning for our research, estimated the best

cutoff points for biochemical tests of smoking cessation used in intervention

trials. This review summarizes the 10 papers that resulted from the Quit for

Life project and offers further observations on the processes used in the

studies.
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TRIALS The main goal of the trials was to test the value of a combination of

commonly advocated strategies for brief physician counseling, using

Trial Objectives rigorous methods with adequate power to reveal even small effects.

addition, we aimed for generalizable results: We sought to create a program

that could be adopted by anyone and to test its value in samples of internists

in different practice settings.

We developed a standardized continuing education program (Quit for

Life) to teach physicians how to counsel smoking patients to quit. The

counseling protocol was designed to be concise, to have an impact, and to

fit into doctors’ busy schedules. We set out to test the hypothesis that

physicians who received controlled and standardized training in effective

counseling about smoking cessation—in combination with intensified office

support and followup counseling—would show higher rates of smoking

cessation among their patients than do physicians who do not receive such

counseling training combined with heightened staff involvement and patient

followup.

Quit for Life We created a standard training program in smoking cessation based

Training on commonly advocated principles of brief counseling. To test the

value of the program, we conducted parallel trials, one involving privatepractice physicians (internists and family practitioners) and one involving

HMO internists. From four medical centers of the HMO, the Kaiser

Permanente Medical Group of Northern California, 81 internists were

recruited; 40 were randomly assigned to the training program and 41 served

in the control group, receiving no counseling training (Cummings et al.,

1989a). In the second trial, we recruited private-practice internists and family

practitioners, 44 in all; 24 were randomly assigned to the experimental (training) group and 20 to the control group (Cummings et al., 1989b). All physicians in the two experimental groups attended three 1-hour training seminars

led by an internist or a psychologist. The seminars demonstrated the five steps

that have been advocated as part of brief physician counseling about smoking

cessation (Cummings et al., 1989a and b). In the first seminar, the instructor

presented a systematic approach to counseling smoking patients to quit.

Physicians viewed a videotape illustrating effective counseling approaches

and then rehearsed their own counseling techniques through role-playing.

The first Quit for Life seminar focused on five steps in the counseling

process:

• Ask all patients whether they smoke.

• Ask all who do whether they are interested in stopping.

For those who say they are interested in quitting, continue with the next

three steps:
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• Reinforce smokers’ motivations to quit. Ask questions about their own

reasons for wanting to quit and demonstrate the personal benefits of

cessation, rather than making general statements about the

consequences of smoking.

• Help those interested in quitting to commit to a specific quit date.

Dramatize the quit date as a tangible goal by presenting the patient with

a signed physician’s prescription form with the patient’s name and the

quit date written on it.

• Offer a self-help booklet to all smokers, even those who say they are not

interested in quitting.

The physicians were urged to practice the five-step counseling approach

at once, before the second training seminar.

During training, the physicians practiced these steps in role-plays. The

sessions ended with positive feedback from the participants and the instructor

for use of the suggested steps during the role-play session.

At the second seminar, 1 or 2 weeks later, the participants discussed their

experiences in counseling patients. They related and discussed obstacles faced

by patients trying to quit—fear of failure; apprehension about gaining weight;

the reactions of spouses, friends, and coworkers who continue to smoke; and

the discomfort of withdrawal symptoms. The instructor suggested specific

ways to overcome each obstacle discussed. Nicotine gum was recommended as

an adjunct to counseling for smokers showing clinical evidence of addiction,

and instructions for how to use nicotine gum were reviewed. The instructor

also discussed the importance of scheduling followup office visits with the

counseled smokers and ways that physicians might respond to problems

encountered in followup visits.

The experimental group also attended a third session (a booster) 4 to

12 weeks later, discussing their experiences in counseling smokers. The

instructor congratulated those who had tried the suggested approaches and

described the medical significance and cost-effectiveness of persistence in

counseling smokers to quit, emphasizing the importance of followup office

visits.

Recruitment for For the HMO trial, we enrolled nearly 50 percent of the eligible

Two Trials Kaiser Permanente HMO internists with relatively little effort

(Cummings et al., 1989a). We first obtained the support of the HMO chiefs

of medicine and patient education, enlisted an investigator from each of the

Kaiser Permanente groups of internists to help contact colleagues about the

study, sent a letter describing the trial to HMO internists, and then made a

single presentation to the regular physician staff meeting at each participating

hospital. The fact that all HMO physicians practice in one building, where

the Quit for Life training was conducted during the time usually devoted to

CME, made participation very easy for the Kaiser Permanente physicians.
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Recruitment of private-practice physicians for the trial was much more

difficult (Cummings et al., 1989b). We enrolled only about 5 percent of

eligible private physicians, despite our using more intensive enlistment efforts

than those employed with HMO internists. We first enlisted the support of

the local medical associations, obtained letters of support from the chief of

staff of each major hospital in the region, sent those endorsements in a letter

(addressed by hand to prevent its being treated as junk mail) to all primary

care physicians in the target region, enclosed a stamped and preaddressed

response card and a phone number to call for those interested, conducted

a followup mailing, and made presentations to many of the hospitals’ staff

meetings. In retrospect, we believe it would be more productive to target

a smaller, randomly selected group of physicians with personal contacts,

perhaps “dear colleague” phone calls from a physician-investigator.

We tried two approaches to recruiting patients for the study. First, we

asked the physicians’ staff members to help recruit; they were instructed to

ask all patients whether they smoke and to invite them to participate in the

studies. Patients who agreed were enrolled and then filled out a baseline

information questionnaire. Despite intensive efforts to enlist the cooperation

of office staffs (see below), recruitment proceeded slowly and unevenly from

office to office. We found that it was better to hire research assistants to

identify smokers in each office, and most participants were enlisted by

research staff. Patients were enrolled until we had accrued from 15 to

30 smokers per physician in 6 weeks.

Data Collection All physicians completed a baseline questionnaire about their training, type of practice, smoking history, and opinions about and practices for

counseling smokers. Selected questions were administered a second time to

physicians in the experimental group after their training.

Prior to seeing their physicians, participating smokers answered questions

about the extent of their commitment to quitting and their level of confidence

in their ability to do so. As soon as possible after each patient’s visit to the

physician, a member of the research staff, who was not aware of the patient’s

assignment to the experimental (physician training) group or the control

group, interviewed each smoker by telephone. The interviewer asked whether

smoking had been discussed during the visit, how many minutes had been

spent in the discussion, what steps the physician had recommended, what the

smoker had agreed to do, and whether the patient had received a selfhelp booklet or a followup appointment about smoking cessation.

One year after the first telephone interview, smokers were interviewed

again by telephone to determine their current smoking habits and how many

times they had tried to quit smoking (a single attempt was defined as abstinence for at least 24 hours). Those who said they had not smoked a cigarette

during the past 7 days were defined as self-reported nonsmokers; they were

offered $25 to have a breath test and give a saliva sample. Investigators

analyzed results of patients’ self-reported and biochemically validated
Smoking and Tobacco Control Monograph No. 5

106

abstinence from smoking. All those lost to followup or who refused biochemical testing were counted as smokers.

Conducting the From the 125 participating physicians, we enrolled 3,004 smokers

Trials in the two trials of private-practice physicians and those in an HMO.

We interviewed more than 90 percent of the smoking patients after they first

received office counseling from their physicians and then interviewed more

than 80 percent of those patients again 1 year later. Of those who claimed

to have quit smoking, 80 percent completed biochemical tests to confirm that

claim, and 10 percent were reclassified as smokers after the testing (Cummings

et al., 1989b). Detailed results of these trials have been published (Cummings

et al., 1989a and 1989b).

These separate trials had three characteristics in common. First, the

smoking cessation counseling and other interventions were designed to be

convenient, specific, and standardized. The training was presented in short

sessions to fit into physicians’ CME schedules. The office materials employed

were simple, inexpensive, and easy to use in a physician’s office without

special training.

Second, the intervention combined many of the elements of other NCIsupported trials—a reminder system and training about counseling involving

videotape demonstrations, rehearsals and role-playing, and building upon

feedback from the smokers, from other physicians in training, and from the

instructor’s exercises in reinforcing positive elements of the continuing

intervention process.

Third, the trials adhered to rigorous principles of randomized studies. For

example, randomization was blinded, all data about cessation outcomes were

collected by research assistants who were blinded to the assignment of patients

to treatment or control groups, and all data were analyzed by initial assignment

(in compliance with the “intention-to-treat” principle).

Office Staff We had difficulty in enlisting and maintaining consistent office staff

Involvement support of physician counseling and other cessation efforts. One member

of the research staff spent at least 1 hour in the office of every experimental

group physician in the trials. Recruitment in private offices was slow and

uneven, with varying levels of cooperation. We also became concerned about

biased sampling because at least one physician instructed his staff to enlist only

smokers he had counseled who seemed likely to quit smoking.

We had further difficulty enlisting cooperation from the Kaiser Permanente

office staff, because staff members frequently rotate from office to office and

station to station within the HMO. Staff members who had been trained for

the trial were frequently replaced by temporary or “float” personnel. Many

HMO staff members expressed the feeling that they were overworked and said

they did not regard participation in the trial as “part of [their] job description.”
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The problem of office staff cooperation was compounded at the HMO

by the fact that staff members’ loyalties do not focus on a specific physician

because they are not employed or supervised by the physicians; they are

instead employees of the HMO nursing service and hospital administration.

Trying to overcome the lack of cooperation, the research staff offered incentive

payments to private and HMO staff members for enrolling smokers and gave

periodic gifts of appreciation; but those inducements seemed to make little

difference. At the HMO, there was poor compliance by staff in identifying

smoking patients, and the prescribed use of stickers to remind physicians of

their counseling obligation was ignored consistently by the staff at two-thirds

of the nursing stations.

In retrospect, the investigators concluded it would be better to work

through the hierarchy of the HMO nursing service from the beginning of

the trial and to invite all staff members to participate in the training seminars

and in the design of the office staff intervention support system.

To test the hypothesis that a different approach to staff involvement

might have a degree of success with staff intervention, we conducted a small

controlled trial with Kaiser Permanente after completion of the main trial.

This trial included intensive staff involvement in planning and carrying

out the intervention as well as designation of followup visits specifically for

counseling about smoking. We found that such an approach enhanced the

identification of smokers and the use of recommended counseling techniques

(Duncan et al., 1991).

Results In the trial involving physicians in private practice, we found, on the basis

of 1-year followup interviews with patients, that physicians in the experimental group who received the special smoking cessation training were more likely

to discuss smoking with patients who smoked than were the physicians in the

control group (64 vs. 44 percent), spent more time counseling smokers about

quitting (7.5 vs. 5.2 minutes), helped more smokers set dates to quit smoking

(29 vs. 5 percent of smokers), gave out more self-help booklets (37 vs. 9 percent), and were more likely to make a followup appointment about smoking

(19 vs. 11 percent of those counseled) (Cummings et al., 1989b). In the trial

involving internists in HMOs, 1-year followup interviews with patients showed

that physicians in the experimental group who received the special smoking

cessation were more likely to discuss smoking with their patients than were

the control group physicians (50 vs. 45 percent), spent more time counseling

smokers (5.4 vs. 4.2 minutes), were more likely to write a prescription establishing a quit date (16 vs. 1 percent), and were more likely to schedule followup appointments to discuss smoking (15 vs. 4 percent) (Cummings et al.,

1989a).

In two categories studied, however, there was no significant difference in

smoking cessation efforts between the physicians who received training and

those who did not. Physicians in the experimental group wrote prescriptions

for nicotine gum for 10.2 percent of their patients, the control group for
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10.4 percent; and 25.6 percent of experimental group physicians suggested a

treatment program for their patients, while 25.4 percent of the control group

did the same.

Thus, we found that a 3-hour continuing education program about how

to counsel smokers, combined with supportive materials for use in the physicians’ offices, substantially changed the way physicians counseled patients

about smoking. In both trials, with physicians in private practice and those

in HMOs, those who received the Quit for Life training counseled patients

more often and longer. Physicians in private practice who received the training helped six times as many patients set dates to stop smoking and gave selfhelp materials to four times as many patients as did physicians in the control

group. Among HMO physicians, those who received training helped six times

as many patients set quit dates and gave self-help material to three times as

many patients as did physicians who did not receive the training.

In both trials, counseling resulted in slightly higher rates of long-term

(9-month) abstinence from smoking, but only among patients who specifically

expressed a desire to quit. Among counseled patients most interested in

quitting, there was a small (2.0 percent) increase in long-term cessation in

the private-practice physicians’ trial; there was a similar small (1.6 percent)

increase in long-term cessation among those most interested in quitting in

the HMO trial.

In the overall patient population, however, the trials showed that improved counseling, as reflected in changes in physician behavior, had very

little impact on patients’ smoking habits. Rates of long-term smoking cessation, confirmed by biochemical tests of patients who report they have quit,

were only 1.1 percentage points higher in the HMO experimental group than

in the control group (2.6 vs. 1.5 percent), and only 0.7 percentage points

higher in the private-practice experimental group (3.2 vs. 2.5 percent).

Neither result was statistically significant.

We found that more intensive staff involvement, combined with diligence

in scheduling followup counseling appointments (“training-plus”) increased

the level of physician counseling beyond that seen with the Quit for Life

training alone. Those physicians receiving “training-plus” staff support

counseled more patients, set more quit dates, and scheduled more followup

appointments to deal with smoking cessation than did those who received

the training without the coordinated staff support. This pilot study of the

effect of staff cooperation and support of physician counseling efforts was

too small to determine whether these changes resulted in higher rates of

smoking cessation.

The investigators found that convincing patients to set quit dates appears

to be an effective technique for encouraging patients to make smoking cessation attempts; patients in the HMO trial who agreed to set quit dates were

about four times more likely to attempt to quit for at least 24 hours, even after
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results were adjusted to account for evaluations of desire to quit, confidence in

the ability to quit, and number of cigarettes smoked per day.

SURVEYS In addition to the controlled trials, investigators conducted surveys of

random samples of internists, dentists, and nurse practitioners to assess and

describe their office-practice use of smoking cessation counseling and other

interventions. The response rate for the survey of internists was 92 percent—

higher than that of any similar previous survey of physicians’ smoking cessation practices. We believe the high response rate resulted from the strategy

of targeting a random sample of physicians, one small enough for the survey

staff to pursue responses aggressively, with hand-addressed letters, multiple

telephone calls, and even personal visits (if necessary) from a doctor on the

survey team.

The authors found that the internists, dentists, and nurse practitioners

surveyed believe that smoking is extremely dangerous to health and that

counseling about smoking cessation is important and just as worthwhile as

other, more widely practiced preventive procedures, such as mammography.

On the other hand, a substantial proportion of physicians never use counseling

strategies that might help patients to quit smoking. Dentists were even less

likely to use counseling strategies such as setting quit dates, providing self-help

booklets, or scheduling followup counseling.

In the dentists’ survey, only 17 percent of San Francisco Bay area dentists

said they frequently discussed smoking cessation with their patients who

smoke, in contrast to 58 percent of a similar group of Bay area internists, who

said they frequently counsel smokers (Gerbert et al., 1989). Dentists attributed

their lack of counseling to inadequate insurance coverage, insufficient time,

lack of training, and apprehension that patients might become irritated and

leave their dental practices.

Nurse practitioners, however, are more likely than physicians to adopt

smoking cessation counseling techniques introduced through CME, investigators found (Zahnd et al., 1990). A study and patient surveys determined that

nurse practitioners are more likely than physicians to counsel smokers to quit.

Internal medicine nurse practitioners and internists at four HMO centers

received training in the Quit for Life program, and their patients were then

surveyed about their counseling practices. It was found that nurse practitioners discussed smoking with patients more often than did physicians (64 vs.

50 percent), asked patients more frequently whether they were interested in

quitting (49 vs. 40 percent), distributed more smoking cessation literature

(37 vs. 25 percent), and made more followup appointments about smoking

(36 vs. 19 percent). These results support the view that nurse practitioners,

because of greater emphasis on counseling during their professional training,

more readily incorporate counseling about cessation into their medical care

of smokers than do physicians.
Smoking and Tobacco Control Monograph No. 5

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We found in another survey that physicians only infrequently prescribe

nicotine gum to their smoking patients, and that a large minority of physicians

(20 to 35 percent) are unfamiliar with important features of how the gum

should be used as an adjunct to smoking cessation counseling (Cummings et

al., 1989c). Thus, there is evidence of a need for physician education about

how to use nicotine gum more effectively. The advent of transdermal delivery

systems for nicotine may, however, circumvent this gap in physicians’

knowledge.

Although more than 90 percent of internists (in HMOs and in private

practice) questioned in another survey believe that smoking is extremely

dangerous to health, fewer than half believed they were effective at motivating

patients to quit smoking, and most felt that counseling about smoking was

extremely frustrating because of the minimal success rate relative to the time

invested with patients (Cummings et al., 1989d).

A majority of private-practice internists believed that physicians are not

adequately reimbursed for counseling about smoking, a sentiment shared by

only 28 percent of the HMO internists surveyed. Only a minority of internists

in both groups thought that insurance coverage would actually increase the

amount of time that they spend counseling smokers. Most internists indicated

that insufficient time was an important barrier to helping smokers quit. This

may partly explain why, when they do discuss smoking with patients, most

internists and other physicians spend fewer than 3 to 5 minutes on counseling.

Few internists ever schedule visits with patients primarily to address smoking

cessation, perhaps because such visits are not reimbursed by third-party payers.

Consistent with previous surveys, we found that HMO internists were much

more likely to refer patients to smoking cessation programs. This is probably

because such programs are often provided on-site at HMO centers and are at

least partially covered by the health plans, which typically provide more

preventive care benefits than do traditional health insurance plans.

OTHER ANALYSES In preparation for the trials, we demonstrated that test cutoff points

for biochemical validation of smoking cessation used in previous studies were

too high (Cummings and Richard, 1988). We devised a method for calculating

the optimum cutoff point for these tests to take into account the prevalence of

deception among those who claim to have stopped smoking. On the basis of

this method, we recommended revised cutoff points for future studies of

smoking cessation.

We also analyzed the cost-effectiveness of counseling about smoking

cessation, as reflected in longer life expectancy among smokers who succeed

in quitting (Cummings et al., 1988). We found that, in terms of cost per years

of life saved, counseling about smoking cessation was more cost-effective

than treatment of moderate hypertension or hypercholesterolemia. If brief

counseling motivated only 1 percent of smokers to quit, the cost per year of

life saved was $2,020 for one middle-aged man among the successful 1 percent.

We estimated that scheduling a single followup counseling session would also
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be quite cost-effective when total population costs of therapy are divided and

expressed as costs of counseling the successful 1 percent—$5,051 per year of life

saved. By way of comparison, we estimated the cost-effectiveness of treating

moderate hypertension at $11,300 per year of life saved.

In additional analyses of data from the Quit for Life trials, we described

racial differences in smoking behavior among patients who smoke (Vander

Martin et al., 1990). Whites were heavier smokers and more likely to feel

addicted to cigarettes. Blacks believed that they were more likely to quit

smoking and felt less addicted than whites. Hispanics were lighter smokers,

and both Hispanics and Asians rated family pressures as an important reason

for wanting to quit smoking.

From our patient questionnaires at baseline and at 1-year followup, we

also found that patients’ concern about their health was the single most

important motivating reason to quit; about three-quarters of those who quit

cited a health-related reason. Most commonly, they said that disturbing

symptoms and diseases related to their smoking led them to quit. However,

most smokers gave more than one reason, often citing social pressures, dislike

of the negative aesthetic image, and the feeling of being the victim of addiction.

We also analyzed factors influencing whether patients participating in the

two main trials received prescriptions for nicotine gum as a physical adjunct

to counseling (S.R. Cummings, unpublished data). Of all the patient factors

analyzed, a patient’s belief that he or she is addicted to cigarettes appeared to

be the most important influence upon physicians to prescribe the gum. In

addition, black smokers were less likely to receive a prescription for the gum

than were members of other racial groups. Physicians were much more likely

to prescribe gum if they were confident of their ability to instruct patients to

use it effectively.

DISCUSSION While many physicians say, when questioned, that they are making

an effort to counsel smoking patients, a substantial proportion of physicians

never use commonly advocated counseling strategies with their smoking

patients. Using rigorous randomized trial methodology, we tested the

hypothesis that training physicians to use strategies such as quit dates would

substantially improve their success in helping smokers quit and remain

abstinent. However, the Quit for Life trials confirmed earlier findings about

other types of CME: Such programs can substantially change physicians’

clinical practices but those changes do not necessarily result in comparable

improvements in patient outcomes (Haynes et al., 1984).

Nevertheless, even very small effects from counseling smokers make the

effort worthwhile. Primary care providers and those who reimburse medical

providers should note that even marginally effective smoking cessation

programs are among the most cost-effective interventions in medicine.
Smoking and Tobacco Control Monograph No. 5

112

REFERENCES

Cummings, S.R., Coates, T.J., Richard, R.J., Hansen, B.,

Zahnd, E.G., Vander Martin, R., Duncan, C.,

Gerbert, B., Martin, A., Stein, M.J. Training physicians in counseling about smoking cessation: A

randomized trial of the “Quit for Life” program.

Annals of Internal Medicine 110(8): 640-647, 1989a.

Cummings, S.R., Hansen, B., Richard, R.J., Stein, M.J.,

Coates, T.J. Internists and nicotine gum. Journal of

the American Medical Association 260(11): 1565-1569,

1988.

Cummings, S.R., Richard, R.J. Optimum cutoff points

for biochemical validation of smoking status.

American Journal of Public Health 78(5): 574-575,

1988.

Cummings, S.R., Richard, R.J., Duncan, C.L., Hansen,

B., Vander Martin, R., Gerbert, B., Coates, T.J.

Training physicians about smoking cessation: A

controlled trial in private practice. Journal of General

Internal Medicine 4(6): 482-489, 1989b.

Cummings, S.R., Rubin, S.M., Oster, G. The costeffectiveness of counseling smokers to quit. Journal

of the American Medical Association 261(1): 75-79,

1989c.

Cummings, S.R., Stein, M.J., Hansen, B., Richard, R.J.,

Gerbert, B., Coates, T.J. Smoking counseling and

preventive medicine: A survey of internists in

private practices and a health maintenance

organization. Archives of Internal Medicine 149(2):

345-349, 1989d.

Duncan, C., Stein, M.J., Cummings, S.R. Staff

involvement and special followup time increase

physicians’ counseling about smoking cessation:

A controlled trial. American Journal of Public Health

81(7): 899-901, 1991.

Gerbert, B., Coates, T., Zahnd, E., Richard, R.J.,

Cummings, S.R. Dentists as smoking cessation

counselors. Journal of the American Dental

Association 118(1): 29-32, 1989.

Haynes, R.B., Davis, D.A., McKibbon, A., Tugwell, P.

A critical appraisal of the efficacy of continuing

medical education. Journal of the American Medical

Association 251(1): 61-64, 1984.

Ockene, J.K. Smoking intervention: The expanding

role of the physician. American Journal of Public

Health 77: 782-783, 1987.

Ockene, J.K., Aney, J., Goldberg, R.J., Klar, J.M.,

Williams, J.W. A survey of Massachusetts

physicians’ smoking intervention practices.

American Journal of Preventive Medicine 4: 14-20,

1988.

Orleans, C.T. Understanding and promoting smoking

cessation: Overview and guidelines for physician

intervention. Annual Review of Medicine 36: 51-61,

1985.

U.S. Department of Health and Human Services.

Clinical Opportunities for Smoking Intervention: A

Guide for the Busy Physician. U.S. Department of

Health and Human Services; Public Health Service;

National Institutes of Health; National Heart, Lung,

and Blood Institute. PHS Publication No. (NIH) 86-

2178, 1986.

U.S. Department of Health, Education, and Welfare.

Smoking and Health: A Report of the Surgeon General.

U.S. Department of Health, Education, and Welfare;

Public Health Service; Office of the Assistant

Secretary for Health; Office on Smoking and

Health. DHEW Publication No. (PHS) 79-50066,

1979.

Vander Martin, R., Cummings, S.R., Coates, T.J.

Ethnicity and smoking: Differences in white, black,

Hispanic, and Asian patients who smoke. American

Journal of Preventive Medicine 6(4): 194-199, 1990.

Wechsler, H., Levine, S., Idelson, R.K., Rohman, M.,

Taylor, J.O. The physician’s role in health promotion: A survey of primary care practitioners. New

England Journal of Medicine 308: 97-100, 1983.

Zahnd, E.G., Coates, T.J., Richard, R.J., Cummings,

S.R. Counseling medical patients about cigarette

smoking: A comparison of the impact of training

on nurse practitioners and physicians. Nurse

Practitioner 15(3): 10-18, 1990.
113

Chapter 2

4 Supported by National Institutes of Health grant no. R01-CA38337.

Physician and Dentist Interventions

For Smoking Cessation4

Stuart J. Cohen, George K. Stookey, and Sue A. Kelly

BACKGROUND As a result of funding from the National Cancer Institute, parallel

studies involving primary care physicians and private-practice dentists were

initiated in August 1984. The goal of the projects was to develop, validate,

and evaluate practical methods to help physicians and dentists encourage their

patients to stop smoking cigarettes and remain nonsmokers. The studies were

designed in two stages. The first stage involved efficacy studies to determine

which office-based interventions had the greatest impact. For the second stage,

effectiveness studies were conducted to determine whether office staff would

adopt and incorporate into routine care the interventions that had been

successful elsewhere and whether the results from the interventions supported

by the office staff would be comparable to the results obtained in practices

receiving the support of the research project staff. This paper describes the

stage I and II studies involving physicians and the parallel studies with

dentists in private practice.

PHYSICIAN The goal of the stage I project was to develop, validate, and

INTERVENTIONS evaluate practical methods to help physicians encourage their

patients to stop smoking cigarettes and remain nonsmokers. To

Purpose of Project: determine the most effective intervention method, participating

Stages I and II physicians and their patients who smoked cigarettes were randomly assigned to one of the following conditions: (1) control (usual care),

(2) nicotine polacrilex available to patients at no charge, (3) a reminder

system for following a practical protocol to help patients stop smoking,

or (4) both nicotine polacrilex and the reminder system.

The purpose of the stage II trials was to determine the extent to which the

“best” smoking cessation intervention identified in stage I was adaptable and

generalizable to medical office settings. When stage II began, the stage I trials

still had 1 year of data collection remaining; therefore, the “best” intervention

method for stage II was determined according to data developed during the

first 20 months of stage I. Preliminary analysis of these data determined that

for the physicians, all three interventions were equally effective and each was

better than the control (Cohen et al., 1989b). However, for the dentists, the

nicotine polacrilex intervention either alone or with the reminders was the

“best” method (Cohen et al., 1989a). To keep the physician and dentist

stage II studies parallel, the method selected as “best” was the nicotine
Smoking and Tobacco Control Monograph No. 5

114

polacrilex (group 2 from stage I). In stage II, new cohorts of participating

physicians and their panel of patients who smoked were randomly assigned

to one of three intervention conditions: (1) control (usual care), (2) nicotine

polacrilex program supported by project staff (as in stage I), or (3) nicotine

polacrilex program supported by office staff.

Stage I Components The stage I cohort involved 97 residents in internal medicine

and 15 faculty general internists who staffed the outpatient

Target Audience general medicine clinic of a city/county teaching hospital.

And Clinical The outpatient clinic was structured so that physicians could

Setting provide continuity of care to their patients. A computerized

scheduling system increased the likelihood that the same

physician-patient dyad would remain together throughout the duration of

a physician’s residency in the program. The clinic was divided into four

different areas or teams, each with its own nurses, clerks, and panel of physicians. To foster the research mission of the clinics and to minimize selection

bias, all new patients were randomly assigned to available patient slots across

teams, as were new physicians. For the stage I study, the intervention conditions (four groups) were randomly assigned such that each team was assigned

to one condition only.

The ambulatory clinics served a predominantly indigent patient population. Patients were eligible for participation in the study if they were between

the ages of 18 and 64, reported smoking one or more cigarettes daily, and

had an alveolar breath carbon monoxide determination of more than 8 parts

per million. Patients were excluded if any of the contraindications for the

use of nicotine polacrilex pertained. The sociodemographic characteristics

of the 1,420 patients who agreed to participate (the refusal rate was less

than 5 percent) were as follows: the mean age was 46.2 (SD 11.6); the mean

number of office visits per year was 2.2 (SD 2); 39 percent were white, and

61 percent black; 63 percent were female; the median education level was

10th grade; and the median annual income was $2,500.

Recruitment The stage I physicians were all affiliated with the Department of Medicine

Procedures at Indiana University School of Medicine. The project had the expressed

support of the chairman of that department, as well as the section chief

of the Division of General Internal Medicine. Consequently, there was

considerable pressure to participate in the study, and no one refused. When

senior residents left at the end of their program, their panel of patients was

retained in the appropriate study condition and assigned to the incoming

replacement physician. The replacement physician was oriented into the

appropriate study condition and became the physician of record. Rarely did

patients change physicians. In the event that a patient was transferred to a

physician in a different study condition, the patient was removed from the

study but was retained in the data analysis up until the time of removal

(e.g., included in 6-month data on smoking status but not in 12-month

analysis if the transfer occurred before the 12-month interval).
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Chapter 2

Specially trained research assistants conducted patient recruitment after

an extensive training program in how to approach and interview patients.

The research assistants memorized a script that explained to patients the

purpose of the study and the fact that people who agreed to participate

were agreeing only to have their smoking status assessed; participation did

not require an attempt to quit smoking. Each research assistant role-played

interviewing and recruiting the other research assistants, who in turn roleplayed patients who were illiterate, uncooperative, or too ill to be interviewed.

Each research assistant spent at least 2 weeks working with his or her assigned

clinic teams to learn the entire office system before contacting any patients

for recruitment into the study. All patients were screened for eligibility for

the study, and they signed an informed consent form that indicated that

their smoking habit would be monitored at each regularly scheduled clinic

visit regardless of their decision to quit or to continue smoking. Patients

were notified that they would be asked to provide a breath sample for carbon

monoxide analysis at each regularly scheduled clinic appointment and to

answer questions immediately after seeing their physician.

Nature of The training program for physicians consisted of two parts: a 1-hour

Training lecture during medical grand rounds and then a special in-clinic followup

Program session to orient each team to its specific study condition. The intent of

the first part of the training program was to provide a common educational background on smoking and its management. Because each of the four

intervention methods involved different procedures, the physicians received

the condition-appropriate orientation at the start of their clinic sessions. The

orientation lasted from 10 to 25 minutes, depending on the nature of the

intervention. Prior to the grand rounds, all physicians completed a two-page

attitude and practice questionnaire about their personal smoking histories,

their current smoking management practices for patients, and their current

interests and beliefs in effectively helping patients to stop smoking. The

1-hour general lecture presented evidence of the health consequences of

smoking, the benefits of quitting, the addictive nature of nicotine, and the

effect of nicotine polacrilex on smoking cessation. Also discussed was the

available evidence that physicians’ advice can be effective in helping counsel

patients. Physicians were encouraged to use a four-step counseling protocol

developed at the National Heart, Lung, and Blood Institute for counseling

smokers: (1) Ask your patients about smoking; (2) deliver a firm quit-smoking

message; (3) mutually agree on a quit date; and (4) check your patient’s

progress at each regularly scheduled visit. Physicians were also given a copy

of a National Cancer Institute pamphlet, “Quit for Good,” and were informed

that copies would be provided to their offices for use with their patients who

smoke.

The small group presentations centered on providing specifics for each

intervention technique. Physicians in the control group were given a booklet

containing the four-step protocol and were encouraged to counsel their
Smoking and Tobacco Control Monograph No. 5

116

patients who smoke. Neither the physicians nor their staffs were informed

as to which of their patients had agreed to participate in the project. Physicians in the other three study conditions (nicotine polacrilex, reminders,

both nicotine polacrilex and reminders) received the same instructions as

the control group plus additional instruction based on their assigned experimental condition.

For the nicotine polacrilex group, physicians were instructed on the use

of fluorescent red stickers to flag the charts of patients who were eligible to

receive the nicotine replacement product. Physicians were told that research

assistants would place the stickers and remove them after the patient had

received the product. The uses, indications, contraindications, and side effects

of nicotine polacrilex were discussed in detail. Research assistants dispensed

the product at no cost when it was requested by a physician for an eligible

patient (i.e., one with an appropriate sticker on the chart and a medication

request initialed by the physician). The education of the patient as to the use

of the nicotine substitute remained the responsibility of the physician or his

or her designee. Physicians were also encouraged to record on the patient’s

chart when the product had been dispensed.

In the reminder condition, physicians were instructed on the use of two

fluorescent chart stickers to help remind them to follow the four-step protocol. A green sticker was used to remind them to ask the patient about smoking, and an orange sticker reminded them to ask the patient to set a quit date.

Physicians were informed that a feedback report issued to them bimonthly

would provide the names of smoking patients they identified as well as the

quit dates they established with their patients.

Physicians in the combined condition (nicotine polacrilex plus reminder)

received instruction on the use of all three stickers.

Results Table 14 shows how physicians behaved under each of the interventions

(Cohen et al., 1989b). The impact of the interventions on the smokers is

shown in Tables 15 and 16.

Because cigarette smokers often quit smoking and later have relapses,

the prevalence of smoking was estimated for two subsequent periods. The

prevalence of smoking at 6 months was defined as the smoking status determined at any visit that occurred at least 3 months after the initial appointment but not more than 9 months after it. The second estimate was at

1 year, defined as at least 9 months and 1 day after the initial visit and up

to 15 months after the initial visit. If there was more than one visit during a

time interval, the smoking status was determined by the status of the last visit

during that interval. For patients who had a regularly scheduled appointment

during the critical period, their smoking status was confirmed through carbon

monoxide assessment, the procedures for which are described elsewhere

(Stookey et al., 1987). Patients who did not visit a physician during the

6- or 12-month period were assumed to be smokers. Thus, the results are
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Chapter 2

Table 14

Reported physician counseling about cigarette smoking

Percentage of Patients Reporting Actions

Asked About Advised Asked About Setting

Smoking To Quit a Quit Date

Physician Group

Advice 41% 27% 2%

Gum 84 61 10

Reminder 75 66 33

Both 95 84 58

Table 15

Confirmed success rates at the 6-month visit for each physician interventiona

Percentage, Percentage,

Returnees Only All Enrollees

(n=895) (n=1,420)

Physician Group

Control 1.3% 0.9%

Reminder 7.0 4.2

Gum 7.7 5.0

Both 6.3 3.8

a A generalized linear model was applied separately to returnees only and to all enrollees. The

significant p values were 0.005 for the reminder by gum interaction for both analyses.

Table 16

Confirmed success rates at the 12-month visit for each physician interventiona

Percentage, Percentage,

Returnees Only All Enrollees

(n=764) (n=1,420)

Physician Group

Control 2.7% 1.5%

Reminder 15.0 7.9

Gum 8.8 4.7

Both 9.6 5.2

a A generalized linear model was applied separately to returnees only and to all enrollees. The

reminder by gum interaction was significant for returnees only (p=0.002) and for all enrollees

(p=0.004).
Smoking and Tobacco Control Monograph No. 5

118

reported both for returnees, for whom biochemical validation was possible,

and for all enrollees, based on the assumption that a patient was a smoker

unless there was biochemical evidence to the contrary.

The range of patients per physician who quit at the 6-month interval

was zero to three and at the 12-month interval was zero to four. Thus,

smoking cessation by patients was widely distributed across physicians and

not clustered into the practices of a few “effective counselors.” A generalized

linear model was used to analyze the results of the quit-smoking rates. The

6-month results are shown in Table 15. There was a significant negative

interaction between nicotine gum use and reminders, both for returnees and

for all medical patients. The combination of nicotine gum and reminders

did not produce a higher rate of patients who quit smoking than the rate for

either condition alone. Pairwise comparisons among the groups (adjusted for

multiple tests with the Bonferroni inequality) showed a significant difference

(p < 0.05) between each of the three intervention groups and the control

group for analyses based on patients who had a scheduled return visit and

for all patients.

The results at 1 year, shown in Table 16, also produced a significant

negative interaction between nicotine gum and reminders. Pairwise comparisons among the groups showed that the three intervention groups were not

significantly different from each other; however, each of them was significantly different from the controls for analyses based on returnees and on all

patients. (For greater detail, see Cohen et al., 1987 and 1989b, and Stookey

et al., 1987.)

Special Resources For a program of this size, involving 112 physicians, lasting 3 years,

Or Procedures and involving more than 1,400 patients, special resources were

necessary to achieve sufficient cooperation from the general medicine clinics. Most critical was the use of research assistants who were permanently based in the clinics. Although there were four clinic teams and four

research assistants, the responsibilities of the research assistants were divided

so that they worked with one team 2 days a week and with another team

3 days a week. This was done so that there was always a backup person

familiar with the operational procedures of each team. This rotation also

helped dissipate any effect that a particular research assistant might have

on patient recruitment or implementation of the study conditions.

For stage I, given the emphasis on training only the physician rather

than the office staff, research assistants concentrated their efforts on integrating the program into the regular office routines. This was accomplished in

two ways. First, each research assistant spent 2 weeks as an apprentice with

his or her designated team, learning all of the office routines and helping

with minor chores. For example, the research assistant would occasionally

volunteer to assist the check-in clerk or the nurses with clerical duties such

as filing charts or helping patients complete registration forms. This work

not only relieved the office staff of these tedious tasks but also provided the
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Chapter 2

research assistant with an opportunity to blend the program functions into

the regular office routine. While research assistants were helping to file

charts, they were able to find the best occasion to place stickers on the

charts of newly recruited patients.

The working relationship that developed among the office staff helped

facilitate program implementation. As part of their job responsibilities and

throughout the study, when research assistants had free time available, they

were expected to help the clinic staff in performing chores that would not

interfere with their primary responsibilities. This system of volunteerism

helped reduce occasions during which the clinic staff members were overburdened and the research assistants were idle. Conversely, when too

many study patients were in the clinic for the research assistant to manage

at one time, the office staff would often keep the patients occupied until

the research assistant could see them. This system of reciprocity helped to

build a supportive relationship between the project and the clinic staff.

Barriers or Problems There were few problems to address in the stage I study. In all

Overcome cases, the research staff learned to adjust to the demands of the

clinic setting. For example, the research assistant usually tried to

enroll patients before they were seen by the physician. However, whenever

an examining room became available, a patient was taken to that room even

if the research assistant was in the middle of explaining the study. Some of

these procedures were established initially by the clinic directors, but other

procedures evolved as more efficient ways of operating became evident.

The training of new office personnel presented some problems. Each

year as interns replaced senior residents, about one-third of the physicians

were new to the clinic. The training of all new physicians was done by

blocking out time in the patient schedule for orientation instructions that

lasted from 15 to 30 minutes, depending on the intervention condition.

The physicians, in turn, were expected to educate their new staff members

on the components of the program, but they often relied on the research

assistant to educate new members. Not only were new staff members not

trained for their responsibilities in the program, but also many were not

informed of the program on accepting the position. Changes in personnel

usually slowed the progress of implementing the smoking cessation program.

The orientation of new physicians was given by one of the senior research

staff members. Followup instruction usually was provided by a research

assistant.

One effort to minimize confusion about the nature of the study was

the use of a one-half page yellow sheet presenting the goal of the project,

the eligibility and exclusion criteria for patients, and a telephone number

to call if there were questions. This information was posted on the bulletin

board above each physician’s desk in the staffing rooms. Despite a careful

effort to explain that the research assistants were not smoking counselors,

some physicians attempted to refer their patients to the research assistants
Smoking and Tobacco Control Monograph No. 5

120

for help in quitting. Such requests usually resulted in a re-explanation of

the program for the physicians.

Stage II Components The second cohort of physicians consisted of 39 general internists and family physicians who saw adult medicine patients

Target Audience at 5 sites of a freestanding HMO serving central Indiana. At

And Clinical the start of the stage II study, more than 80,000 patients were

Setting active enrollees in the 9 sites of the HMO. Each of the five

largest HMO sites participating in the project contained two

adult medicine clinics. Each adult medicine clinic had its own check-in clerk,

nurses, physician assistants, and physicians. Patients were scheduled to see a

primary health care provider only within their designated clinic. The interventions were assigned such that at each site two different interventions were

conducted, one at each clinic. All combinations of two of the three study

conditions were determined and then randomly assigned to each of the five

sites of the HMO. This procedure helped offset the fact that there could be

differences in the sociodemographic characteristics of the patients, depending

on the location of the site they visited for care. For the most part, those

patients enrolled in the HMO were from working class or professional class

backgrounds.

Recruitment Stage II was initiated 1 year before the completion of the 3-year stage I

Procedures study. The HMO’s medical director and director of adult medicine were

enthusiastic supporters of the project. Through their efforts, all physicians

in adult medicine were notified about the project during a routine monthly

staff meeting and asked to share any concerns or reservations about participation in the study. The only concern that physicians voiced was the extent to

which their workload would be affected. They were assured that the study was

designed to help them clearly identify which of their patients were smokers

and that they would then determine the extent to which counseling was

appropriate as part of those patients’ visits. All physicians were also informed

that they were expected to attend a site-specific special orientation meeting.

At each of the five sites, the nurse manager was recruited to serve as the project

liaison during a special meeting held with the principal investigator of the

project and the chief of adult medicine at the HMO. The function of the

liaison was to help arrange the logistics of integrating the project into the

routines of that site. No additional compensation was offered for that effort.

Unlike the orientation in stage I, stage II orientation emphasized the level

of team commitment required of the office staff. Project orientation luncheons

were held at each site and included physicians, nurses, other health care

providers, receptionists, medical records clerks, and other pertinent support

staff. The chief of adult medicine stressed the importance of the project in

terms of the benefits to patients at the HMO. He also noted that what staff

members were being asked to do should be considered the standard for good

care. No one overtly refused to participate in the study.
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Chapter 2

Nature of The educational seminar used a format similar to the stage I training

Training session. Physicians completed an attitude and practice questionnaire

Program at the beginning of the meeting. A general orientation seminar on

smoking and its management was followed by the breakup of the group

into two smaller groups to discuss the details of the particular intervention.

The first half of the program lasted about 30 minutes and included the

same information as the stage I general seminar but emphasized the team

approach. The team approach required the involvement of most staff members, in particular the check-in clerk and the nurse manager. In addition,

physicians were encouraged to tailor the smoking cessation program to

maximize the resources, skills, and interests of the team. At all sites, the

site nurse manager was asked to serve as a program coordinator and to be

responsible for maintaining the program and providing communication

between the office staff and research personnel.

During the general seminar, the emphasis was on specific techniques for

physicians to use when counseling their patients who smoke. A videotape,

developed at the University of California at San Francisco, was used to show

physicians talking with patients about smoking. Shown is an interaction to

assess a patient’s interest in quitting, establishing a quit date, and receiving

educational materials and encouragement. Also shown is an interaction

between a physician and a patient who had made a quit attempt and then

relapsed before the office visit. One segment depicts a conversation with a

patient who is interested in discussing exercise but not smoking. The videotape illustrates a positive, nonthreatening approach to smoking counseling.

For example, rather than lecturing patients and emphasizing the health

consequences of smoking, the physician role models engage in asking questions such as, “Have you thought about quitting?” and “Are you ready to

make another quit-smoking attempt?” The vignettes illustrate how to tailor

the counseling for patients who have varying degrees of interest in stopping

smoking. Physicians were encouraged to use these skills with their patients

who smoke.

At the conclusion of the general seminar, attendees were given a copy

of the “Quit for Good” pamphlet. They were informed that copies would be

provided at no charge for their patients who smoke.

During the second half of the instructional program, specific techniques

pertaining to each intervention condition were outlined and discussed.

Persons in the control group were given the same booklet as was given the

stage I group, and they were encouraged to follow the step-care protocol for

counseling their patients who smoke. Those in the other two interventions

received the same instruction as the control group plus additional instruction

based on their assigned condition.

Those individuals in the free nicotine polacrilex group supported by

research staff were instructed in basically the same manner as their
Smoking and Tobacco Control Monograph No. 5

122

counterparts in stage I. They were informed that red fluorescent stickers would

be placed by research assistants on the charts of patients who were eligible to

receive the nicotine replacement product. Physicians were made aware that

the stickers would be permanently removed once the product had been prescribed. The uses, indications, contraindications, and side effects of nicotine

polacrilex were discussed in detail. This small group instruction took about

20 minutes.

Physicians assigned to the nicotine polacrilex prescription method

supported by office staff were instructed on the use, indications, contraindications, side effects, and recordkeeping procedures for nicotine polacrilex

in a manner identical to the free-product group described above. However,

because the purpose of this trial was to determine the feasibility of having

a physician and his or her office staff carry out the step-care protocol of a

cessation program with only minimal support from the research team, this

group of participants was taught how to perform the procedures needed to

support the program on their own. Instead of offices being provided with

free nicotine polacrilex to dispense to patients, this group was instructed on

how to prescribe the product and instruct patients in its use. Staff members

were provided with a one-page handout about use of nicotine polacrilex,

which reviewed basic information such as “quit smoking before starting to

use the product.” Office staff members (usually check-in clerks) were instructed to insert a copy of the handout in the chart of all eligible patients

and to review the items with them when nicotine polacrilex was prescribed.

Check-in clerks were instructed in the method for placing stickers on the

charts of eligible patients. They were informed that the research assistant

permanently assigned to their site would provide a list of patients recruited

that week who were eligible for a prescription and who should have a sticker

placed on their chart. Research assistants periodically checked charts to

determine if stickers had been placed. As with the second group, physicians

or their designees were encouraged to review the product usage instructions

with the patient and to record in the chart when the product had been prescribed. Those physicians and staff members unable to attend the regular

orientation meeting were given a personalized presentation before their

involvement in the project. This was required for approximately 15 percent

of the staff, and 15 to 20 minutes were scheduled before the morning or

the afternoon clinic for this small group orientation.

Results To determine the extent to which the office staff performed the tasks

requested of them, the research staff examined the office charts of the

patients enrolled in the study. In comparison with the 100 percent of charts

that were flagged in the research-support condition, only 43 percent of the

charts were flagged in the office-staff condition, and only 31 percent of appropriate charts had nicotine polacrilex instruction sheets attached to them.

These results were much lower than anticipated and could be attributed in

part to the numerous changes in management and high staff turnover of the

HMO during the course of the project.
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Not surprisingly, the behavior of the physicians in counseling smokers

was affected by the intervention condition. Office exit interviews of patients

showed that 44 percent of control group patients, 41 percent of office-staff

patients, and 61 percent of research-support patients reported that their

physician had talked to them that day about smoking. Also, the percentages

of patients who were given or prescribed the nicotine substitute were 15 percent, 22 percent, and 39 percent, respectively, for the control, office-staff, and

research-support conditions. Neither the 6- nor 12-month smoking cessation

results produced statistically significant differences among the three groups.

Special Resources In stage II, the emphasis was on working with the entire office staff

Or Procedures in a team approach. Developing a rapport with the entire office was

a major priority. Research assistants worked at making staff members

feel that they were an integral part of the success of the program. In addition,

for each HMO site, the nurse manager who already had supervisory responsibility for most of the office staff was designated as the office program coordinator. Communication on specific program details was relayed through the

program coordinator. In return, any problems or concerns regarding the

in-office mechanisms of the program were communicated to the research staff

through the program coordinator. The use of this new position was vital for

clarifying the lines of communication and avoiding the misunderstandings

that sometimes occurred during stage I. For example, some of the stage I

physicians did not want the research assistants to start interviewing patients

about study participation until patients had finished their visit with the

physicians. Other physicians did not care, so long as their patient flow was

not interrupted. A program coordinator would have been helpful in establishing appropriate procedures to reduce potential conflict between the research

assistants and clinic staff.

As in stage I, the research assistants were solely responsible for recruiting

patients who smoked into the study and obtaining signed informed consent

forms. Research assistants were responsible also for conducting all patient exit

interviews after patients had been seen by their health care provider and for

biochemically verifying the smoking status of those who claimed that they

were no longer smoking cigarettes or using other tobacco products.

Barriers or Stage II presented some new barriers that had not existed in stage I.

Problems Before the study was initiated, the HMO had been locally owned and

Overcome operated for 13 years. During the 3-year course of the study, the HMO

changed management three times. These changes, and the uncertainties

they produced, created problems such as low staff morale and subsequent

high staff turnover. In this context, the requirements of the study, such as

flagging charts of smokers, frequently became viewed as an additional

burden and source of frustration.

These changes placed additional demands on the diplomacy of the

research assistants. In some cases, research assistants took office staff

members to lunch. Also, in an effort to engender rapport and support,
Smoking and Tobacco Control Monograph No. 5

124

research assistants contributed to all office social events, such as pitch-in

lunches. Despite these efforts, the requirements for maintaining an officebased smoking cessation program, such as flagging charts and having an

instructional system in effect, were never made part of the job descriptions

and responsibilities of the new staff. Had such changes occurred, some of

the problems caused by high staff turnover might have been prevented.

What Worked Much of the success of stage I can be attributed to the support of the

And Why directors of the general medicine clinic. They made sure that all new

physicians were aware of the project and its importance to the Department

of Medicine, making the task of orientation much easier for the research staff.

The fact that much of the logistical support (e.g., putting stickers on

charts and attaching nicotine polacrilex instruction sheets to the charts of

eligible patients) was performed entirely by the research assistants probably

expedited their receptivity by the clinic staff. Another essential ingredient

for success was the ability of the research assistants to work without disrupting

the routines of the clinic. In time, they became viewed as part of the staff in

their teams. When the project concluded, there were requests for them to

stay and work as regular staff members on their respective teams.

For stage II, the initial attempt to create a team spirit and orientation

appeared to be successful. Having one staff member in each practice serve as

the program coordinator expedited communication with the office. Unfortunately, the subsequent frequent changes in management made the continuation of this approach difficult, if not impossible. The coordinators’ efforts

were shifted toward dealing with morale problems and training new clinic

staff members in their routine functions. Thus, little time was left to help

resolve problems pertaining to the study. Obviously, medical practices that

are in flux are poor candidates for taking on additional projects. However,

determining in advance which practices will remain stable is easier said than

done. The general principle is that the best predictor of future behavior is

past behavior. Thus, for subsequent projects, an examination of staff turnover

rates could be helpful in determining which practices to select and which to

avoid.

What Did Not Obviously the concentration of the training on the physician in

Work and Why stage I, compared with training the office team in stage II, affected

the rate of integration of the program into routine care. Physicians were

simply too busy with patient care to concentrate their efforts on all the

details of providing orientation to their staffs. The investigators’ shortsighted approach to training was, in part, compensated by the continuing

presence of the research assistant who often became the primary source

for educating the office staff. Thus, for the second study, the investigators

opted to provide orientation and training for the entire office staff and not

just the physicians.
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Chapter 2

In stage II, the goal was to foster a team approach. Unfortunately, the

unforeseen changes in management of the HMO in large part undermined

that effort. The high staff turnover meant that much time was required by

the research staff to ensure that new personnel received an orientation to

the project. In hindsight, one additional step should be considered: namely,

insist that the changes in responsibility required for the smoking cessation

program become part of the written job description of all pertinent employees. Had that been done, the study might have fostered the continuity of

effort and commitment to tasks required by the project coordinator, the

check-in clerks, the nurses, and the physicians.

Another consequence of the changes in management was that the

medical director and the director of adult medicine became absorbed with

the logistics of changing administrative systems such as billing and reporting

responsibilities and were diverted from providing the project with the additional support it needed. At one point, a new medical director was hired,

and his first project-related action was to suspend the ongoing project and

prevent the research assistants from gathering any information on the

patients. About 2 weeks’ work was lost. Reinstatement occurred only after

one of the senior research staff and the director of adult medicine convinced

the new director that patients participating had signed consent forms and

that the project had been approved by the Institutional Review Committees

of both Indiana University and the HMO.

What Would Two areas should be emphasized in implementing office-based

Be Done smoking cessation programs. The first is the fostering of a team

Differently Now approach and a team spirit to implement the program. The

second is the creation of conditions so that the program not only is integrated into routine care but also is sustained after the project support system

is no longer present. Were the program to be implemented again, the investigators not only would continue to emphasize the team approach but also

would concentrate more on having each of the roles involved in the officebased system for smoking cessation become clearly defined and part of the

written job roles and responsibilities for appropriate office staff. Furthermore, one of the roles that needed to be assigned was that of instructor for

new office staff members about their program responsibilities. Ideally, this

instructional role would be the responsibility of the program coordinator.

One task that could have been performed better was the instruction of

patients in the use of a nicotine substitute. To increase the likelihood of

patients’ adherence to the proper use of a nicotine substitute, free, individually packaged samples (from the manufacturer) could be provided to each

office for trial use. This would allow the physician or other health professional to field questions concerning the correct usage of the product before

the prescription is purchased.

Another task that could have been improved was the use of chart reminders. In both stages I and II, stickers were provided to flag the charts of
Smoking and Tobacco Control Monograph No. 5

126

patients who were smokers. When a chart did not have a sticker, it was not

apparent whether the patient was a nonsmoker or had never been asked about

smoking. Ideally, receptionists could be trained to use stickers that identify

patients as smokers or nonsmokers. This system immediately distinguishes

smokers from nonsmokers and identifies those patients whose smoking status

has not yet been determined. This type of reminder system requires commitment on the part of the receptionist and office team, but it is an appropriate

measure in determining long-term commitment by the practice to a smoking

cessation program.

Because of the investigators’ interest in having a sample size sufficient to

test the hypotheses under investigation, they enrolled all practices interested

in participating. Had this not been a research study, the investigators might

have produced better results by establishing a certain number of prerequisites

before allowing a practice to participate. Just as the time and effort to counsel

smokers will produce maximal results with those most ready to change their

behavior, so too the time and effort needed to train practices may be best

spent with those most receptive to making changes. In making such a determination, it may be best to avoid offices that have a high level of staff turnover and to assess in advance the extent to which physicians and their office

staffs have both the time and interest to establish a smoking cessation program

as part of routine care. A preassessment questionnaire might identify those

ready for change and those disinclined to change. For example, the physicians

might be asked, “Are you willing to use office staff time to put smoking identifiers on all patient charts?” A question to front office staff might be, “Are you

willing to put smoking identifiers on all patient charts?”

In working with physicians in future cessation programs, the nature of

the training sessions could be modified to produce a more individualized

training session. The office could be given a list of very specific job duties to

be distributed to all staff members with the understanding that a commitment

to each person’s responsibilities is necessary to make the program work under

a team approach. Specific emphasis would be placed on a team member’s

accepting the role of “trainer” when new office personnel are hired. This list

would go one step beyond telling the office to make it a team commitment

by demonstrating how the roles can be distributed. Also, group training

in the office could be more effective than a large group session held away

from the clinic environment. The general background seminar could still

be accomplished through a large group program, but individual intervention

techniques might be better demonstrated in smaller site visits to further

personalize the program. Although these changes would increase considerably the time demands on the research team, the final payoff of increased

team commitment would make the initial investment of time worthwhile.
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Chapter 2

DENTIST The goal of the stage I project was to develop, validate, and

INTERVENTIONS evaluate practical methods to help dentists encourage their

patients to stop smoking cigarettes and remain nonsmokers. To

Purpose of Project: determine the most effective intervention method, participating

Stages I and II dentists and their panel of patients who smoked cigarettes were

randomly assigned to one of the following conditions: (1) control (usual

care), (2) nicotine polacrilex available for patients at no charge, (3) a

reminder system for following a practical protocol to help patients stop

smoking, or (4) both nicotine polacrilex and the reminder system.

The purpose of the stage II trials was to determine the extent to which

the “best” smoking cessation intervention method identified in stage I was

adaptable and generalizable to private dental practice settings. When stage II

began, the stage I trials still had 1 year of data collection remaining. Thus,

the “best” intervention method for stage II was determined on the basis of

data developed during the first 20 months of stage I. Preliminary analysis of

these data for dentists determined that the nicotine polacrilex intervention

alone or with the reminders was the “best” method, and it was, therefore,

applied in stage II (Cohen et al., 1989b). In stage II, new cohorts of dentists

in private practice and their panel of patients were randomly assigned to one

of three intervention techniques: (1) control (usual care), (2) free nicotine

polacrilex program supported by the project staff (as in stage I), or (3) prescription nicotine polacrilex program supported by the office staff.

Target Audience: For both phases of the study, participation was limited to private

Stages I and II dental practitioners who primarily treated adult patients on a

regular basis. Thus, the participating dentists were general practitioners

and periodontists. Excluded were dentists specializing in oral surgery,

pedodontics, orthodontics, and removable prosthodontics.

Clinical Setting: All participating dental offices were in Indianapolis and adjacent

Stages I and II suburban areas. Practice size ranged from offices with single practitioners to clinic or group practices. The number of established patients, the

number of staff members employed, and the use of a hygienist varied from

office to office, as did the use of a recall system and a means for identifying

smokers.

To minimize practice size as a potential bias source, offices were stratified

on the basis of the number of eligible and interested practitioners at each

site. They were then assigned to an intervention condition according to

random permutations of four for stage I and random permutations of three

for stage II.

Patients were eligible for participation in the study if they were between

the ages of 18 and 64, reported smoking one or more cigarettes daily, and

had an alveolar breath carbon monoxide determination of more than 8 parts

per million. Patients were excluded if any of the contraindications for the

use of nicotine polacrilex pertained.
Smoking and Tobacco Control Monograph No. 5

128

The sociodemographic characteristics of the 1,027 stage I patients who

agreed to participate (less than a 10-percent refusal rate) were as follows:

the mean age was 37.1 (SD 10.4); the mean number of office visits per year

was 1.2 (SD 1.2); 95 percent were white, and 4 percent black; 57 percent were

female; the median education level was 1 year of college completed; and the

median income was $40,000 annually.

Stage I Procedures to recruit the dentists for participation in stage I began in

Components August 1984. With names drawn from the American Dental Association’s

Directory of Practicing Dentists in Indianapolis, more than 350 letters

Recruitment of introduction, briefly explaining the proposed program, were sent to

Procedures eligible area dentists. Two weeks later, a followup telephone call was

made to each eligible dentist; 297 offices were reached by telephone

and 92 expressed an initial interest in participating. Next, either the project

coordinator or project dentist met with each practicing dentist to further

discuss and describe their potential for participation. During this meeting,

a brief overview of the project was given, and the role of the dentist in the

program was emphasized; 54 dentists agreed to participate and signed up to

attend the educational seminar.

The dentists were motivated to participate in the program for a number

of reasons. One important factor was the encouragement of the chairman

of the Department of Preventive Dentistry, a long-term advocate for a more

active role by dentists in smoking cessation. In general, those dentists who

had a sincere interest in working with the researchers and in developing a

successful cessation program for their offices adapted best to the program

components and maintained an organized program throughout the study

period.

Patient recruitment was conducted by specially trained research assistants.

All patients were screened for eligibility for the study (see “Clinical Setting,”

above). Patients signed an informed consent form that indicated their smoking

habit would be monitored at each regularly scheduled clinic visit, regardless

of their decision to quit or to continue smoking. Patients were notified that

they would be asked to provide a breath sample for carbon monoxide analysis

at each regularly scheduled dental appointment and to answer questions

immediately after seeing their dentist.

Nature of Except for logistics, the training program for dentists was essentially

Training identical to that provided for physicians. To accommodate the dentists

Program from the practicing community, the lecture seminar was offered on four

different dates: two afternoon sessions and two evening sessions. The

first half of the program was intended to provide a common educational background on smoking. Because each assigned intervention method involved

different procedures, the dentists went to one of four smaller group sessions

during the second half of the seminar. Separate presentations were given

to each group to review the appropriate procedures for each assigned

intervention.
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At the beginning of the general lecture, all dentists completed a twopage attitude and practice questionnaire concerning their personal smoking

histories, their current smoking management practices for patients, and their

current interests and beliefs in effectively helping patients stop smoking.

The 1-hour general lecture presented evidence of the medical consequences

of smoking, the benefits of quitting, the addictive nature of nicotine, and

the effect of nicotine polacrilex on smoking cessation. Also discussed was

the available evidence that dentists’ advice could be effective in counseling

patients. Dentists were encouraged to use a four-step counseling protocol

developed at the National Heart, Lung, and Blood Institute for counseling

smokers: (1) Ask your patients about smoking; (2) deliver a firm quit-smoking

message; (3) mutually agree on a quit date; and (4) check your patients’

progress at each regularly scheduled visit. Dentists were also given a copy

of an NCI pamphlet, “Quit for Good,” and were informed that copies would

be provided to their offices for use with their patients who smoke.

The small group presentations centered on providing specifics for each

intervention technique. Dentists in the control group were given a booklet

containing the four-step protocol and were encouraged to counsel their patients who smoke. Dentists in the other three methods received the same

instruction as the advice method plus additional instruction based on their

assigned experimental condition. Information and handouts provided to

the dentists were physician-based materials because dentist-based materials

were not available at that time. The dentists had little resistance to using the

materials and were able to adapt the physician-oriented information to their

context.

Dentists in the nicotine polacrilex group were instructed on the use of

fluorescent red stickers to flag charts of patients who were eligible to receive

the nicotine replacement product at no cost. Dentists were told that research

assistants would place the stickers and remove them after the patient had

received the product. The uses, indications, contraindications, and side

effects of nicotine polacrilex were discussed in detail. Offices were provided

with product log books to record when nicotine gum was dispensed, and

dentists were encouraged to record on the patient’s chart when the product

was dispensed. It was mandated that the product be stored in a safe, locked

place.

In the reminder condition, dentists were instructed on the use of two

fluorescent chart stickers to help remind them to follow the step-care protocol.

A green sticker was used to remind them to ask the patient about smoking,

and an orange sticker indicated that they should ask the patient to set a quit

date. Dentists were informed that a feedback report issued to them bimonthly

would provide the names of smoking patients they identified as well as the

quit dates they had established with their patients. Unfortunately, it seemed

that many feedback reports were not read or were ignored by the dentists.

It is unlikely that the reports had any great impact on the dentists’ behavior.
Smoking and Tobacco Control Monograph No. 5

130

For the dentists in the combined condition (nicotine polacrilex plus

reminder), instruction was given on the use of all three stickers and the

dispensing and storing of nicotine polacrilex. For those dentists unable to

attend any of the four seminars, a similar in-office presentation was given.

Approximately 1 week before the initiation of the intervention method

in each office, a project director and research assistant assigned to that office

(research assistants were assigned to an office on the basis of the office location—southwest, southeast, north) visited the office for a 1-hour meeting to

review the record-keeping procedures and to answer any questions resulting

from the general seminar. Initiation of offices was staggered for logistical

purposes, to adequately train and monitor offices and to accommodate those

offices that requested a delayed starting date. In-office training procedures

began in October 1984, and all offices were initiated by April 1985. Three

research assistants were employed to initiate and maintain the offices, allowing for each research assistant to be responsible for 14 to 17 offices throughout

the study period. Of the 54 dentists trained, 50 actively participated in the

program.

Results The results of the study have been described in detail elsewhere (Cohen

et al., 1987 and 1989b). The dentists’ behavior under each intervention is

shown in Table 17.

Because cigarette smokers often quit smoking and later relapse, the prevalence of smoking was estimated at two subsequent intervals. The first estimate

(6 months) was defined as the smoking status determined at any visit that

occurred at least 3 months after the initial appointment but not more than

9 months after it. The second estimate was at 1 year, which was defined as

at least 9 months and 1 day after the initial visit and up to 15 months after

the initial visit. If there was more than one visit during a time interval, the

smoking status was determined by the status at the last visit during that

interval. For patients who had a regularly scheduled appointment during

Table 17

Reported dentist counseling about cigarette smoking

Percentage of Patients Reporting Actions

Asked About Advised Asked About Setting

Smoking To Quit a Quit Date

Dentist Group

Advice 31% 18% 3%

Gum 72 32 6

Reminder 59 29 14

Both 95 54 31
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Chapter 2

the critical period, their smoking status was confirmed through carbon

monoxide assessment, the procedures for which are described elsewhere

(Stookey et al., 1987). Patients who did not visit the dentist during the 6- or

12-month period were assumed to be smokers. Thus, the results are reported

both for returnees, for whom biochemical validation was possible, and for all

enrolled patients on the basis that a patient was a smoker unless there was

biochemical evidence to the contrary.

A generalized linear model was used to analyze the results of the quitsmoking rates. The 6-month results are shown in Table 18. The generalized

linear model for all enrollees produced borderline significant main effects for

the gum group and for the reminder group. However, the coefficient for

the reminder effect was negative. Statistically, this result is caused by the

high cessation rates in the gum group coupled with the lower rate in the

gum and reminder group. These rates for all returnees may not reflect the

effectiveness of the intervention but may, in part, be artifacts of the number

of patients who returned during the time window. Whereas those patients

who did not return were classified as smokers, the cessation rate in both

gum and reminder groups was depressed by a lower 6-month return rate

(32.3 percent) than in the other groups (control 43.8 percent, reminder

43.3 percent, and gum 49.5 percent).

The results at 1 year are shown in Table 19. At 1 year, there was a significant effect of the gum for both those patients who returned during that time

interval and for all patients. No other effects were significant.

Table 18

Confirmed success rates at the 6-month visit for each dentist intervention

Percentage Who Quit

Returnees Only All Enrollees

(n=428) (n=1,027)

Dentist Group

Control 7.1% 3.1%

Reminder 7.4 3.2

Gum 18.2 9.0

Both 9.4 3.0

Generalized Linear Model Significant p Values

Reminder > 0.10 0.051

Gum 0.072 0.061
Smoking and Tobacco Control Monograph No. 5

132

Table 19

Confirmed success rates at the 12-month visit for each dentist intervention

Percentage Who Quit

Returnees Only All Enrollees

(n=374) (n=1,027)

Dentist Group

Control 7.7% 3.1%

Reminder 8.6 2.8

Gum 16.3 7.7

Both 16.9 4.7

Generalized Linear Model Significant p Values

Gum 0.012 0.038

Special Resources For a program of this size and intensity, special resources were

Or Procedures necessary to achieve sufficient cooperation from the dental offices.

Maintaining each office’s motivation level and commitment to the

program required constant attention from the research team.

In stage I, with program emphasis on the dentist rather than on the

dental team, research assistants concentrated their efforts on implementing

the program components, especially identifying patients who were smokers,

and on providing open communication with the dentist. These two objectives

proved difficult to achieve without the development of rapport between the

research assistant and the office staff. Office staff members were often resistant

to an outsider potentially disturbing their daily routine. Many were reluctant

initially to include the research assistant as a working part of their program. It

became apparent that the research assistants needed to find a way to integrate

themselves and the program components into a regular part of the dental

offices. This rapport development was crucial to the success of each office

program.

The means to develop rapport varied with each office. In some offices,

the research assistant would occasionally volunteer to assist the receptionist

with clerical duties, such as filing or confirming patient appointments. This

work not only relieved the receptionist of these tedious tasks but also provided

the research assistant with an opportunity to blend the program functions

into the regular office routine. While filing, the research assistant added

stickers to the charts of newly recruited patients; while confirming appointments, the assistant obtained patients’ smoking status. The working relationship that developed between the receptionist and the research assistant, and
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Chapter 2

the subsequent routine implementation of the program components by the

receptionist, soon led to a well-maintained smoking cessation program.

Personnel in some offices were not comfortable with having the research

assistant help with clerical duties. In those offices, the research assistant tried

to establish rapport with a specific staff member. Taking the time to make

light conversation and to show an interest in the staff member gradually

contributed to the development of trust between the two parties.

In other offices, the research assistant found a means to intercede with

a solution to a current office problem. For example, one office was preparing

to move and was struggling to find time to purchase file boxes to pack patient

records. The research assistant surprised the office one afternoon by delivering

a case of file boxes. This one simple gesture created a rapport with the office

and prompted a newfound interest in the program. For the research assistant,

finding a way to develop an essential positive rapport with the office was the

most efficient way to assure smooth implementation of the program.

Barriers or Implementing a program of this nature led to the identification of a

Problems series of barriers or problems that needed to be overcome. Approaches

Overcome initially anticipated to work often had to be adjusted to meet the demands

of a given situation. For example, the logistics of covering offices from

such a wide geographic area was anticipated to cause some difficulty with the

requirement for research assistants to conduct an exit interview with every

smoker to determine their status and the nature of the counseling they

received. Initially, this problem was managed through reduction of the

number of office sites; only group offices of two or more dentists each were

recruited. When initial interest by some group practices decreased, single

practitioner offices were then invited to participate. To help offset the increased site locations and provide a more even recruitment and followup

schedule, dates for initiation of the program were staggered, and research

assistants were assigned to a territory of Indianapolis to reduce travel time

between sites as much as possible. Research assistants also carried voice

pagers to relay messages from the research institute and eliminate the need

for unnecessary travel to offices where a patient had failed to arrive or had

canceled an appointment.

Another problem involved the slower than anticipated rate for identifying

smokers in each dental practice and then subsequently recruiting them into

the study. In stage I, dental offices were expected to identify and recruit 30 to

100 patients (an average of 40 patients per office) in an 8-month period. At

7 months into the program, only 471 of the anticipated 1,000 patients had

been recruited in offices involved in the study. For those offices having

difficulty in identifying patients who smoked, the research assistant and

dentist met to discuss alternative ideas.

Originally, it was presumed most offices would have the smoking status

indicated on the patients’ charts. For those that did not, office staff members
Smoking and Tobacco Control Monograph No. 5

134

were expected to ask patients their smoking status over the phone when

they confirmed recall appointments. However, in more than half the offices

involved, smoking status was not available through the patients’ records and

the receptionists did not want to risk antagonizing patients by asking their

smoking status over the telephone. The following suggestions were given

to the dentist as alternatives for obtaining smoking status: (1) update each

patient’s medical history through the use of a new medical history form that

included smoking status; (2) keep a running list of names in the operatory

of patients who smoke as they were identified (hygienists had the best means

for identifying smokers, through visible tar and nicotine stains at the time of

the teeth cleaning); (3) have the dentist or hygienist check the appointment

book each week to identify patients they recognized as smokers; and (4) have

the research assistant stationed in the waiting room on a given afternoon each

week to ask patients their smoking status as they arrived (given as a last choice

because of constraints on the research assistant’s time).

For those offices having difficulty with adjusting to the routine of a

smoking cessation program and with overcoming their hesitancy to address

patients about their smoking habit, a meeting was arranged among the dentist,

research assistant, and project coordinator. An attempt was made to better

tailor the program to each office’s specific needs and to provide further ideas

on approaching the patient about smoking.

In many cases these procedures, singly or in combination, catalyzed

renewed interest in the program and resulted in an increase in the number

of patients recruited. For those offices where a rapport was difficult or

impossible to achieve, patient recruitment continued to be difficult.

Once the program had been initiated, a system was needed to identify

followup appointments and to assess the smoking status of patients at 6 and

12 months after their recruitment date. The use of a 6-month preappointment

recall system was presumed to be the means for obtaining followup interviews.

The objective was to establish the patient’s recall visit at the completion of

the initial appointment. However, a wide range of office recall systems was

used in the different offices. The following two systems were recommended:

(1) the research assistant provided the receptionist with a list of patients due

each month and the office staff, in turn, notified the research assistant when

a patient scheduled an appointment (this was the weaker of the two systems

because it mandated the cooperation of the receptionist in recognizing the

participant and notifying the research assistant); and (2) the research assistant

checked the appointment book weekly to determine if anyone in the study

was scheduled for a recall appointment. The second method was preferred

to the first but was not always permitted by the office staff. The second

method also did not account for patients scheduling last-minute appointments. The best approach, still, was to develop a good rapport with the

office staff to ensure cooperation with recall appointments. If a patient

missed a recall appointment and the research assistant was notified about

it within 24 hours, a followup interview over the phone was obtained.
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Chapter 2

The training of new office personnel also presented some problems. In

stage I, the dentists were expected to educate their new staff members on the

components of the program, but they often relied on the research assistant to

do so. Not only were new staff members not trained for their responsibilities

in the program, but also many were not informed of the program upon

accepting their positions. A well-run recruitment and followup program

could quickly be devastated by the arrival of an unwilling new employee.

Research assistants took great pains to establish a rapport with new staff

members. Treating the new employee to lunch to discuss participation in

the program and carefully following progress each week helped to gradually

reinstate the program to its original operation. Turnover in participating

dental offices was high, and the retraining of new personnel was a continual

responsibility of the research assistant.

Stage II As previously stated, stage II was initiated 1 year before the completion

Components of stage I. In August 1986, 354 dentists listed in the American Dental

Association Directory and not currently participating in stage I were

Recruitment contacted by mail with a similar letter of introduction. Followup

Procedures telephone calls found 53 dentists interested in meeting to further

discuss the program. During meetings in the dentists’ offices, the project coordinator explained the project goals, objectives, and procedures.

Unlike the meetings in stage I, the level of team commitment required from

the dental office was emphasized. The 42 dentists who agreed to participate

were strongly encouraged to bring their staff members to the seminar.

Nature of Dentists and their office staffs participating in the stage II program

Training attended a seminar offered on one of four dates. This educational

Program seminar used a format similar to the stage I training session. A general

orientation seminar on the background of smoking opened the meeting

and was followed by a breakout into three smaller groups for intervention

training. Dentists also completed an attitude and practice questionnaire at

the beginning of the meeting. Throughout the seminar, the dentists and

office staffs were trained as a unit to emphasize team collaboration and

commitment.

The first half of the program included the same information as the stage I

general seminar but emphasized the team approach to a successful program.

In stage I, it was observed that the hygienist often took the primary role of

counselor, with the dentist providing reinforcement counseling and prescribing nicotine polacrilex when indicated. The team approach presented in the

stage II seminar emphasized the involvement of staff members, in particular

the hygienist, and encouraged the dentist to tailor the smoking cessation

program to maximize the resources, skills, and interests of the dental team.

The dentists were asked to assign an office coordinator to be responsible for

maintaining the program and providing communication between the office

and research personnel.
Smoking and Tobacco Control Monograph No. 5

136

Experience in stage I showed that the mechanics of addressing the

patient were a major concern for office personnel. The dentists and staff

members were hesitant about addressing smoking with their patients. They

were concerned about offending the patients and subsequently losing them

from the practice. Therefore, during the stage II general seminar, specific

techniques were illustrated for dentists to use when counseling the patients

who smoke. A videotape developed at the University of California, San

Francisco, was used to show physicians talking to patients about smoking.

Shown is an interaction to assess a patient’s interest in quitting, establishing

a quit date, and receiving educational materials and encouragement. Also

shown is an interaction between a physician and a patient who had made a

quit attempt and then relapsed before the office visit. One segment depicts

a conversation with a patient who is interested in discussing exercise but

not smoking.

The videotape is very adaptable for the dental setting, and the taped

interactions illustrate a positive, nonthreatening approach to smoking

counseling. For example, rather than lecturing patients and emphasizing

the health consequences of smoking, the physician role models ask questions

such as, “Have you thought about quitting?” and “Are you ready to make

another quit-smoking attempt?” The vignettes illustrate how to tailor the

counseling for patients who have varying degrees of interest in stopping

smoking. Dental teams were encouraged to use these skills with their

patients who smoke.

After viewing the videotape, dental teams were encouraged to practice

the techniques demonstrated on the tape. Despite the fact that the role

models were physicians, the dental teams reported that the information was

of great value to them.

At the conclusion of the general seminar, dentists and their office staffs

were given copies of the “Quit for Good” pamphlet. They were informed

that copies would be provided at no charge to their offices for patients who

smoke.

During the second half of the seminar program, specific techniques

pertaining to each intervention condition were outlined and discussed with

the offices randomly assigned to those interventions. Dental practices in the

control group were given the same booklet that the stage I group was given

and were encouraged to follow the step-care protocol for counseling their

patients who smoke. Dental practices in the other two interventions received

the same instruction as the control group plus additional instruction based

on their assigned condition.

Those persons in the free nicotine polacrilex method supported by

research staff were instructed in basically the same manner as their counterparts in the stage I method. They were informed that red fluorescent stickers

would be placed by research assistants on the charts of patients who were
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eligible to receive the nicotine replacement product. The dental teams were

made aware that the stickers would be permanently removed once the product

had been prescribed. The uses, indications, contraindications, and side effects

of nicotine polacrilex were discussed in detail. The requirements for storing

the product were also reviewed. Offices were provided with log books for

recording when the product was dispensed, and participants were encouraged

to enter on the patients’ charts the date that the product was dispensed.

Offices assigned to the nicotine polacrilex prescription method supported

by office staff were instructed on the use, indications, contraindications, side

effects, and record-keeping procedures for nicotine polacrilex in a manner

identical to the free-product group. However, because the purpose of this

trial was to determine the feasibility of a dental team’s carrying out the stepcare protocol of a cessation program with only minimal support from the

research team, this group of participants was taught how to perform the

procedures needed to support the program on their own. This group was

told that it was the responsibility of the office staff to take the provided

stickers and label the charts of the patients listed on the enrollment roster.

As stated in the results section, 77 percent of the charts were flagged by

office staff as a result of the weekly roster of eligible patients.

Instead of offices being provided with free nicotine polacrilex to dispense

to their patients, these offices were instructed on how to prescribe the product

and were given a carbon-copy, prestamped prescription pad. The carbon copy

allowed research personnel to periodically check when the product had been

prescribed. Office personnel were instructed on the method for flagging the

charts of eligible patients. They were informed that the research assistant

would provide a list of patients recruited that week who were eligible for a

prescription and who should have a sticker placed on their chart. The research assistant periodically checked charts to determine if stickers had been

placed. As with the second group, dentists and hygienists were encouraged

to review the product usage instructions with the patient and to record in

the chart when the product had been prescribed. Those dentists and staff

unable to attend any of the scheduled seminars (about 10 percent) were

given a similar in-office presentation.

One week before each office began the study, the study coordinator and

research assistant assigned to that office visited the office to deliver program

material and review the program again with the dental team. Initiation of

dental offices in stage II was again staggered for optimum recruitment and

followup procedures. Of the 42 offices initially trained, 35 completed the

program.

Results To determine the extent to which the office staffs performed the tasks

requested of them, office charts of the patients enrolled in the study were

examined. In comparison with the 100 percent of charts that were flagged

in the research-support condition, 77 percent of the charts were flagged in

the office-staff condition.
Smoking and Tobacco Control Monograph No. 5

138

Not surprisingly, the behavior of the dentists in counseling smokers

was affected by the intervention condition. Office exit interviews of patients

showed that 16 percent of control group patients, 20 percent of office-staff

patients, and 34 percent of research-support patients (p=0.07) reported

that their dentist had talked to them that day about smoking. Also, the

percentages of patients given or prescribed the nicotine substitute were

6 percent, 14 percent, and 46 percent, respectively, for the control, officestaff, and research-support conditions (p < 0.0001). Neither the 6-month

nor 12-month smoking cessation results produced statistically significant

differences among the three groups, although the rates for the 12-month

point were 3.1 percent, 6.9 percent, and 9.2 percent (p=0.10) for the control,

office-staff, and research-support conditions, respectively.

Special Resources In stage II, the work of the dental office as a team was emphasized.

Or Procedures Developing rapport with the entire office was a major priority.

Research assistants worked at making staff members feel they were

an integral part of the success of the program. Some new procedures were

integrated into stage II to aid implementation of the program. One such

procedure was the requirement that one member of the office staff serve

as the office program coordinator. Communication on specific program

details was relayed through the office coordinator. In return, any problems

or concerns regarding the in-office mechanisms of the program were communicated to the research staff through the office coordinator. The use of this

new position was vital for opening the lines of communication and avoiding

misunderstandings that arose in some of the offices involved in stage I.

Another procedure involved a scheduled weekly visit by the research

assistant to the office. Regardless of the number of patients interviewed in

each office in a given week, the research assistant made a visit to each office

on the same day and time each week. The day and time were established

by the office staff and then worked into the research assistant’s schedule as

closely as possible. This established a routine for the program and allowed

staff members to share questions, concerns, or ideas about the program and

present them to the research assistant at one time. Also at this time, and

depending on the conditions mandated by the intervention technique

assigned, the research assistant verified that there were ample supplies,

checked the log book with the nicotine polacrilex count to determine if

all of the product dispensed had been recorded, checked prescription pads

to see if the product had been prescribed, and reviewed charts to see if

stickers had been placed. The research assistant became a routine part of

the office through the use of these weekly visits and, in addition, met with

staff members once a month to field questions from the group as a whole.

This fostered an exchange of ideas and emphasized the team approach to

the program. The meetings lasted 10 to 15 minutes and usually were made

a part of the regular monthly staff meeting. For those offices that did not

hold regular monthly meetings and were unwilling to assemble as a group,

the research assistant continued to conduct a monthly meeting with the

office coordinator to discuss the program.
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Incentives were also used as a new special resource in stage II. At the

beginning of the recruitment period, offices were informed that a free lunch

at a local restaurant would be awarded to each office that reached its quota

for the number of patients recruited (i.e., 50 patients per dentist during the

first year). The number of patients recruited to date was also reviewed at

each staff meeting to continually motivate the teams toward their goal. For

offices that were particularly struggling but making progress, coffee and

donuts were given as an incentive to keep up the good will among the staff.

These special resources provided a vital connection in propelling the

dental team toward a successful implementation of the smoking cessation

program.

Barriers or There were fewer barriers and problems in stage II. Problems that had

Problems occurred in stage I could be anticipated and solved before they progessed

Overcome in stage II. Continued emphasis was given to developing a rapport with

the dental team, and approaches for handling familiar problems were

refined. Problems such as high staff turnover and finding a means for

determining patients’ smoking status still occurred, but experience from

stage I aided in the adoption of procedures discussed previously. No new

problems surfaced in stage II that had not been confronted in stage I.

What Worked In stage II, the focus of a team approach brought together a group

And Why of interested staff members who all felt involved and consequently

were more willing to work toward their goal. Those offices in which the

program was most successful integrated the smoking cessation program with

their office routine (Cohen et al., 1990). Those offices that never allowed

the research assistant to get involved with their office routine never really

integrated their programs. In successful offices, the research assistant was

perceived as part of the office team. Dental staff turnover was great in many

participating offices, and this hampered the ability of the research assistant

to form a rapport with the team. To best sum up the success of this program,

stages I and II required a dedicated research team, an interested dental team,

and a trusting relationship.

What Did Not During stage I, the target of the intervention and training was the

Work and Why dentist. In stage II, it was the entire practice. The initial assumption, that dentists in stage I would orient and organize their staffs, proved

faulty. The dentists were simply too busy to concentrate on orienting their

staffs. Many tried to delegate their duties to a staff member, but a lack of

communication often led to misunderstandings, and interest declined.

Without the team approach, other staff members felt slighted and made

no effort to become involved in the program.

There were some dental offices where the dentist did very well and

accepted primary responsibility for the program. In most of these cases,

however, the office had previously developed a true commitment to the

values of the program and were motivated to succeed. Some dentists signed
Smoking and Tobacco Control Monograph No. 5

140

up for reasons other than the desire to help their smoking patients quit.

These offices rarely developed successful programs (unless a motivated

staff member, such as the hygienist, had enough influence and interest to

keep the program going). In some cases, dentists later admitted becoming

involved only to look good in the dental community or because they hoped

to receive a free product to hand out to their patients.

What Would Two areas should be emphasized in implementation of office-based

Be Done smoking cessation programs. The first is the fostering of a team

Differently Now approach and team spirit when implementing the program. The

second is the creation of the conditions so that the program not only is

integrated into routine care but also is sustained after the project support

system is no longer present. Were the program to be implemented again,

the investigators not only would continue to emphasize the team approach

but also would concentrate more on clearly defining each of the roles involved in the office-based system for smoking cessation and including them

as part of the written job roles and responsibilities for appropriate office staff.

Furthermore, one of the roles needed was that of instructor for new office

staff in their program responsibilities. Ideally, the instructor’s role would

be the responsibility of the office coordinator.

One task that could have been performed better was the instruction of

patients in the use of a nicotine substitute. To increase the likelihood of the

patient’s adherence to the proper use of a nicotine substitute, free, individually packaged samples (from the manufacturer) could be provided for trial

use in the office. This would allow the dentist or other health professional

to field questions about correct use of the product before the prescription is

purchased.

Another task that could have been improved was the use of chart

reminders. In both stages I and II, stickers were provided to flag the charts

of patients who were smokers. When a chart did not have a sticker, it was

not readily apparent whether the patient was a nonsmoker or had never

been asked about smoking. Ideally, receptionists could be trained to use

stickers that identify patients as smokers or nonsmokers. They could immediately distinguish smokers from nonsmokers and identify those patients

whose smoking status has not yet been obtained. This type of reminder

system requires commitment on the part of the receptionist and office team

but is an appropriate measure of long-term commitment by the practice to

a smoking cessation program.

Because the investigators were interested in having a sample size sufficient to test the hypotheses under investigation, they enrolled all practices

interested in participation. Had this not been a research study, the investigators might have produced better results by establishing a certain number of

prerequisites before allowing a practice to participate. Just as the time and

effort to counsel smokers will produce maximal results with those most

ready to change their behavior, so too, the time and effort needed to train
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practitioners may be best spent with those most amenable to making changes.

In making such a determination, it may be best to avoid offices that have

a high level of staff turnover.

In future cessation programs involving dentists, the nature of the training

sessions could be modified to produce a more personalized training session.

The office could be given a list of very specific job duties to be distributed to

all staff members with the understanding that a commitment to each person’s

responsibilities is necessary to make the program work under a team approach.

Specific emphasis would be placed on a team member accepting the role of

trainer when new office personnel are hired. This list would go one step

beyond telling the office to make it a team commitment by demonstrating

how the tasks can be distributed. Also, group training at the office would be

more effective than in a large group session held away from the clinic environment. The general background seminar could still be accomplished through a

large group program, but individual intervention techniques might be better

demonstrated in site visits with small groups to further personalize the program. Although these changes would increase considerably the time demands

on the research team, the final payoff of increased team commitment would

make the initial investment of time worthwhile.

DIFFERENCES BETWEEN In some respects, a dental practice is an easier environDENTAL AND MEDICAL ment for establishing a smoking cessation program as

PROGRAMS part of routine care. First, the purpose for most visits is

prophylaxis, so patients start with a prevention orientation and often are not

there for acute care. Another important factor is the amount of time a patient

spends in the office. Most dental visits last from 30 minutes to 1 hour,

whereas medical visits are often scheduled at 15-minute intervals. Thus,

the time for adequate counseling is more available in most dental settings

than in most medical settings. On the other hand, physicians perceive

counseling patients about smoking as part of their clinical responsibility,

while many dentists still are not comfortable with the role of smoking

cessation counselor. This is demonstrated by many dentists having much

greater interest in continuing education about smokeless tobacco than in

cigarette smoking cessation.

Progress is continuing through a number of excellent dental team

training programs conducted through the National Cancer Institute. The

availability of materials tailored for the dental team appears to facilitate

the willingness of dentists and their staffs to be involved in the national

effort to make counseling about smoking cessation a routine part of

health care.
Smoking and Tobacco Control Monograph No. 5

142

REFERENCES

Cohen, S.J., Christen, A.G., Katz, B.P., Drook, C.A.,

Davis, B.J., Smith, D.M., Stookey, G.K. Counseling

medical and dental patients about cigarette

smoking: The impact of nicotine gum and chart

reminders. American Journal of Public Health 77:

313-316, 1987.

Cohen, S.J., Kelly, S.A., Eason, A.A. Establishing

smoking cessation programs in dental offices.

Journal of the American Dental Association 20

(Suppl.): 28S-31S, 1990.

Cohen, S.J., Stookey, G.K., Katz, B.P., Drook, C.A.,

Christen, A.G. Helping smokers quit: A

randomized controlled trial with private-practice

dentists. Journal of the American Dental Association

118: 41-45, 1989a.

Cohen, S.J., Stookey, G.K., Katz, B.P., Drook, C.A.,

Smith, D.M. Encouraging primary care physicians

to help smokers quit: A randomized controlled

trial. Annals of Internal Medicine 110(8): 648-652,

1989b.

Stookey, G.K., Katz, B.P., Olson, B.L., Drook, C.A.,

Cohen, S.J. Evaluation of biochemical validation

measures in determination of smoking status.

Journal of Dental Research 66: 1597-1601, 1987.
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5 Work on the TRACC program is supported by National Cancer Institute grant no. CA-44648.

The Tobacco Reduction and

Cancer Control (TRACC) Program:

Team Approaches to Counseling

In Medical and Dental Settings5

Jack F. Hollis, Thomas M. Vogt, Victor Stevens,

Anthony Biglan, Herbert Severson, and Edward Lichtenstein

INTRODUCTION Physicians and dentists are effective smoking interventionists

(Cohen et al., 1989a and 1989b; Cummings et al., 1989; Janz et al., 1987;

Li et al., 1984; Ockene, 1987a; Wilson et al., 1988). Although surveys of

physicians indicate that about half report advising “most” of their patients

to stop smoking (Fortmann et al., 1985; Wells et al., 1984), the consistent

success of controlled physician intervention studies emphasizes the need for

improvements in smoking interventions delivered through the medical care

setting. Wells and colleagues (1984) presented a model that related physician practices used in counseling smokers to personal habits, the reimbursement system, clinical training, motivation, perceived risk of smoking, perceived skill in counseling, and perceived benefit. To this model should be

added the time constraints faced by so many physicians, particularly those

in prepaid group practice settings.

Physician-delivered smoking interventions have distinct advantages and

disadvantages. The advantages include the credibility of the physician, the

teachable moment created by the juxtaposition of that credibility with an

illness experience, and the potential for reinforcement of the intervention

over many years. Disadvantages of physician interventions include inconsistent compliance by physician interventionists, variable levels of counseling

skills, lack of training, lack of time, lack of incentive, and competition from

more acute medical problems.

The Tobacco Reduction and Cancer Control program was designed

as a mechanism for using the strengths of physician interventions while

overcoming the disadvantages (Vogt et al., 1989). The general approach

of TRACC has three steps: (1) randomized efficacy trials of intervention

approaches; (2) demonstration studies of large-scale implementation; and

(3) evaluation of the demonstration programs and dissemination to large

medical care systems. TRACC was initiated in 1987 as a group of five randomized studies designed to determine effective methods for integrating
Smoking and Tobacco Control Monograph No. 5

144

smoking counseling into the medical care setting. It addressed interventions

in outpatient, inpatient, and dental settings and included direct outreach

to adolescents. TRACC interventions were, in most situations, introduced

by providers but conducted by other appropriately trained medical personnel. Centralized systems identify smokers and also keep track of quit dates

so that supportive followup calls can be made by trained phone callers.

These approaches are applicable to other aspects of cancer control and

behavior change as well. Currently, TRACC is completing step 1 (randomized efficacy studies) and is moving into a large-scale demonstration program. The following section discusses the approaches used in TRACC interventions and their impact on smoking behavior of patients in the Northwest

Region of Kaiser Permanente, the Nation’s largest managed care health

maintenance organization.

NURSE-ASSISTED Medical office smoking interventions generally rely on physicians

COUNSELING to assess patient smoking status, provide advice and materials,

determine readiness to quit, deal with barriers to change, and encourage

patients to set quit dates and develop effective strategies for coping with

withdrawal symptoms. Although motivated physicians with an appropriate

training program and a well-organized system for monitoring and reinforcing

physician compliance can significantly enhance cessation rates among

patients (see reviews by Kottke et al., 1988; Ockene, 1987a; Pederson, 1982),

it is less clear that such programs can be widely disseminated and easily

sustained, especially in medical settings that are not research oriented.

In many primary care settings, physicians may spend only 15 minutes

with the average patient. That time must be used to diagnose, discuss, and

treat the presenting complaint; arrange needed referrals or routine screening;

and respond to a variety of other patient concerns. As important as it is,

smoking counseling frequently gets short shrift or is avoided altogether

because of the pressures of acute care delivery. Physician-centered counseling also makes little use of nurses and other intervention resources available

in clinical settings. Kottke et al. (1988) have concluded that various and

repeated messages from all staff members through a number of communication channels constitute the most effective way to enhance impact.

Our initial aim was to develop a smoking intervention in the medical

care setting for Kaiser Permanente, Northwest Region. To be practical, it

had to be not only effective but also relatively easy to implement and sustain

within a large managed care setting. We concluded that the intervention

should contain the following components: (1) assessment of smoking status;

(2) firm advice to stop smoking; (3) cessation videos, manuals, and mailings;

(4) encouragement to set a specific quit date; and (5) a followup phone

contact to check on progress. Assessment of smoking status at each visit

highlights the importance of cessation to patients and is needed to direct

intervention to those who need it. A physician’s firm advice to quit takes

advantage of his or her credibility and authority and creates a teachable

moment. To reduce the burden on staff, information on cessation strategies
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and how to overcome barriers can be provided effectively and economically

in the form of videos, manuals, and followup mailings. Patients who are

ready to quit should be encouraged by staff to make a commitment to a

personal action plan and select a specific quit date. To enhance perceived

support and accountability, a followup call should be scheduled for 1 or

2 days after the quit date. Although all of these components may be helpful,

we thought it unrealistic to expect that most primary care providers would

consistently carry out all of these steps with their smoking patients. Instead,

we decided to minimize the burden on the provider and test a team approach

involving physicians, nurses, and other clinic staff.

The team approach to counseling offered several advantages over a

physician-centered model. This approach took advantage of the physician’s

prestige and credibility to initiate the intervention process. Physician time

and effort were minimized, however, by having nurses or other clinic-based

staff reinforce the stop-smoking message, provide stop-smoking videos and

manuals, encourage patients to set quit dates, and provide followup phone

contacts. To reduce the burden on support staff, most of the motivational

and educational information was delivered through manuals and videos

tailored to the needs of the local patient population. Periodically, newsletters and other cessation materials were mailed by centralized clerks

using a computerized patient tracking system.

The purpose of this project was to assess the feasibility and effectiveness

of nurse-assisted outpatient smoking intervention procedures. The primary

outcome was a comparison of the impact of physician-nurse team approaches

to smoking counseling to brief physician advice alone. The study methods

and findings are described below, and a more detailed presentation is available

elsewhere (Hollis et al., 1991; Lichtenstein and Hollis, 1992).

Intervention A phase III randomized clinical trial was carried out within two large

Setting And Kaiser Permanente medical offices. All 60 internal medicine and family

Methods practice providers in the two medical offices were invited, and all

participated in the intervention. The physician’s role was simple; it

Procedure included 30 seconds of clear advice to quit plus a referral to a nurse

smoking counselor for additional intervention. Physician training was

carried out in a single 1-hour meeting with some individual clinic followup.

Training emphasized how to deliver brief cessation advice and refer patients to

the clinic-based smoking counselor (e.g., a nurse). Role-playing, questions, and

discussion were encouraged.

The nurse-delivered components were provided by several project staff

members, headed by a lead counselor who was a nurse with no previous

smoking cessation experience. Each counselor could handle the smoking

patients of 16 to 20 physicians. The training for the counselors included roleplaying from an intervention outline, observing a stop-smoking class, and

several weeks of pilot testing. Others of the clinic staff were oriented to their

roles during regular weekly staff meetings with some individual followup.
Smoking and Tobacco Control Monograph No. 5

146

Receptionists asked all primary care patients to complete a brief health

habits questionnaire while waiting for their appointments. Regular clinic

nurses or clinical assistants collected the questionnaires as the patients were

taken to exam rooms and attached a colored form to the medical chart of

smokers to alert physicians to deliver the cessation advice and referral

message.

Physicians delivered a 30-second stop-smoking advice message that was

designed to minimize defensiveness and create a teachable moment. The

form on the chart included the following script, but physicians were free

to deliver the message in their own words:

The best thing you can do for your health is to stop smoking, and I

want to advise you to stop as soon as possible. I know it can be hard,

and many try several times before they finally make it. You may or

may not want to stop now, but I want you to talk briefly with our

smoking specialist who has some tips to make stopping easier when

you decide the time is right.

At the end of the visit, patients saw the on-site smoking counselor (i.e.,

a trained nurse). Two random digits in the patient’s health record number

were used to assign patients randomly to one of the following four conditions:

advice only, self-quit training, group recruitment, or a combination treatment.

Advice-only control subjects received the physician advice message and the

brief National Cancer Institute pamphlet, “Why Do You Smoke?” Although

little information on how to stop smoking was offered, clear and systematic

physician advice was expected to be more effective than no treatment or

usual care.

Self-quit subjects received physician’s advice, and the nurse tested them

for carbon monoxide. Patients were then left alone to watch a 9-minute video

on how to quit on their own. The video was produced by Independent Video

Services and Anthony Biglan, Ph.D., at the Oregon Research Institute, and it

is available from Dr. Biglan. The video focuses on the steps other patients

had used to quit successfully, the frequent need for repeated efforts, and the

importance of setting a quit date and using substitutes for smoking. Patients

were given a stop-smoking kit (e.g., gum, toothpicks, cinnamon sticks, quit

tips) and a choice of one of three stop-smoking manuals (provided by the

National Cancer Institute and the American Lung Association). Patients could

also call a local stop-smoking hotline or attend a free 90-minute session on

how to stop smoking, although those resources were almost never used. The

counseling nurse also encouraged patients to set a specific quit date and a

followup call was planned, usually within 2 to 4 weeks, to check on progress

toward cessation. Finally, patients were mailed a set of stop-smoking tip s

heets and, on request, a series of six attractive bimonthly newsletters devoted

to smoking cessation.
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Group-recruitment subjects also received physician advice, the carbon

monoxide assessment, and a video. In this condition, the video encouraged

patients to join the HMO’s intensive nine-session stop-smoking program

known as Freedom From Cigarettes (Stevens and Hollis, 1989). Patients were

provided a brochure, a group schedule, and a time-limited coupon to waive

the program fee. Patients were then invited to sign up for an upcoming

group, and reminder postcards were sent 1 week prior to the scheduled

meeting. The counseling nurse also called patients several days after the

meeting to provide support for any progress.

Combination-treatment subjects also received advice, the carbon monoxide test, and a third video, which describes both self-directed cessation

techniques and the pros and cons of joining a professionally run program.

The self-help manual, stop-smoking kit, and the group materials and coupons were all provided. Subjects were encouraged to set a quit date or sign

up for an upcoming group, and a phone call was arranged to check on

progress. Tip sheets and the bimonthly newsletters also were provided.

Results About 24 percent of this outpatient population reported smoking, and

a total of 3,161 eligible smokers were identified over the year-long recruitRecruitment ment period. Of these, 2,707 (86 percent) received brief stop-smoking

advice from a medical care provider. In this intent-to-treat design, all

smokers who received physician advice were considered randomized subjects

even if they failed to see the nurse for additional intervention. Fortunately,

the vast majority of advised patients (87 percent) agreed to see the clinic

counselor (Table 20). This rate was similar across the four groups. The four

treatment conditions were similar also in terms of baseline age, sex, race,

education, occupation, cigarettes per day, contemplation status, confidence

in ability to quit, perception of weight status, and subjective health status.

Table 20

Cessation activities, by treatment condition

Percentage in Treatment Condition

Advice Self- Group Combination

Only Help Recruitment Treatment p <

Saw Counseling Nurse 89% 88% 85% 87% 0.06

Set a Quit Date 0 28 3 22 0.001

Attended Group Program 1 0 11 8 0.001
Smoking and Tobacco Control Monograph No. 5

148

Acceptance of Two-thirds of all randomized self-quit (69 percent), group-recruitment

Intervention (68 percent), and combination-treatment (67 percent) patients completed

a baseline carbon monoxide test as part of the intervention, and some

what fewer saw the stop-smoking videos (63 percent, 57 percent, and 62 percent, espectively). Manuals and small, inexpensive “quit kits” were provided

by hand (or mailed) to a majority of self-quit (91 percent) and combinationtreatment (90 percent) patients. A brochure and fee waiver coupon for the

group cessation program were accepted by 82 percent of group-recruitment

patients, but only 60 percent of combination-treatment patients accepted.

Table 20 also shows that 28 percent of all self-quit subjects agreed to set

quit dates, usually within 2 to 4 weeks of the initial visit. It was our sense

that encouraging patients gently to set quit dates was an important part of

the process, and those who agreed to a specific quit date were significantly

more likely to achieve abstinence than those who did not (16 percent vs.

11 percent, p < 0.02). About 11 percent of group-recruitment subjects

attended at least one session of the HMO’s intensive cessation program,

but only 1 percent in the advice-only condition attended. Combination

subjects chose a mix of cessation strategies.

Three months after the visit, subjects were mailed a brief survey and a

subsequent reminder. Those who did not respond were contacted by phone

and the survey was administered as a structured interview. The followup rates

(88 percent) were similar across conditions.

At 3 months (Table 21), subjects in all three nurse-assisted conditions

were significantly more likely to report one or more serious quit attempts

than were those who received only physician advice. The three nurse-assisted

conditions had similar abstinence rates (i.e., no cigarettes in the preceding

week, with nonrespondents counted as smokers), and all three nurse-assisted

interventions led to significantly higher quit rates (about 80 percent) than

the rate for brief physician advice alone. Similar outcomes were noted when

abstinence was defined as no tobacco use of any kind.

Table 21

Outcomes at 3-month followup

Percentage in Treatment Condition

Advice Self- Group Combination

Only Help Recruitment Treatment p <

Recalled Advice To Quit 56.4% 57.8% 60.8% 60.0% NS

A Serious Quit Attempt 39.0 50.2 44.8 46.3 0.001

No Cigarettes in 7 Daysa 7.6 12.9 14.1 13.0 0.001

No Current Tobacco Usea 6.2 11.0 12.0 10.6 0.002

a Survey nonrespondents counted as smokers.
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Patients were asked on the baseline questionnaire if they were seriously

interested in quitting in the next 6 months. Logistic regression analyses

indicated that those contemplating quitting prior to intervention were

significantly more likely to quit than were precontemplators, i.e., those

not considering quitting (odds ratio=2.82, 95-percent confidence

interval=1.95-4.08). However, contrary to our predictions, contemplation

status did not interact with any of the three nurse-assisted treatment

conditions. This indicates that the nurse-assisted interventions enhanced

cessation equally for precontemplators and contemplators alike.

Discussion About 3 to 5 minutes of physician counseling is an effective stop-smoking

intervention, but many physicians find it difficult to consistently spend this

amount of time in counseling. Team intervention approaches involving

physicians, nurses, and other clinic staff offer two important advantages

over traditional physician-centered approaches. First, they shift the timeconsuming components of the intervention to other staff and to videos, thus

facilitating physician participation in training and implementation. In this

way, the approach minimizes what has been a major barrier to widespread

dissemination of clinic-based smoking interventions. Furthermore, this shift

does not produce a large burden for the nurse. With an organized system

of information collection, physician referral, and use of videos, nurses can

deliver the intervention in approximately 2 to 3 minutes of additional time

per smoker. Second, relative to brief physician advice alone, the additional

attention, support, and cessation tools provided by the clinic-based smoking

counselor significantly enhanced both quit attempts and successful shortterm abstinence. Preliminary analyses of 1-year followup data suggest that

these positive effects are being maintained.

This study was unique in that it tested both a self-quit intervention

and an approach designed to recruit smokers into an intensive stop-smoking

class of the type that normally only a small minority of smokers (< 2 percent)

are willing to use (Epstein et al., 1989; Ockene, 1987a and 1987b). In this

intent-to-treat design, the abstinence rate for the group-recruitment condition

included all subjects randomized to this treatment, whether they elected to

attend the intensive program or not. Though actual attendance was modest

(11 percent), it was 10 times greater than that for the advice-alone (1 percent)

condition. Combination-treatment subjects received all intervention components. They chose a mix of cessation strategies but did no better than self-quit

and group-recruitment subjects. Because all three nurse-assisted approaches

similarly boosted the quit rates over physician advice alone, the most economical approach would seem most attractive. Analyses of cost-effectiveness are

currently under way, but it is probable that training patients to quit on their

own will be the easiest and least expensive to implement in most settings.

However, heavier smokers may do better if referred to intensive stop-smoking

programs, and some referral lists should be available.
Smoking and Tobacco Control Monograph No. 5

150

As would be expected, patients who were seriously contemplating quitting prior to intervention were more likely than precontemplators to be

abstinent 3 months later. We also expected that the nurse-assisted interventions would be more effective for contemplators than for precontemplators.

There was no evidence that treatment interacted with contemplation status,

however, and the nurse-delivered components increased quit rates roughly

80 percent for both contemplators and precontemplators alike. Still, because

precontemplators were much less likely to quit, it may be worthwhile to

tailor the intervention to the patient’s level of readiness and to focus limited

intervention resources on those who are seriously considering quitting in

the near future.

Special features of this intervention that appeared to work well included

the clinic team concept and the brief physician message that was so essential

in gaining physician cooperation and consistency. Although it would

certainly be useful for physicians with time and interest to do more of

the smoking counseling themselves, even a minimal 30-second advice

and referral message can be effective if a nurse can carry through with brief

counseling immediately after the visit. The videos were also well received

by staff as they reduced the time needed to motivate and teach patients

how to quit. It was not possible to determine the separate impact of the

videos on quit rates, but by reducing staff burden they may increase the

chances of success. Another key element was the face-to-face contact with

a trained and supportive nurse who provided strong encouragement to set

a specific quit date in the near future.

Some aspects of the intervention did not work well. Receptionists did

not hand out the lifestyle questionnaires consistently, and some patients

did not complete the instrument. A better approach would be to have the

nurse simply ask for smoking status when placing the patient in the exam

room. Very few patients called the heavily promoted stop-smoking telephone hotline (Glasgow et al., 1991a). Even fewer chose to attend the wellpublicized single-session stop-smoking programs (i.e., one 90-minute class).

In replicating this approach, we would (1) eliminate the baseline survey

and have nurses or physicians assess smoking status; (2) simplify the nurse

intervention by dropping the carbon monoxide assessment; (3) have the

nurse assess readiness to quit after showing the video; (4) tailor the nurse

intervention to each patient’s stage of change; and (5) see that smoking

status is reassessed and that stage-appropriate followup counseling is

repeated at every subsequent visit.

Intervention can be tailored to the patient’s level of readiness to quit in a

variety of ways. First, the video that all smokers see should contain different

segments relevant to smokers at the precontemplation, contemplation, and

action stages of change. After the video, patients who are ready to quit

should be encouraged to set a specific quit date in the near future and review

strategies for cessation in a stop-smoking manual. Arrangements should be
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made for a followup call 1 or 2 days after the quit date. Patients who are

contemplating quitting but who are not ready to set a quit date should be

asked about their perceived barriers to cessation (e.g., fear of failure or weight

gain) and should be encouraged to read relevant sections of a self-help manual.

The staff should also express confidence in the patient’s ability to quit and

look for other ways to enhance self-efficacy. Contemplators can then be asked

to consider the benefits of quitting between now and their next visit. We

recommend that the counseling staff devote less time to precontemplators,

who have little or no interest in quitting. There is little to be gained from

lecturing such individuals. They should simply be encouraged to look over

a manual and consider the benefits of quitting. The staff members should let

these patients know that they are there to help when the patient decides the

time is right.

Perhaps the most important findings to date are the attractiveness of this

team approach to physicians and nurses and the relative ease with which it

was implemented and maintained within a busy outpatient medical care

delivery setting. After long-term effectiveness is confirmed, the effectiveness

of nurse-assisted counseling within entire health plan populations will be

evaluated and disseminated. This will require some additional training for

nurses and a modest readjustment of their traditional role in outpatient

settings. Fortunately, many nurses are eager to play a more active role in

counseling patients about health-related behaviors and disease prevention.

Though this study was conducted in an HMO, we believe a physician and

nurse team approach to counseling smokers would be well suited to any

medical office with personnel interested in seriously addressing the tobacco

problem.

INTERVENTION The most powerful smoking intervention strategy may be to

WITH HOSPITAL identify situations in which smokers are most likely to quit on

PATIENTS their own and then tailor interventions to take advantage of those

teachable moments. Because patients’ concerns about health are among the

most frequently cited reasons for wanting to stop smoking (Pederson, 1982),

interactions with health care providers provide some of the best opportunities

for smoking intervention. In particular, health crises associated with hospitalization dramatically increase patients’ concerns about smoking and provide

a strong stimulus to stop. The purpose of the study reported here was to

develop and evaluate a brief, inexpensive smoking cessation and relapse

prevention program for hospitalized smokers.

Although relatively little is known about smoking cessation attempts

and success among hospitalized patients, what is known is encouraging.

Studies of patients with cardiovascular and pulmonary diseases (Daughton

et al., 1980; Ockene et al., 1985) have produced relatively high but widely

varying estimates of cessation rates, ranging from 20 to 51 percent among

patients with pulmonary disease and from 22 to 62 percent among survivors

of myocardial infarction (Burling et al., 1984; Ockene, 1987a). Outside of
Smoking and Tobacco Control Monograph No. 5

152

these special population studies, there have been very few studies of smoking

cessation in the general population of hospitalized patients.

Effects of Hospitali- In the Northwest Region of Kaiser Permanente, inpatient medical

zation on Smoking care is provided in two hospitals—the 220-bed Bess Kaiser Medical

Center and the 236-bed Sunnyside Medical Center. A preliminary

Survey of Hospitalized study that was conducted prior to implementation of a smoke-free

Smokers hospital policy assessed the natural history of smoking cessation

associated with hospitalization (Glasgow et al., 1991b). The

purpose of the study was to determine the frequency of various cessation-related

behaviors of patients during and after hospitalization and to identify variables

associated with those behaviors. A heterogeneous sample of 526 HMO members

who smoked prior to hospitalization and were hospitalized for nonterminal and

not pregnancy-related conditions was surveyed 12 to 18 months later. Three

events were studied: not smoking while hospitalized, attempting to quit after

hospitalization, and smoking status 1 year after hospitalization. Similar factors

were associated with not smoking in the hospital and quit attempts; for example,

older persons and patients admitted with circulatory or respiratory problems

were less likely to smoke in the hospital and more likely to try to quit. Selfreported abstinence from smoking for 1 month or longer at the time of followup included 16 percent of the former hospital patients. Overall, this initial

study suggested that the hospital can be an effective setting for smoking

cessation programs, especially those aimed at heavy smokers.

Smoke-Free Both of the HMO’s hospitals adopted a strict no-smoking policy in midHospitals 1988. This policy prohibits smoking by staff, visitors, and patients inside

the buildings. As a result, most hospitalized smokers do not smoke during

their stay, although a few do leave their beds to smoke outside. This policy

results in an enforced period of abstinence from smoking at a time when

patients are highly motivated to take health-protective actions. Initial results

from subjects hospitalized subsequent to the hospital smoking ban are consistent with the earlier results. Approximately the same proportion of patients

(18 percent) reported cessation after the policy was in effect as did those

hospitalized before the ban. These results and conclusions of reviews of

other smoking interventions (Glasgow and Lichtenstein, 1987; Schwartz,

1987) suggest that a smoke-free policy, by itself, is unlikely to result in

permanent cessation for many patients.

Although the smoke-free hospital setting may not increase long-term

smoking cessation by itself, it does provide an opportunity to reach patients

with stop-smoking advice, counseling, and support. Typically, the immediate

effects of nicotine withdrawal are surprisingly mild when patients are hospitalized, possibly because of other medical, surgical, and pharmacological interventions; the unique environment; and the fact that patients may attribute their

discomfort to other sources. In any case, a stay in a smoke-free hospital provides a period of not smoking, often the longest period of abstinence since the

patient started to smoke, and thereby provides an excellent opportunity for
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Chapter 2

health care professionals to counsel patients in relapse prevention strategies

(e.g., Curry et al., 1988; Marlatt and Gordon, 1985; Stevens and Hollis, 1989)

before they return home.

Design and The study was designed as a test of the efficacy of smoking cessation

Intervention services provided to the general population of hospitalized smokers.

Methods Because of our interest in developing interventions applicable to

the broadest possible population, we included virtually all of the

Study Design nonobstetric adult patients, regardless of diagnosis or motivation to

quit smoking. The only patients excluded were those whose hospital

stay was less than 36 hours, postpartum patients, the terminally ill, and

those who were hospitalized for alcoholism, drug abuse, or mental illness.

Smoking status and research consent were assessed by questionnaire at

hospital admission. Those who reported smoking regularly any time during

the preceding 3 months and who did not object to being contacted again in

the next year were eligible for the study. To maximize the participation rate,

the intervention was not mentioned in the explanatory portion of the initial

questionnaire. Consent to participate in the intervention portion of the

project was requested in person by the interventionist.

Randomization Assignment of smokers to either the intervention condition or the

usual-care control condition presented considerable logistic difficulties.

Because most hospital rooms were doubles, simply randomly assigning

patients to a condition might result in control participants’ watching and

listening to their roommates receiving the intervention. Therefore, randomization was accomplished by having the intervention team move back and

forth between the two hospitals. During the first month, all research subjects

in the first hospital received the smoking cessation intervention, whereas

those in the second hospital received usual care. In the second month, the

intervention team moved to the second hospital, and all of the participants

in that hospital received the intervention while those in the first hospital

received usual care. By alternating between the hospitals, the intervention

team was able to minimize contamination between groups while dividing

their efforts equally between the two hospitals. Subjects assigned to the

control condition were not identified to the hospital staff or other health

care providers and therefore received usual care. Usual care undoubtedly

included advice to quit smoking in some cases.

While controlling for contamination between conditions, this research

design had the disadvantage of not involving the nurses and other hospital

staff members in the intervention effort. Our concern was that, once sensitized and trained in smoking cessation techniques, most hospital staff members would not be willing to limit their counseling efforts to intervention

patients and not provide the smoking intervention to the control group

patients. This conservative design provides a clean test of the effectiveness

of the intervention without the addition of supportive efforts from nurses,

an adjunct that would be expected to increase intervention effectiveness.
Smoking and Tobacco Control Monograph No. 5

154

Intervention Hospital-based intervention components included a bedside counseling

session, a 12-minute videotape, an array of printed self-help material,

chewing gum and other cigarette substitutes, and access to a free telephone

advice service. Attempts were made to provide all of these components to

each intervention patient, although logistic difficulties and patient requests

sometimes interfered. After leaving the hospital, subjects received a 1-week

followup call from the smoking counselor, a monthly series of followup

mailings, and continued access to the telephone advice service. These

intervention components are described below.

Experienced smoking counselors with master’s degrees attempted to

contact all intervention patients prior to their discharge from the hospital.

Although some patients were seen in an intermediate care unit, most were

seen in the general medical and surgical wards. Counseling began with

asking the patients if they would be willing to talk to a smoking counselor.

Only 4 percent declined to see the counselor. After obtaining consent,

counselors assessed readiness to quit by asking patients whether they had

smoked since entering the hospital and whether they planned to resume

smoking after leaving the hospital. Because of the hospital smoking ban,

only 20 percent reported leaving their beds to smoke (typically 1 to 2 cigarettes per day), and more than half of the intervention patients indicated a

desire to remain nonsmokers after leaving the hospital. Patients were then

asked if they would be willing to watch a 12-minute videotape produced for

hospital patients. Those who agreed were shown the tape, but counselors

had the option of not showing the tape if the patients were heavily drugged

and likely to fall asleep while watching the tape. The videotape included

discussion of advantages of quitting smoking during hospitalization, interviews with ex-smokers who stopped smoking as a result of hospitalization,

advice about what to expect on returning home (for example, strong urges

to smoke), and tips on how to deal with urges to smoke while in the hospital

and after going home. Of the 78 percent of intervention subjects who saw

a counselor, 44 percent viewed the videotape.

In addition to showing the videotape, the counselors spent about

15 minutes with each patient discussing smoking cessation methods.

Patients who were not considering quitting (precontemplators) were urged

to consider the hospital stay as a golden opportunity to quit. It was pointed

out to patients that, in spite of their not having had much control over their

health, one positive thing they could do was to plan to quit smoking.

Those who were already contemplating quitting were encouraged to

consider themselves ex-smokers from this point on and to make a resolution

to not smoke when they returned home. Those who had resolved to not

start smoking again (recent quitters) were encouraged to anticipate upcoming

difficult situations and to develop specific plans of action to deal with those

situations. The focus of this part of the intervention was to carefully prepare

for dealing with urges to smoke that were likely to occur after the return

home.
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At the end of the counseling session, the interventionist scheduled a

followup phone call with the patient. The purpose of this call, made about

1 week after discharge, was to provide the patient with continued support

and provide an opportunity for the counselor to give further advice regarding

relapse prevention. A second call was attempted a few weeks later to all of

those who reported not smoking 1 week after discharge.

Additional self-help materials and six issues of a bimonthly newsletter

were mailed to participants after their discharge from the hospital. The

purpose of the mailings was to reinforce the efforts of those who had

stopped smoking and to trigger renewed efforts to quit for those who were

still smoking. Newsletters included testimonials from those who had stopped

smoking, tips on how to quit on your own, and phone numbers to call to

obtain further self-help information. Each issue included a reminder that

TRACC participants had access to a special 24-hour advice line.

Smoking All intervention and control participants were surveyed approximately

Cessation 3 months after hospital admission. Those we were unable to contact

Followup between 60 and 120 days after hospitalization were considered lost to

followup. The questionnaire response rate was excellent, with 49 percent

returned by mail, 39 percent completed as an interview, 5 percent refused,

and 6 percent lost to followup. Return rates did not differ between the

intervention and control groups.

Results from the 3-month assessments of 1,114 patients are encouraging,

with 13.6 percent of the control subjects and 20.4 percent of the intervention

subjects reporting no smoking in the previous 7 days (χ2=8.7, p=0.003), and

9.5 percent of the controls and 14.6 percent of the intervention subjects

reporting no smoking for 2 months or more (χ2=6.59, p=0.01). Subjects

who refused assessment or were lost to followup were considered smokers.

Table 22 presents the 3-month outcome data, by hospital.

Implementing a The essential elements of this intervention could be readily impleHospital-Based mented by most acute-care hospitals. Probably the most important

Intervention component of the intervention was the bedside counseling session.

This portion of the intervention could be delivered by nurses, respiratory therapists, health educators, or other qualified staff after they received

training in smoking cessation counseling techniques. Such training is now

available in most American cities. Potential counselors will be much more

effective with 30 to 40 hours of training. They will be most effective if they

can quickly assess a patient’s readiness to change, and if they have some

experience dealing with denial, overconfidence and, most important, relapse

prevention techniques. A skilled smoking counselor will be more effective

than an inexperienced one in the hospital setting. This is in contrast to

the outpatient setting, where minimal training and skills are sufficient.

The written self-help materials used in this project were obtained either

directly from the National Cancer Institute, the American Lung Association,
Smoking and Tobacco Control Monograph No. 5

156

Table 22

Participants from hospitals reporting no smoking for

at least 7 days at 3-month followup

Percentage in Each

Treatment Condition

Usual Care Intervention p Value

Bess Kaiser

Medical Center (n=601) 14.4% 21.1% 0.032

Sunnyside

Medical Center (n=513) 13.4 21.0 0.022

and the American Cancer Society or adapted from materials obtained from

those sources. New written materials are probably unnecessary, except for

special populations for which there are no available materials.

The video developed for our program would be appropriate for the Pacific

Northwest, but developing new videos for use outside this area, with regionally

appropriate scenes and with local ex-smokers as role models, is recommended.

Tapes for the current study were produced for about $1,000 per minute.

Quality tapes can be produced for $500 to $1,500 per minute or less if other,

prepared tapes are used as a source. The relatively low cost of modern videotape production allows for the customizing of materials for the intended

audience. In the future, this research team hopes to expand the audience by

using interactive videodiscs to assure that the models in each segment match

the viewer in age, sex, and ethnic identity.

After hospital discharge, a followup phone call about 1 week later is

an important relapse prevention tool. One week after leaving the hospital,

most patients who stopped smoking in the hospital had not yet relapsed and

reported that a followup call was helpful. Perhaps a call from a centralized

source, that is, someone other than the original counselor, would be as

helpful as it was in the outpatient study. As in the outpatient study, very

few persons called the advice line, and unless such a telephone resource is

available from local agencies at no cost, we do not recommend it as a prerequisite for the intervention. Followup mailings may have been of some

help, but we have no way to evaluate their impact.

ST INTERVENTION Although the proportion of the American population that smokes

FOR DENTAL has been steadily declining over the past 25 years (US DHHS,

PATIENTS 1986), consumption of chewing tobacco and moist snuff (smokeless tobacco, ST) has been increasing (Marcus et al., 1989). Although less

research has been done on the health effects of smokeless tobacco, there

is a clear association between ST use and oral cancer as well as cancer of
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the esophagus, larynx, and stomach (US DHHS, 1986). The growing body

of evidence about the harmful effects of smokeless tobacco has led to an

increasing interest in intervention programs for ST users.

There have been few published reports of smokeless tobacco intervention

effects. There are published reports of ST cessation programs with adolescents

(Eakin et al., 1989) and adults (DiLorenzo et al., 1991) that have used smoking

cessation methods with smokeless tobacco users in small-group treatment.

The results of those interventions have been encouraging, but a more costeffective program is needed to affect large numbers of ST users. The study

described here evaluated routine dental clinic visits as an opportunity to

intervene in the use of smokeless tobacco. Because a large proportion of

the population receives some dental care annually (Cohen et al., 1989a)

and because the oral health effects of ST use are often obvious during an

oral examination, the dental office is an ideal setting in which to conduct

an ST cessation program.

Building on the success of smoking cessation programs delivered in

medical offices (Cohen et al., 1989b; Secker-Walker et al., 1987), the

investigators developed an ST cessation program suitable for the dental

care setting. The intervention program was designed for delivery by dental

hygienists and dentists in the context of regular oral health care. The dental

care providers used this opportunity to assess any oral health effects of each

patient’s use of smokeless tobacco and then give the patient unequivocal

advice to stop. It was hypothesized that this is a time when ST users would

be most receptive to advice to quit. A regularly scheduled oral health visit

to the dentist could provide a unique teachable moment for counseling

the ST user.

Survey of Dentists, Prior to the project intervention, a survey was conducted to

Hygienists, and determine the receptivity of both patients and dental office staffs

Patients to ST interventions (Severson et al., 1990). Overall, 42 dentists,

44 hygienists, and 1,506 age-eligible male patients completed the survey.

The survey of patients indicated that 4.7 percent used smokeless tobacco

and 39.0 percent of the ST users were interested in receiving cessation advice.

One-third of the ST users reported that they would consider such advice.

Dentists were more comfortable giving advice to ST users than to smokers.

The relevance of chew and snuff to oral health is the most obvious explanation for this. Dentists and hygienists reported that they customarily discussed

health hazards of ST use (77 percent) and sometimes advised smokeless tobacco users to quit or cut down (23 percent).

Results of the dental office survey were encouraging. Patients reported

being receptive to cessation advice (41 percent) and, in fact, expect it from

dental professionals. That receptivity to advice from dentists and hygienists

is supported by data from in-depth interviews with smokeless tobacco users

(Severson et al., 1990). Dentists and hygienists were interested in having
Smoking and Tobacco Control Monograph No. 5

158

specific materials on smokeless tobacco and receiving training in giving

cessation advice, and they felt more comfortable and effective in giving

advice to ST users than to smokers.

Intervention This project was conducted in the Kaiser Permanente Dental Care

Setting and Program, a prepaid, managed-care, group-practice, HMO program

Methods that currently provides comprehensive dental care to more than

160,000 members in the Pacific Northwest. The project was a

Setting randomized clinical trial in which patients were assigned to either

usual care (control) or the smokeless tobacco intervention condition.

Patients were identified as ST users via a tobacco use survey that they

completed when coming for a routine dental hygiene visit. Emergency

patients and those appearing for surgery or orthodontic care were excluded.

Intervention When they arrived at the clinics, patients aged 15 or older were asked

by the receptionist to complete a one-page questionnaire on tobacco use.

Those who agreed to complete the survey and reported current use of smokeless tobacco became participants in the study. Eligibility was assessed by

the clinic receptionists, who then assigned the patient to a usual-care or an

intervention group. Although most patients complied with the request to

complete the tobacco use survey, the member assistant (receptionist) often

neglected to give out the survey, and approximately 60 percent of eligible

members actually completed the questionnaire. Despite frequent prompts

by the research project staff, most noncompletion was because of the

receptionist’s failure to pass out the survey instrument.

After completing the tobacco use survey, patients assigned to the control

condition did not receive special attention from the dental clinic staff. No

mention of their involvement in the study was made in the patients’ dental

care charts, and their status as ST users was not revealed to the hygienists

and dentists. Depending on the individual practice habits of the dental care

providers, patients receiving usual care may or may not have been advised

to stop using tobacco. For patients assigned to the intervention condition,

an envelope was put into each dental chart identifying them to the hygienist

and dentist as ST users and intervention participants. The envelope included

special data collection forms as well as self-help intervention materials.

Intervention activities were designed to fit comfortably into the usual

routine of any dental office. Typically, the visits begin with the hygienist

making a complete oral exam and then providing prophylactic treatment.

This routine includes feedback on oral health status and advice on how to

improve oral self-care procedures. When seeing an intervention patient, the

hygienist recorded plaque and inflammation data on a special research data

form and made a thorough examination of soft tissues, looking for keratotic

lesions (leukoplakia). Although a soft tissue exam is routine, the research

protocol called for a more detailed report of all lesions and their precise

location in the mouth. The hygienist also asked the patient to show where
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he kept tobacco in his mouth. After assessment and dental treatment, the

hygienist gave the patient direct advice to quit using all tobacco products.

Routine clinic procedures call for the dentist to examine patients after

they have seen the hygienist. The dentists also discussed keratotic lesions

with patients, discussed the harmful effects of smokeless tobacco, and gave

their own brief message to stop using tobacco. It was emphasized that care

providers must deliver an unambiguous message to ST users: All tobacco

products are harmful to health and they should stop now. This constituted

the counseling component of the special intervention.

As part of the intervention, the patient was asked to view a 10-minute

videotape at the end of the visit. The video produced for this project begins

with a humorous segment designed to help the patient relax and includes

an interview with a dentist discussing the health consequences of ST use.

The video also includes a series of interviews with former users describing

the benefits of quitting and the methods they used to quit. After viewing

the video, the hygienist encouraged the patient to use a self-help booklet,

“Enough Snuff,” provided to them and to call a 24-hour advice line for

further assistance. The hygienist also attempted to get the patient to set

a specific quit date and noted whether he was willing to do so. At the end

of this brief counseling session, the subject was given a quit kit containing

chewing gum, toothpicks, a nontobacco mint-leaf tobacco substitute, and

a set of tip sheets with advice on how to quit.

Followup About a week after the dental clinic intervention, subjects were called

Phone by a project staff member to reinforce the clinic-based intervention

Calls activities and to offer further advice and support for quitting efforts.

Additional support activities after the clinic visit included bimonthly

mailings of tip sheets and a newsletter.

Followup Data To assess the effects of intervention, all intervention, control, and

Collection comparison-site participants were surveyed approximately 2 to 3 months

after being seen at the dental office. Sixty days after entering the study,

all subjects were sent a followup questionnaire about their tobacco use since

their dental office visit. If they did not return the questionnaire within

14 days, they were sent a second copy, and if a questionnaire was not returned

after another 14 days, they were called and asked to complete the questionnaire as a telephone interview. Those not contacted within 120 days after

their dental visit were considered lost to followup.

Results A total of 245 intervention subjects and 272 usual-care controls were

recruited for the study. As expected, the use of smokeless tobacco was highest

in the younger age groups (15- to 19-year-olds and 20- to 29-year-olds). The

portion of ST users who did not also smoke was also highest in the youngest

groups. Thirty-five percent of the chew-only group was in the 20 to 29 age

range.
Smoking and Tobacco Control Monograph No. 5

160

Acceptability of The hygienists and dentists provided excellent cooperation in this

Intervention study. Most were enthusiastic about delivering the intervention, and

they failed to do so only on rare occasions. However, the clinic receptionists sometimes neglected to administer the tobacco use survey. The busy

nature of the clinic and demands on staff time made the administration of a

separate tobacco survey problematic. It is recommended that those implementing similar programs include smoking questions as part of a routine

intake form or use other identification methods that do not make additional

time demands on receptionists.

Somewhat surprisingly, the intervention was acceptable to the vast

majority of patients. Fewer than 5 percent of the intervention subjects

refused intervention completely, and an additional 10 percent refused to

watch the video.

Three-Month The followup questionnaire response rate was excellent, with 47 percent

Followup returned by mail and 43 percent completed as telephone interviews.

Of the remainder, 7 percent of the participants declined to complete the

interview and 3 percent were lost to followup. The overall followup rate

for the intervention group was 91 percent, and for the usual-care group

89 percent.

Self-reported abstinence from all tobacco use at 3 months included

22 percent of the intervention subjects and 14 percent of the control subjects. Table 23 shows a breakdown of tobacco use at 3 months according

to tobacco use at baseline. The success of the intervention appears higher

for patients who report using only smokeless tobacco at baseline (26 percent

abstinent at followup) than for men who used both cigarettes and chew

(12 percent abstinent at followup). This was true for both intervention

and control subjects. Of additional interest is the fact that very few of the

ST-only subjects reported cigarette use only at followup (1 percent and

4 percent for intervention and control subjects, respectively), so we have

some confidence that quitting smokeless tobacco use did not prompt the

use of cigarettes as an alternative.

Discussion The 3-month followup data of the dental office intervention for smokeless tobacco cessation support the efficacy of the intervention. Twenty-two

percent of the ST-using patients randomly assigned to the brief intervention

reported they had quit the use of all tobacco, whereas only 14 percent of the

usual-care subjects reported quitting. This significantly higher rate of selfreported quitting is strong support for the use of office visits for oral health

care as teachable moments for advising patients to quit using smokeless

tobacco.

The results of this study are similar to other tobacco-use interventions

in outpatient settings that have also reported a significant effect of having

dentists (Cohen et al., 1989a) and medical office staff provide direct advice to

quit (Glynn, 1988). Glynn reports that most physician advice and minimal
161

Chapter 2

Table 23

Three-month followup tobacco use, by baseline tobacco use

Followup Tobacco Status

No Chew Chew and Smoke No

Tobacco Only Smoke Only Followup Total

% (n) % (n) % (n) % (n) % (n) (n)

Intervention Participants,

Baseline Use

Chew only 26 (45) 57 (97) 3 (5) 1 (2) 12 (21) 170

Chew and smoke 12 (9) 12 (9) 27 (20) 32 (24) 17 (13) 75

Total 22 (54) 43 (106) 10 (25) 11 (26) 14 (34) 245

Control Participants,

Baseline Use

Chew only 17 (33) 67 (128) 3 (5) 4 (7) 9 (18) 191

Chew and smoke 6 (5) 19 (15) 46 (37) 17 (14) 12 (10) 81

Total 14 (38) 53 (143) 15 (42) 8 (21) 10 (28) 272

interventions offered in medical settings report average quit rates of 10 to

12 percent at 1 year. It is likely that the 3-month self-reported quit rates

for smokeless tobacco will decline over the year as many patients relapse.

However, even if 50 percent of the patients in both study conditions relapse

between the 3-month and 1-year evaluations, the ST quit rates would still

appear to be consistent with previous research using a 1-year biochemically

confirmed quit assessment.

For the intervention group, men who reported using only smokeless

tobacco reported a 25-percent quit rate, whereas men who reported at

baseline that they used both cigarettes and chew had only a 17-percent quit

rate. The two quit rates are significantly different (p < 0.01). It appears that

men who use both cigarettes and smokeless tobacco find it more difficult to

quit.

This intervention was implemented by the dentist and hygienist in the

context of routine oral health care. Although the demands on receptionists

should be minimized, dentists and hygienists reported that brief, direct

advice to quit using smokeless tobacco fit well within the time allotted for

the regular oral health exam. In practice, this intervention would require

even less time, since the research protocol required extra data collection

forms. Hygienists played the key role by pointing out the smokeless

tobacco-related oral health effects to the patient, showing the video,

providing a self-help manual, and encouraging the patient to set a quit

date. This brief interaction was critical, and most of the patients were
Smoking and Tobacco Control Monograph No. 5

162

willing to take the extra time to be briefly counseled. Dental hygienists were

comfortable pointing out oral lesions and relating them to ST use but less

comfortable in asking the patient to watch a video or providing counseling

advice. The video viewing was sometimes a problem because of lack of

privacy.

Previous studies have confirmed that smokeless tobacco users expect to

receive a message to quit from their physician or dentist and are receptive to

it. In a recent interview of ST users, 54 percent reported wanting to quit in

the next year and 69 percent reported recent attempts to quit (Severson et al.,

1990). Dentists and hygienists have an opportunity to advise users of smokeless tobacco to quit, and the context of an oral health care office visit provides

a unique teachable moment in which the user may be most receptive to

cessation advice. Although the long-term cessation rates are not yet known,

these early results suggest that dentists and hygienists can have a significant

impact on smokeless tobacco use and thus on public health.

SMOKING CESSATION Any comprehensive effort to reduce the prevalence of

AMONG ADOLESCENTS smoking among members of an HMO should include a

program to prompt cessation among adolescents. AdolesPurpose and cence is the time when most smokers begin smoking.

Target Group Many novice smokers are not yet addicted, so cessation

could prove easier than it is for adults. Moreover, it would seem appropriate

to have a program that is uniquely tailored to the needs and interests of

adolescent smokers, rather than offering them the same program that is

provided to adults.

On the other hand, the efficacy of a smoking cessation program for

adolescents cannot be assumed. A number of programs that have been

evaluated have not produced significant quitting among adolescents

(Diguisto, personal communication, August 1990). Therefore, the authors

developed and evaluated a smoking cessation program for adolescent

members of Northwest Kaiser Permanente.

Methods The program was designed to provide continuing contacts with adolescent smokers in an effort to increase their willingness to quit, prompt

Intervention them to make quit attempts, and provide skills and social reinforcement

for quitting. The centerpiece of the program was an office visit with a

nurse practitioner at a convenient Kaiser Permanente clinic.

Adolescents were invited to attend these visits during in-home assessments

that were made in the course of a survey of adolescent health behavior. However, the majority of visits (70 percent) were actually scheduled through phone

contacts. These recruitment methods were dictated by the need for experimental evaluation of the program. It is unlikely that they would be used by a clinic

in normal circumstances. Rather, contact with adolescent smokers would most

likely occur in the course of their coming to the clinic for treatment of other

problems.
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Chapter 2

Sessions typically lasted 60 minutes. They began with a brief discussion

of family history of cancer and the provision of information about breast

self-exam to girls and testicular self-exam to boys. The family smoking

history and the young person’s smoking history and current behavior were

then discussed. Reasons for quitting and barriers for quitting were discussed

next. Most patients reported having tried quitting and failed.

Carbon monoxide testing was done initially, but it was later dropped

because of the low CO levels resulting from the relatively low level of smoking

by the young people (Biglan et al., 1985). Giving the adolescents feedback

about their carbon monoxide levels thus tended to suggest that their

smoking was not a problem.

A key component of the program was a videotape that was made

especially for this program. It was designed to make smoking cessation seem

like a popular option for teens and to provide information from attractive

young people about how to quit. After the video, the nurse practitioner

discussed its contents with the teenager and provided information about

quitting. The discussion centered on the situations in which smoking

occurred and the barriers to quitting. With light smokers, two questions

that helped get at the need to quit were, “Do you have cravings?” and

“When do you have your first cigarette?” These opened up discussion of

getting hooked and the value of trying to quit. The adolescent was then

given a “quit kit” that contained the same materials that were given to

adults (a cinnamon stick, sugarless chewing gum, a rubber band, and a

refrigerator magnet with the number of our quit-smoking hotline).

Most teens indicated a desire to quit smoking, and they were assisted in

developing a plan for quitting. It included specific things to do in situations

where smoking was most likely, a plan to talk to friends and family members

who were likely to be helpful, and ideas for self-rewards for accomplishing

small goals such as a day without cigarettes. In the initial work, an explicit

quit date was elicited from each teen; however, very few actually quit on their

quit date. The practice was subsequently discontinued, because failure to quit

on the targeted date seemed likely to undermine commitments to the other

features of the plan.

In an additional effort to reinforce quitting, a lottery was developed.

Teens received chances for a $100 gift certificate. They had to be abstinent

to win.

Followup phone calls were routinely made. The investigators tried to

contact each adolescent 1 week after the office visit. This sometimes proved

very difficult, because many teens were hard to reach by phone. In the event

that young patients did not want to attempt to quit at the time of the office

visit, they were asked if they could be called a month later. Repeated contacts

by phone were common. They occurred over a period of 2 to 3 months and

only when the adolescent expressed continued interest in quitting and in

having phone contacts.
Smoking and Tobacco Control Monograph No. 5

164

Experimental The evaluation of this program was designed to reveal whether the proEvaluation gram reduced the prevalence of smoking among adolescents aged 14 to

17 whose families were members of Northwest Kaiser Permanente and

who were identified as smokers at the outset of the program. For the assessment, 16,399 teens were sent a questionnaire on a variety of health habits.

Of these teens, 8,126 returned the questionnaire. The 1,155 teens (14.2 percent) who reported having smoked a cigarette in the prior 7 days (as well as

a small sample of nonsmoking comparison adolescents) were asked to participate in an extensive assessment of teen health that was conducted in their

homes. Among the girls, 325 (46.0 percent) agreed to participate, whereas

168 boys (37.2 percent) agreed to participate. This difference was statistically

significant.

In the home assessment, adolescents were asked about their smoking

behavior and asked to provide samples of expired air CO (Biglan et al., 1985)

and saliva, which were analyzed for cotinine (Jacob et al., 1981). They also

answered extensive questions about their engagement in other forms of

problem behavior. A parent—typically the mother—was also asked to complete a questionnaire about the adolescents’ behavior, family interactions,

and parental health behavior. Subjects completing the home assessment were

randomly assigned to either a smoking cessation program or a no-treatment

control group. There were 229 smokers and 61 nonsmokers in the cessation

condition, and 257 smokers and 52 nonsmokers in the control condition.

These same home assessment procedures were repeated 12 months and

approximately 18 months later. Data from the 1-year assessment are currently

available.

Results There was simply no evidence that the intervention program prompted

the adolescents to stop smoking. Table 24 presents means and tests of differences between treatment and control subjects who reported smoking at the

time of the screening questionnaire. The groups do not differ on any selfreport or physiological measure of smoking behavior. The subjects in the

treatment program reported more quit attempts, but the difference was only

significant at p=0.06.

Can Adolescents Our results, thus far, cast doubt on the utility of smoking cessation

Be Prompted programs for adolescents. It can, of course, be argued that a differTo Quit? ent program—perhaps one that involved more extensive contacts—

could be successful. However, the nurse practitioners who conducted this

program would point out that it was very difficult to achieve the small

amount of contact that was achieved with these young people. An effort

to increase contact might be very costly in practitioners’ time.

It might also be argued that a program that worked only with those

adolescents who volunteered that they wanted to quit might prove efficacious.

However, our contacts with this sample of young people make us skeptical.

Although most said they wanted to quit, when asked, it was extremely rare
165

Chapter 2

Table 24

Effects of the program on adolescent smoking

Treatment Control F p

Variable

Cigarettes in past month 194.83 228.24 0.02 0.89

Percentage who smoked in past 7 days 36.00 34.00 30.00 0.59

Percentage who smoked in last 30 days 27.00 25.00 3.00 0.87

Cigarettes in past 24 hours 6.02 7.11 0.00 0.98

Current smoking 6.59 6.98 2.31 0.13

Carbon monoxide 5.91 6.34 0.02 0.90

Cotinine 93.14 117.09 0.27 0.61

Index of smoking -0.15 -0.08 0.04 0.96

Attempts to quit in past year 2.78 2.30 3.45 0.06

for a young person to contact us in response to our mailed advertising about

the cessation program; most contacts were prompted by our phone calls or

invitations delivered at the first home assessment.

Some hints as to why it is hard to get these young people to stop smoking

are provided by analysis of the correlates of their smoking behavior. The

multiple correlation between an index smoking behavior and measures of

seven other problem behaviors (alcohol consumption, high-risk sexual behavior, poor grades, lack of prosocial behavior, antisocial behavior, use of illicit

drugs other than marijuana, and use of marijuana) was 0.60, accounting for

36 percent of the variance in smoking. The multiple correlation predicting

smoking from measures of five aspects of family interaction and six aspects of

peer influence was also 0.60. Thus, cigarette smoking occurs in the context of

many other problems and in the context of a problematic social environment.

It may be impossible to excise this behavior from such a context. Instead, it

may be necessary to develop programs that comprehensively address the

social conditions that produce the above-mentioned problem behaviors.

It may be premature to conclude that programs focused solely on smoking

cessation among adolescents will not work. However, given the evidence thus

far, it seems probable that some radically different approach to prompting

quitting among adolescents will be needed.

SUMMARY AND The implementation and outcome data presented for the four

IMPLICATIONS TRACC interventions provide consistent support for the team

approach. Not only was it possible to enlist clinic assistants, nurses, physicians, dental hygienists, dentists, and counselors to provide brief cessation

advice and counseling augmented by written materials and videos, but also,

once under way, the program received strong support from providers and
Smoking and Tobacco Control Monograph No. 5

166

their staffs. Some receptionists found the patient screening, recruitment,

and consent process burdensome, but these problems could be minimized

or avoided in a nonresearch environment. With this exception, staff and

providers found the “required” activities to be feasible and convenient.

Providers had positive feelings about the interventions because they

perceived that they were addressing an important, previously neglected

health issue in a nonburdensome manner.

The data also consistently show that patients—who were being seen

for typical medical or dental problems—both accepted and responded to

the interventions. Most patients agreed to receive the interventions, and

the short-term data for adult patients show significant treatment effects.

Providers need not worry about patients’ negative reactions to raising the

smoking issue.

The three projects aimed at adult tobacco use all yielded significant

reductions in tobacco use, indicating that the team approach is at least as

effective as sometimes more intensive physician or dentist interventions

(Cohen et al., 1989b; Cummings et al., 1989; Janz et al., 1987; Li et al., 1984;

Ockene, 1987a; Wilson et al., 1988). One-year followup data are needed

before assessment of the long-term impact of these interventions is made.

The preliminary 1-year results are consistent with the data presented here.

The single, and unfortunate, exception is the failure of the trial intervention to affect adolescent tobacco use. Whether health care settings can affect

adolescent tobacco use remains an open question. Certainly, adolescent

motives for smoking and patterns of use (as well as adolescent health and

psychology) suggest that interventions in the medical care setting are unlikely

to have a major short-term impact on adolescent smoking. School and peergroup approaches are more promising.

The investigators are already moving toward institutionalizing the adult

tobacco use interventions in outpatient and hospital settings by turning them

over to provider staff, as was done originally in the dental clinic intervention.

For example, nurses—again assisted by videos—can provide most of the

outpatient intervention with respiratory therapists leading the inpatient

program.

There is the potential for applying this team approach in many settings,

including the private sector. Nurses are typically interested in expanding their

treatment and educational responsibilities. Video interventions are feasible in

many health care settings, and video materials can reduce the instructional

burden on staff. The exciting potential of interactive video is being explored

also. This new technology permits patients to select change strategies suitable

to their particular needs and can even further reduce staff counseling time.
167

Chapter 2

A key role remains for the physicians: They must initiate or sanction

the introduction of the smoking issue. Moving the interventions out of a

research context will permit better use of repeated prompts and messages,

for example, outpatient followup of hospitalized patients.

The interventions all were enhanced by a sophisticated, computerized

tracking system that triggered the delivery of telephone and mail prompts

(and data collection). Other large health care systems would also have such

systems available. They can also be conscripted to yield other information

relevant to cancer control, such as that pertaining to cervical or breast

screening.

The TRACC projects illustrate the potential for low-cost, populationbased cancer control interventions that exploit the teachable moments in

medical settings. The keys to successful implementation and maintenance

included promoting change at the organization or system level, applying

available technology (computerized tracking, tailored videos), and using

support staff to assist primary care providers in counseling patients. This

approach appealed to providers and patients, and it overcame many of the

barriers to implementation of cessation advice in medical settings.

ACKNOWLEDGMENTS We gratefully acknowledge the high level of cooperation received from the

management and medical care staff of the Northwest Region of Kaiser Permanente. We also

thank the staff of the Oregon Research Institute and Independent Video Services for their key

roles in producing the instructional videos used in this project.

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169

Chapter 2

APPENDIX A

Screening Form for Study on Assessing Patient’s Health Risks

Date ____________________________

Subject No. _____________________

The health center thanks you for considering being in our study.

We are assessing health risks to patients in our practice. If you decide to enter the study,

you will benefit by having your physician discuss one of your risks in depth and provide

you with free health information.

Before you decide whether to enter our study, we would like you to answer the following

questions to determine whether you are eligible for the study.

1. Your age: ________

2. Your sex: male female (please circle one)

3. Do you exercise regularly? Yes No

4. Do you smoke cigarettes daily? Yes No

5. Do you consider yourself overweight? Yes No

6. Do you use safety belts regularly? Yes No

7. Do you drink alcohol? Yes No

Please return this screening form to the practice research coordinator to determine if you

are eligible for the study. The coordinator will inform you of your eligibility and provide

you with further information if you are interested.
Smoking and Tobacco Control Monograph No. 5

170

APPENDIX B

Study on Physician Advice for Smoking Cessation

You are invited to be in a study on physician advice about smoking. The study only

requires you to stay a few minutes longer so your physician can talk to you about smoking. In addition, based on chance, you may receive a prescription for nicotine gum. A

follow-up visit to further discuss smoking will be offered to you. You and a spouse or

friend will be asked to fill out a one-page questionnaire 2 weeks and 6 months from now.

If at 6 months you are not smoking, you will be asked to return to the clinic to give a

breath sample. For this inconvenience you will receive $10.

The only risk of this study will be possible withdrawal symptoms and side effects from

nicotine gum. Serious side effects from the gum are rare. Minor side effects such as

irritated throat, nausea, upset stomach, hiccups, jaw ache, and dependence on the gum

occur in less than 25 percent of smokers. These side effects can be controlled by how

vigorously you chew the gum.

Although we can foresee no significant risk for this research, in the event that this research activity results in a physical injury, medical treatment will be available, including

first aid, emergency treatment, and followup care [as] needed. Payment for any such

treatment must be provided by you and your third-party payor, if any (such as health

insurance, Medicare, and so forth).

If you should decide not to participate, or to withdraw from this study, your decision will

not prejudice your future medical care.

If you have any questions about this study, please contact Dr. William Wadland at the

University of Vermont [phone number]. You may contact Caryn Gronvold at the University of Vermont [room number, phone number] for more information about your rights

as a research subject or for more information about how to proceed should you believe

that you have been injured as a result of your participation in this study.

You are making a decision whether or not to participate. Your signature indicates that

you have read the information provided and have decided to participate.

signature date

signature of research coordinator
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Chapter 2

APPENDIX C

Entry Questionnaire

Entry Date _________

Subject No. ________

1. Give the full name of your cigarettes:

_______________________________________________________________

Check the blanks which describe your cigarette:

Filtered _______

King Size _______

120mm _______

100mm _______

85mm _______

Regular _______

Menthol _______

Hard pack _______

Lights _______

Ultralights _______

2. The average number of cigarettes you smoke per day ___ (only one number please).

3. Your age when you started smoking on a regular basis. _____

4. Do you use cigars, pipes, or smokeless tobacco?

___ Yes ____ No

5. Do you inhale? Always Sometimes Never (circle one)

6. Do you smoke more during the morning than during the rest of the day?

___ Yes ____ No

7. How soon after you wake up do you smoke your first cigarette? _____ minutes _____ hours

8. Which cigarette would you hate to give up? _______________________________________

9. Do you find it difficult to refrain from smoking in places where it is forbidden, e.g., in

church, at the library, cinema, etc.? Yes ____ No ____

10. Do you smoke if you are so ill that you are in bed most of the day? Yes ____ No ____

11. Circle the highest grade you have completed:

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 16+

12. What is your major present occupation? (Describe fully, including student, housewife,

unemployed, or retired. Also describe your business as small, medium, or large.)

___________________________________________________________________________________
Smoking and Tobacco Control Monograph No. 5

172

13. Are you married? Yes ____ No ____

14. Does insurance pay for any part of your prescriptions?

___ Yes ____ No

15. How many of the people who live with you smoke cigarettes? _____

16. For the purposes of the study, we need to know your total family yearly income.

(This will be kept confidential.)

Less than $15,000 ____

$15,000 to $29,000 ____

$30,000 to $44,999 ____

More than $45,000 ____

17. Most people have mixed feelings for and against their smoking, with a part of them

wanting to stop and a part of them wanting to go on smoking.

a. How much would you say that you want to stop smoking?

_____ not at all _____ a little _____ some _____ a lot _____ don’t know

b. And how much does a part of you want to go on smoking?

_____ not at all _____ a little _____ some _____ a lot _____ don’t know

18. Do you intend to quit smoking in the next month or so?

___ definitely not ___ probably not ___ possibly ___ probably ___ definitely ___ don’t know

19. If you decided to give up smoking within the next month, do you think you would succeed?

___ definitely not ___ probably not ___ possibly ___ probably ___ definitely ___ don’t know

We need to collect identification data from you so that we can find you 6 months from now:

20. What is your full name? ___________________________________________________________

21. Give your full home address.

Street: ________________________________________________________________________

City, Zip: ________________________________________________________________________

Phone: ________________________________________________________________________

22. Give your work address.

Company: ________________________________________________________________________

Immediate supervisor: _______________________________________________________________

Street: ________________________________________________________________________

City, Zip: ________________________________________________________________________

Phone: ________________________________________________________________________
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Chapter 2

23. Give name and address of spouse/friend who can act as your observer. This person will

verify your smoking status.

Name: _____________________________________________________________________

Street: _____________________________________________________________________

City, Zip: _____________________________________________________________________

Phone: _____________________________________________________________________
Smoking and Tobacco Control Monograph No. 5

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APPENDIX D

Medical Screening Form

Name ________________________________________________

Subject No. ___________________________________________

Date _________________________________________________

Physician_____________________________________________

Heart attack in the last 6 months Yes No

Irregular heart or arrhythmia Yes No

Active temporomandibular joint disease Yes No

Worsening or unstable angina Yes No

Pregnant or planning to be Yes No

Breast-feeding Yes No

Able to chew gum Yes No

Other __________________________________________________

OK for patient to be on nicotine gum:

Physician’s signature
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Chapter 2

APPENDIX E

Generic Reminder Sheet

1. Ask if ever thought about quitting and reason. If none, volunteer one.

2. State reversibility of symptom (2 weeks), disease (1 year), or risk (10 years).

3. Recommend cessation (use word “I”).

4. Describe “Quit and Win”:

a. It’s for habit part of smoking.

b. Tips from successful ex-smokers.

c. Use as menu. Choose 3 to 5 strategies that are do-able.

5. Open assignment envelope.
Smoking and Tobacco Control Monograph No. 5

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APPENDIX F

Reminder Sheet for Gum Group

6. Instructions on gum.

Give rationale: to decrease withdrawal.

It works.

Stop smoking abruptly.

Chew PRN early in craving.

Chew slowly to control side effects. Side effects decrease in first week.

Use till no craving, and then decrease gradually.

Biggest mistakes: use too little for too short a time.

Keep gum with you.

Read booklet.

The Rx is good for 6 months in case you decide to quit later.

7. Ask for questions.

8. Ask for commitment to quit.

9. Ask for quit date.

10. Offer followup by appointment or phone.
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Chapter 2

APPENDIX G

Reminder Sheet for No-Gum Group

6. Ask biggest fear:

a. Generic responses

Withdrawal symptoms are transient.

Distract yourself by keeping busy.

Decrease demands on yourself.

Avoid tempting situations for a while.

Use time-outs or remember reason for cessation for urges.

Increase activity (not necessarily exercise).

Read booklet.

b. Specific responses for weight:

Weight gain doesn’t necessarily occur or last.

To counteract loss of anorectic and oral behavior, watch snacks and sweets

but don’t change meal sizes.

To counteract decreased BMR, increase activity.

7. Ask for questions.

8. Ask for commitment to quit.

9. Ask for quit date.

10. Offer followup by appointment or phone.
Smoking and Tobacco Control Monograph No. 5

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APPENDIX H

Physician Data: Initial Visit

Subject No. ___________________________________________

Date _________________________________________________

Physician_____________________________________________

Did you obtain a commitment to quit? Yes No

Did you obtain a quit date? Yes No

If so, what is the date? ________ ________ ________

Month Day Year
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Chapter 2

APPENDIX I

Exit Questionnaire #1

(All Patients)

Subject No. _______________________________

Did your physician:

1. Ask you a reason to stop smoking?

_____ Yes _____ No

2. Tell you that the effects of smoking are reversible?

_____ Yes _____ No

3. Tell you about the booklet to aid the habit part of smoking cessation?

_____ Yes _____ No

4. Ask you to try to quit?

_____ Yes _____ No

5. Ask you for a quit date?

_____ Yes _____ No

6. Offer to see you 1 to 2 weeks after your quit date?

_____ Yes _____ No

Please answer the following questions. Some are the same questions you answered prior

to receiving physician’s advice.

7. Most people have mixed feelings for and against their smoking, with a part of them

wanting to stop and a part of them wanting to go on smoking.

a. How much would you say that you want to stop smoking?

____ not at all ____ a little ____ some ____ a lot ____ don’t know

b. And how much does a part of you want to go on smoking?

____ not at all ____ a little ____ some ____ a lot ____ don’t know

8. Do you intend to quit smoking in the next month or so?

___ definitely not ___ probably not ___ possibly ___ probably ___ definitely ___ don’t know

9. If you decided to give up smoking within the next month, do you think you would succeed?

___ definitely not ___ probably not ___ possibly ___ probably ___ definitely ___ don’t know
Smoking and Tobacco Control Monograph No. 5

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10. Rate how much your physician convinced you to stop smoking.

0=Not at all

1=A little

2=Somewhat

3=Very much

11. Rate how confident your physician was in giving you advice to stop smoking.

0=Not at all

1=A little

2=Somewhat

3=Very much
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Chapter 2

APPENDIX J

Exit Questionnaire #2

(No-Gum Group)

Subject No. ____________________________

Did your physician:

1. Ask your biggest fear about cessation?

____ Yes ____ No

2. Give you a way to combat your feared problem with cessation?

____ Yes ____ No
Smoking and Tobacco Control Monograph No. 5

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APPENDIX K

Exit Questionnaire #3

(Nicotine Gum Group)

Subject No. _____________________________

Did your physician:

1. Tell you about nicotine gum to aid the withdrawal part of smoking cessation?

____ Yes ____ No

2. Tell you that if you use the gum you should:

Stop abruptly?

____ Yes ____ No

Use the gum when you have an urge for a cigarette?

____ Yes ____ No

Chew the gum slowly to avoid side effects?

____ Yes ____ No

Chew the gum till you have no craving for cigarettes, and then taper off the gum?

____ Yes ____ No

Read a booklet about the gum when you get it at the pharmacy?

____ Yes ____ No
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APPENDIX L

One- to Two-Week Followup for Smoking Cessation Study

Subject No. ____________________________

Date ___________________________________

Please fill out this form and return in the self-addressed envelope as soon as possible.

If we do not receive the form within 1 week, we will need to call you at home.

1. Have you tried to stop smoking since you entered the study?

____ Yes ____ No

IF YES, ANSWER QUESTIONS 2-6.

IF NO, YOU ARE FINISHED. THANK YOU.

2. How many times have you tried to stop since you entered the study? _____

3. When was the first time you tried to stop after seeing your physician?

________ ________ ________

Month Date Year

(1-12) (1-31) (19--)

4. Are you smoking cigarettes now? ____ Yes ____ No

5. Rate how helpful your physician’s advice was in stopping smoking.

01 2 3

not at all somewhat moderately helpful most helpful

6. Rate how helpful the “Quit and Win” booklet was in stopping smoking.

01 2 3

not at all somewhat moderately helpful most helpful
Smoking and Tobacco Control Monograph No. 5

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APPENDIX M

Six-Month Followup for Smoking Cessation Study

Subject No. ____________________________

Date ___________________________________

Please fill out this form and return in the self-addressed envelope as soon as possible.

If we do not receive the form within 1 week, we will need to call you at home.

1. Have you tried to stop smoking since you entered the study?

____ Yes ____ No

IF YES, ANSWER QUESTIONS 2-4.

IF NO, YOU ARE FINISHED. THANK YOU.

2. How many times have you tried to stop since you entered the study? ____

2a. When was the first time you tried to quit after you entered the study?

________ ________ ________

Month Date Year

(1-12) (1-31) (19--)

3. Are you smoking now? ____ Yes ____ No

3a. If you are not smoking, when did you last have a cigarette?

________ ________ ________

Month Date Year

(1-12) (1-31) (19--)

4. Are you using cigars, a pipe, or smokeless tobacco?

____ Yes ____ No
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Chapter 2

APPENDIX N

Followup Questionnaire on the Use of Nicotine Gum

Subject No. _____________________________

Date ____________________________________

You received a prescription for nicotine gum from your physician. Please answer the

following questions and return in the self-addressed envelope.

1. Did you fill the prescription?

____ Yes ____ No

2. Rate how helpful you found the nicotine gum in quitting smoking:

01 2 3 4

not at all somewhat moderately most helpful didn’t use

If you answered yes to question #1, please complete the following questions.

Please name the pharmacy that you used to obtain nicotine gum.

____________________________________________________________________________

(pharmacy name)

____________________________________________________________________________

____________________________________________________________________________

(address of pharmacy)

___________________________________________

(telephone of pharmacy)

We will contact your pharmacy to verify your use of the nicotine gum. We appreciate

your assistance.

THANK YOU.
Smoking and Tobacco Control Monograph No. 5

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187

Chapter 3

Chapter 3

Training of Physicians in Training

CONTENTS Introduction

Thomas E. Kottke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Interventions for Smoking Prevention and Cessation

Robert Goldberg, Judith K. Ockene, Katherine Kalan,

and Jean Kristeller . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Purpose of the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Rationale and Special Requirements . . . . . . . . . . . . . . . . . . . . . . . . 191

Target Audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

Recruitment Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Nature of the Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Smoking Intervention Approaches . . . . . . . . . . . . . . . . . . . . . . . . . 196

Special Resources and Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . 198

Products of the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

Study Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

Questions To Resolve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

What Might Be Done Differently . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Effects of Two Realistic Interventions To Teach

Smoking Cessation Counseling to Primary Care Residents:

A Randomized Trial

Victor J. Strecher, Michael S. O’Malley, Victor G. Villagra,

Elizabeth E. Campbell, Jorge J. Gonzalez, Thomas G. Irons,

Richard D. Kenney, Robert C. Turner, C. Stewart Rogers,

Mary F. Lyles, Susanne T. White, Clare J. Sanchez,

Frank T. Stritter, and Suzanne W. Fletcher. . . . . . . . . . . . . . . . . . . . . . . . 207

Purpose of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Training Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222

Appendixes

A. Smoking Intervention Communication Grid . . . . . . . . . . . . 223

B. Outline of the Advice and Counseling

Smoking Intervention Approaches . . . . . . . . . . . . . . . . . . . . . 224

C. Physician Responses to Patients’ Concerns . . . . . . . . . . . . . . . 226
Smoking and Tobacco Control Monograph No. 5

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189

Chapter 3

Training of Physicians in Training

Editor: Thomas E. Kottke

INTRODUCTION If physicians in training, particularly residents, are to become

effective smoking cessation interventionists, the following questions must

be answered:

• Can smoking cessation experts train residents to deliver effective

smoking cessation advice?

• Can residents be trained in smoking cessation techniques effectively

by nonspecialists?

• What sort of environment is required if residents are to be trained

in smoking cessation techniques?

The two papers in Chapter 3 focus on these issues. In the first paper,

Goldberg and colleagues demonstrate that after just a few hours of training,

residents can successfully help their patients stop smoking. These residents

were in the training programs of the Department of Internal Medicine and

Department of Family Practice at the University of Massachusetts. Their

training consisted of a 1-hour small-group session and a brief period for

residents to receive feedback on individual performance. The residents

were trained to use one of three interventions with each patient: advice

only, counseling, or counseling plus prescription of nicotine-containing

gum. According to data collected from 1,224 trial participants, the 6-month

rates for smoking cessation increased significantly in proportion to the

intensity of the intervention the residents delivered. Counseling plus prescription of nicotine-containing gum was more effective than was counseling

alone; and both of those interventions were more effective than was advice

alone.

In the second paper, Strecher and colleagues describe how medical

education generalists can successfully transfer smoking intervention skills

to residents. They also demonstrate that prompting residents to intervene

is not enough if the residents do not know what the intervention should be.

Recognizing that most residency programs would devote only minimal time

to training physicians in the delivery of smoking interventions, Strecher and

coworkers tested two interventions—a prompt on the medical record and a

two-session tutorial for the resident—in a design that compared the effects

of a control group, a group that received the prompt alone, a group that

received the training alone, and a group that received both the prompt and

the training. The ability of the interventions to increase both the frequency

of counseling and the number of techniques used to help the patient was

tested in 11 primary care training programs.
Smoking and Tobacco Control Monograph No. 5

190

While frequency of counseling was increased by both the tutorials and the

prompts, the increase in counseling associated with the prompts alone

(5 percentage points) was not statistically significant. In addition to increasing

the frequency of counseling, the tutorial doubled the number of intervention

techniques used by the residents.

Both papers demonstrate that residents can be trained to give successful

smoking intervention advice only if adequate resources and priority are

devoted to the task. Even though the chief of medicine and the training

program directors supported the program at the University of Massachusetts,

educating the 196 residents was, in the words of Goldberg and colleagues,

“a formidable and demanding organizational task.” A full-time project

coordinator was needed both to recruit residents to the training sessions

and to reschedule the sessions when the residents did not attend. Goldberg

and coworkers also found that it was “essential” for a research assistant to

be present in each clinic to assure that the interventions were delivered as

indicated. Likewise, support by all individuals, from the department chairs

to the clinic staff, was considered essential for success.

Strecher and colleagues shared these experiences: Arranging for followup

of the initial tutorial session required a concerted effort, and integration of

the prompt form into the medical record proved difficult. They concluded

that without the commitment of a faculty member at each site, the program

would have failed.

The message from these two papers is clear and consistent: While resident

physicians need prompting, they need more than prompting alone if they

are to help their patients stop smoking. However, the necessary skills can be

acquired in as little as 2 hours. Furthermore, the training can be provided

by faculty generalists; experts in smoking cessation are not required. It is

very clear, however, that neither training in smoking cessation nor the interventions that result from such training will diffuse into training programs

spontaneously because serious attention to smoking is not currently on the

medical agenda. If doctors are to be trained in the skills to deliver smoking

cessation counseling, and if they are to believe that dealing with smoking is

not an optional activity, adequate time, along with the necessary human

and fiscal resources, must be devoted to the task.
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Chapter 3

Interventions for Smoking

Prevention and Cessation

Robert Goldberg, Judith K. Ockene, Katherine Kalan,

and Jean Kristeller

PURPOSE OF The goals of the randomized clinical trial reported here were (1) to

THE PROJECT develop and evaluate a structured educational program for training

medical residents (and, secondarily, attending physicians) to intervene with

their patients who smoke cigarettes and (2) to evaluate, using a randomized

clinical trial design, the effect of three physician-delivered smoking intervention approaches (advice only, counseling, and counseling plus nicotinecontaining gum) in combination with two followup approaches (minimal,

maximal) on the 6-month smoking cessation rates of an ambulatory outpatient population. In addition, the investigators examined the effect of

these intervention approaches on patients’ long-term smoking behavior

at 12, 18, and 24 months after randomization.

RATIONALE Physicians have contact with at least two-thirds of all smokers

AND SPECIAL annually. Therefore, the majority of the 50 million current adult

REQUIREMENTS smokers in the United States could potentially be reached by

physicians during the course of ongoing medical care. This high patientphysician contact rate, even if coupled with only a small absolute effect

on smoking prevalence, could produce substantial changes in smoking

behavior in the general population of smokers.

A number of earlier clinical trials demonstrated that physicians’

provision of simple advice to stop smoking could increase the quit rates

of patients seen in a general medical population (Ewart et al., 1983; Handel,

1973; Li et al., 1984; Porter and McCullough, 1972; Russell et al., 1979;

Wells et al., 1984; Wilson et al., 1982). Recent randomized clinical trials

have consistently demonstrated that physicians who are prompted to intervene, or who receive special training to assist smokers during the course of

regular medical encounters, have a greater effect on the smoking behavior

of their patients than that of physicians not so trained or prompted (Cohen

et al., 1987; Cummings et al., 1989; Kottke et al., 1988; Ockene et al., 1991;

Wilson et al., 1988).

Physicians indicate that their willingness to intervene with smokers

in their practice would be enhanced if they felt confident of their ability

to have a positive effect on patients’ smoking habits. Medical school and

residency training programs, however, do little to foster the development

or maintenance of skills in this area. Residency programs in particular offer

little or no opportunity for training in communication skills and behavioral

intervention for problems such as unhealthy lifestyle behaviors.
Smoking and Tobacco Control Monograph No. 5

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Given that physicians can have a potentially substantial impact on a

large group of smokers, questions remain as to whether there is yet more

that the physician can offer the smoker within the context and constraints

of usual medical care. In particular, little investigative work has been carried

out to adapt the successful behavioral counseling approaches of psychologists

and health educators to the physician-patient encounter. Questions also

remain as to whether the physician’s role in smoking cessation could be

augmented with additional counseling by health counselors who are not

physicians. The present trial was carried out among resident physicians

in training to address these concerns and others.

TARGET Medical residents in training, from the Departments of Internal Medicine

AUDIENCE and Family Practice affiliated with the University of Massachusetts

Medical School, were targeted as the physician study sample during

Residents each of their postgraduate years. These residents were selected for the

following reasons:

• The physicians were at a stage in their careers where training is

a natural accompaniment to their career and practice aspirations.

Residents expect to be taught novel approaches to lifestyle and

lifestyle-related problems that could be incorporated into their

eventual clinical practices. As this is a logical training point, any

positive findings drawn from this study in the training of physicians

in smoking cessation techniques and of their effective use of such

techniques could be assimilated easily into other training programs

and medical practice settings.

• Physicians in training are young and energetic, and typically they

welcome participation in research projects, provided that their

involvement does not consume too much time and does not detract

from other areas of their training and from patient care responsibilities.

• The structured environment of ambulatory care teaching clinics,

which are organized under the aegis of a medical school, provides an

ideal setting for the conduct of such a randomized trial and for data

collection and monitoring.

Patients Patients attending five ambulatory clinics (two internal medicine and

three family practice) affiliated with the University of Massachusetts Medical

Center were recruited for this study. Each of the clinics was located within a

25-mile radius of the University of Massachusetts Medical Center. Participating patients averaged 35 years of age; slightly more than half (57 percent)

were female; 91 percent were white; their average level of education was

12.5 years; and they smoked, on average, slightly more than one pack of

cigarettes per day.
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RECRUITMENT The time slot for training residents in internal medicine was taken

PROCEDURES from their daily noon educational sessions, which are carried

out on a regular basis throughout the academic year. Originally,

Medical Residents letters were sent by the Chief of Medicine from the Department

of Internal Medicine to reinforce the importance of the study and the key role

of participation by residents. Further support for the residents’ participation in

the study was provided by the director of the residency training program, who,

on a number of occasions, discussed the importance of training in smoking

intervention and of the overall study. The director provided members of

the study staff with the time needed for training sessions. In addition, each

of the directors from the clinics where the study took place supported the

training activities of the study and allocated clinic time for residents to be

trained as needed.

Residents in the Department of Family and Community Medicine were

recruited through the directors of their training program and trained in a

relatively similar fashion. An appropriate amount of time was allocated from

their clinical responsibilities for attending the group training sessions and the

individual feedback session. Reflecting the success of the training program

and genuine interest and commitment to learning new smoking intervention

techniques, a large proportion of the attending physicians in the participating

primary care clinics requested and received training in smoking intervention.

Despite the support of key persons involved in the educational training

of the internal medicine and family practice residents, recruitment and training of the 196 house officers over the 4 years of the project turned out to be a

formidable and demanding organizational task. A full-time project coordinator

spent a considerable portion of her time in the first years of the project writing

letters to residents who missed the training sessions to inform them of the

future training dates and times; placing telephone calls to all eligible residents

to encourage them to attend the training sessions; and coordinating the

pretraining assessments, group training, and individual tutorial sessions.

Although it was impossible to examine systematically the extent of time

spent by the project staff in recruiting residents to the smoking intervention

training sessions, it was estimated that the project coordinator spent approximately half of her time on such activities. Residents who were unable to

attend the group training sessions were provided individual teaching sessions.

The important structural elements in facilitating resident attendance were

(1) keeping the training sessions relatively brief (less than 1 hour at a time)

and task oriented and (2) providing a free lunch as an incentive for residents

to attend the training sessions. Later sections of this paper describe approaches

to recruitment that were particularly helpful, as well as those approaches that

might have been modified in light of the experience from this trial.

Patients To facilitate the recruitment of patients to this study, as well as monitor

the delivery of the various smoking interventions by the residents, a research

assistant was placed at each of the participating clinics. Each of the respective
Smoking and Tobacco Control Monograph No. 5

194

research clinic assistants was placed in a highly visible and accessible area of

the clinic to enhance recruitment activities. This person determined the

eligibility of potential study participants, obtained informed consent, and

randomized each eligible and consenting subject to the study.

NATURE OF The entire training and research protocol of the Physician-Delivered

THE PROGRAM Smoking Intervention Project was approximately 3 hours in length

(Ockene et al., 1988 and 1991; Quirk et al., 1990). One-half hour was devoted

to pretraining assessments of residents’ baseline knowledge, attitudes, and

skills. Two hours were devoted to formal group training, which included

some discussion of the research protocol, and one-half hour to individual

posttraining assessment and protocol review with members of the study staff.

Thus, the actual resident training took approximately 2 hours.

A total of 196 internal medicine and family practice residents affiliated

with the University of Massachusetts Medical School participated in the study

and attended the training sessions, held about 2 weeks apart during regularly

scheduled teaching times. Generally, residents were trained in groups of 10;

however, because of their schedules, it sometimes became necessary to conduct the training sessions in smaller groups. In the first 2 years of the study,

66 residents were trained each year; in the final 2 years, only new incoming

interns, 32 each year, were trained. It was necessary to conduct 18 training

sessions to completely train the 66 eligible residents during the first year of

the study. In the second year, after determining that residents were generally

available during the scheduled noon conference hour, the investigators

reduced the number of training sessions to 14. In subsequent study years,

after the training protocol was well established in the curriculum, there

was an average of eight training sessions annually.

Sessions typically were offered during the residents’ regularly scheduled

noon conference teaching hour, during which the residents are exposed to

daily lectures from all clinical departments. Lunch was provided free to the

participating residents. Two weeks prior to the training sessions, each resident

received a letter from the residency director and study investigators to inform

them of the upcoming training and the importance of their participation.

To encourage the residents’ participation in the trial, several reminders of

the training session were sent close to the time of actual training; on the day

prior to training, notes were placed in the residents’ mailboxes; and on the

morning of the training session, study staff members telephoned residents

to confirm the meeting time and place and further encourage them to attend.

During the project’s training sessions, residents were trained in three

physician-delivered interventions: provision of personalized advice to assist

patients in stopping smoking; use of brief, patient-centered behavioral counseling; and use of the behavioral counseling approach plus the prescription

of nicotine-containing chewing gum. The educational methods used in the
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Chapter 3

residents’ training included the following: a slide presentation reviewing

epidemiological findings on the risks associated with smoking; discussion

of the benefits of cessation in both healthy persons and those with chronic

disease; and discussion of smoking as an addictive behavior. In addition,

the residents observed each of the smoking interventions via a videotaped,

simulated interaction that demonstrated the smoking cessation techniques.

The residents then practiced each quit-smoking approach by first critiquing

a simulated encounter between two residents and then through role-playing,

with each resident playing the role of physician or patient. The videotape

and role-playing exercises were used in both sessions. At the second training

session, evaluation of nicotine dependency and appropriate prescribing

practices for nicotine gum were discussed. Residents were also informed of

the importance of followup contacts in the counseling and the counselingplus-nicotine-gum interventions and the need to keep within the intervention protocol to which the patients were randomly assigned.

The final half-hour training session was completed with each resident

individually. During this session, the resident was videotaped using the

counseling approach with a surrogate patient and the videotape was reviewed

and feedback given by a project instructor. At this final session, a member of

the study staff reviewed the study protocol with each resident and addressed

questions concerning the project and the resident’s role in it.

The patient-centered counseling intervention emphasized the use of

guided questioning of patients by residents, as related to the following

content areas (see Appendix A):

• Desire and motivation to change smoking behavior;

• Past experience with smoking cessation;

• Factors that inhibit smoking behavior change (barriers or problems);

• Resources for change (strengths) and methods for dealing with factors

that may interfere with the smoking cessation or reduction plan; and

• A plan for change.

In each of the content areas of the counseling protocol, the counseling

skills of the residents were assessed in the areas of eliciting and providing

information as well as in eliciting and responding to patients’ feelings.

At the completion of the individual training session, each resident was

provided with a $25 gift certificate to use toward the purchase of books or

other educational materials at the university bookstore. In addition, each

resident’s name was placed into an annual lottery from which one resident

was eventually chosen and given a further financial incentive.
Smoking and Tobacco Control Monograph No. 5

196

SMOKING The three physician-delivered interventions consisted of the condiINTERVENTION tions described in the following sections (Ockene et al., 1988 and

APPROACHES 1991; Quirk et al., 1990).

Advice Only Patients assigned to the advice-only condition received a brief

smoking cessation message from the resident physician that personalized each

patient’s risk of smoking and encouraged each patient to stop smoking. For

example, the resident might say to the patient, “Stopping smoking is particularly important for you because you have high blood pressure and an elevated

cholesterol level, and stopping smoking could help reduce your risk of heart

disease.” Interested patients were also offered a list of available smoking

cessation resources in the community. Although participating physicians

were asked not to extend further smoking interventions or counseling to

patients randomly allocated to this condition, if the patient initiated questions

about how to stop smoking or requested specific help, such as a prescription

for nicotine-containing gum, the residents were free to respond as they believed was clinically appropriate. A sample of the script recommended for

use by residents for patients randomized to the advice-only intervention and

the particular aspects of this intervention are presented in Appendix B.

Counseling In addition to receiving the minimal advice-only intervention, each

patient randomized to the counseling condition received behavioral counseling. As previously described, this intervention approach explored a number

of patient-centered areas related to behavior change. Through open-ended

questions, the resident elicited information about the patient’s desire and

motivation to change smoking behavior, past experiences with stopping,

problems that might inhibit the change, current concerns, resources available

for changing smoking behavior, and interest in developing a personalized

plan for cessation and followup. Trained residents were taught to structure

the counseling approach around these specific behavior-related content areas

and were provided with model questions, such as “How do you feel about

your smoking?”, “Have you ever stopped smoking before?”, and “How were

you able to stop smoking in the past?” A sample script for the counseling

intervention and guidelines for its use are shown in Appendix B.

The sequence of questioning developed for use by the residents has a

cognitive and behavioral theoretical basis with the principal focus on the

development of positive self-efficacy in the patient. In other words, the

counseling intervention helps patients to identify the personal skills and

resources necessary to stop smoking and to feel confident of their ability

to stop smoking and their commitment to do so. This approach was chosen

because previous studies of smoking behavior change have shown that when

an individual believes it is possible to make the desired change, there is greater

likelihood that such change will occur. Residents were also trained to provide

simple behavioral self-management recommendations (such as taking a walk

after dinner instead of smoking a cigarette) and to be supportive of the

patient’s cessation and/or tapering efforts. A written agreement or a plan
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for change in the patient’s smoking behavior was formulated between the

patient and physician as a form of contracting between the two parties.

The plan for change included a quit date, if deemed appropriate, and other

changes in smoking behavior such as changing brands or tapering the number

of cigarettes smoked each day. A copy of the agreement was given to the

patient along with a list of community resources and an NCI-produced selfhelp booklet, “Quit for Good.”

Patients were requested to schedule a followup appointment with the

resident within 2 weeks or a followup telephone call if a visit was not possible.

At that time, the physician was to address changes in the patient’s smoking

behavior and intervene appropriately. Trained residents were also provided

with a single page of suggested responses to patients’ concerns about stopping

or reducing smoking (Appendix C). The responses were important because

physicians often reported feeling at a loss when patients expressed feelings

or concerns that the physicians were not prepared to address. The recommended responses helped to increase the physician’s own feelings of efficacy.

Although it was impossible to assess systematically the amount of time residents spent in each of the intervention approaches, the interventions were

designed to be relatively brief and to be incorporated into a regular medical

care encounter.

Counseling Plus Patients randomly assigned to the counseling-plus-gum condition

Prescription Gum received the basic patient-centered counseling intervention and

also were offered nicotine-containing chewing gum as a resource to aid in the

cessation process. Patients interested in using the gum and willing to set a

specific quit date were provided with a prescription for up to three boxes of

the gum at no charge. Patients who were not ready to stop smoking were

informed that they could request the gum at any time during the course

of the project once they agreed to stop smoking. As part of the training

program, residents were taught about how to instruct patients in the proper

use of the gum and how best to respond to concerns that patients might raise

about using the gum. After seeing their physicians, patients were seen for

several minutes by a clinic assistant associated with the study, who instructed

them more fully in the use of the gum.

Followup to In addition to the three physician-delivered intervention approaches,

Intervention patients were further randomized to two followup conditions, as

described below.

Maximal Patients randomized to the maximal-followup condition received teleFollowup phone calls from trained counselors (master’s-level psychologists or health

educators) at approximately 1, 2, and 3 months after the initial physician

contact and randomization. The same counselor made all three telephone

calls to a single study participant. Personalized letters followed each counseling call and were keyed to the patient’s smoking status as determined by the

previous call. Patients were congratulated for any changes they had made in

their smoking behavior and encouraged to continue to work toward complete
Smoking and Tobacco Control Monograph No. 5

198

cessation. The calls were somewhat structured and were keyed to information

from the baseline questionnaire and to changes in smoking status. The counselor used a series of open-ended questions similar to those the physicians

used in the patient-centered counseling approach, provided behavioral

recommendations, and negotiated a smoking cessation or maintenance plan

with the patient, as appropriate.

Minimal When patients were assigned to the minimal-followup condition, no

Followup further counseling contact was provided. All patients, whether in the

maximal- or minimal-followup group, were informed of the initial

6-month telephone monitoring calls at the time of their initial physician

visit. They were informed also that they would be called to determine

changes in their smoking status at 12, 18, and 24 months after randomization.

SPECIAL As noted previously, a research assistant was placed at each of the

RESOURCES AND participating clinic sites to facilitate the recruitment of patients

PROCEDURES and oversee the physician-delivered interventions. These assistants

were essential because they reminded the clinic staff, physicians and nurses,

that they were participating in the study. The research assistant delivered a

sealed intervention packet to the resident who would be intervening with

the enrolled and randomized patient. The resident then broke the seal of the

intervention package, which contained a brief suggested script that could be

tailored for use with each randomized patient. This script reduced the need

for recall on the part of the intervening physician and standardized the delivery of the assigned intervention. The packet also contained all appropriate

support materials, such as the list of available community resources and selfhelp materials to be used with each randomized patient.

To further support the participation of residents in this study, and to

emphasize the importance of the counseling techniques and their relevance

for use with other lifestyle-related problems, interested attending physicians

at the respective clinics were also informed of the goals and objectives of the

study and were trained in the various quit-smoking intervention approaches.

PRODUCTS OF Samples of the counseling intervention approach used in this study

THE PROJECT and sample scripts of the intervention protocols are provided in

Appendixes A and B, respectively. In addition, physician responses to

patients’ concerns that might be commonly raised when they are asked to

stop or reduce the number of cigarettes they are presently smoking are outlined in Appendix C. The responses that could be used by the trained

residents were developed so that the residents would feel more secure and

comfortable in replying to the most typical concerns that patients had in

terms of stopping or reducing the number of cigarettes they were currently

smoking. During the initial role-playing exercises involving residents,

members of the research staff became aware of the need to emphasize that

the residents did not have to be experts about all factors that would assist

patients in making the behavioral changes necessary to stop smoking.
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Chapter 3

However, the residents clearly felt more comfortable with delivery of the

various smoking interventions once they had several responses that they

could draw upon to allay patients’ concerns.

This study developed a training package that includes a facilitator’s

manual, 47 slides, a 35-minute videotape, structured role-plays, and training

materials that integrate the physician-delivered smoking intervention

approaches of advice, counseling, and prescription of nicotine polacrilex

(Nicorette) into a unified intervention algorithm. An office practice

management kit also was developed as part of the study and is included

in the training package.

STUDY RESULTS Pretreatment and posttreatment measurements showed that residents

exhibited significant positive change in the three skill areas of providWhat Worked ing information, eliciting information, and eliciting and responding

And Why to feelings expressed by patients with respect to smoking cessation

(Ockene et al., 1988; Quirk et al., 1990). Overall scores, based on a

Physician Changes point scale from 0 (no evidence of the skill) to 3 (highly appropriate

use of the skill), showed significant changes after training in providing information (1.23 to 1.48), eliciting information (0.95 to 1.74), and

eliciting and responding to feelings (0.47 to 1.03) (all p < 0.001). Significant

differences also were observed in the application of these skills to a number

of content areas. In the complete pretraining and posttraining resident data,

residents showed improvements after training in assessing patients’ desire and

motivation to change their smoking behavior, in questioning patients about

their previous experiences with smoking changes, in identifying factors that

might inhibit any changes in their patients’ smoking status, and in helping

patients identify and use available resources for changing their smoking

behavior. Residents also showed significant improvements after training in

formulating specific plans for change with their smoking patients. Baseline

measurements conducted at the commencement of the trial indicated that

participating residents thought that in general it was very important to help

both healthy and sick patients to stop smoking and that formal training in

smoking cessation was very important (mean=4.3 on a 1- to 5-point scale).

Favorable changes in residents’ knowledge of the risks of smoking cigarettes

and attitudes toward smoking and smoking cessation also were observed

over the course of the study.

From the patients’ perspective, those in the behavioral counseling and

counseling-plus-nicotine-gum conditions were significantly more likely to

report that their physician had been very helpful in their efforts to alter their

smoking behavior than were those individuals assigned to the advice-only

group. These differences were seen regardless of the patients’ success or lack

thereof in quitting smoking.

For assessing maintenance of counseling skills, a subsample of residents

was selected to examine changes in residents’ long-term counseling behavior

(Quirk et al., 1990). Although the findings from this small and select sample
Smoking and Tobacco Control Monograph No. 5

200

of residents call for cautious interpretation, the surveyed residents continued

to exhibit positive and measurable changes in the three general skill areas

at 1 year after training completion. In spite of the inherent difficulties in

identifying particular aspects of the training sessions that may have facilitated

the effective training of residents (given the different staff involved, training

conditions, group dynamics, and other factors), the use of role-playing seemed

to be particularly effective in opening up residents and in giving them experience in administering the program interventions.

Although the investigators had some initial trepidation about the use

of role-playing with residents and the likelihood of getting residents actively

involved in such exercises, it became readily apparent that, in an appropriate

context, residents were receptive to role-playing. They enjoyed the interactive

exchange of playing patient and provider, and they became demonstrably

more comfortable in the delivery of the various smoking intervention approaches. Role-playing became a highly informative educational approach

in that, by observing the study staff as well as other residents and then delivering the intervention themselves, residents were able to provide and receive

feedback on those approaches and techniques that could assist their patients

with smoking cessation.

Patient Smoking According to data from 1,224 trial participants, 6-month cessation

Cessation rates increased significantly as the intensity of the physician-delivered

intervention increased (p < 0.005) (Ockene et al., 1988). Among

patients randomized to the advice-only condition, 9.1 percent reported cessation for at least 1 week at the time of the 6-month telephone contact. Patients

receiving the behavioral-counseling and counseling-plus-gum interventions

reported 1-week cessation rates of 11.9 percent and 17.4 percent, respectively.

Comparable differences in adjusted cessation rates were seen when multiple

regression analysis was used to control for a variety of potentially confounding

baseline characteristics. The adjusted findings revealed that patients in the

counseling-plus-gum group demonstrated almost twice the likelihood of

quitting (95-percent confidence intervals=1.2, 3.2) as those in the adviceonly group; whereas patients in the counseling group demonstrated a

likelihood of quitting 1.6 times that of patients in the advice-only group

(95-percent confidence intervals=1.0, 2.6). However, no significant differences

were observed in the 6-month cessation rates of randomized patients according

to type of followup (minimal phone followup was 11.2 percent; maximal

phone and letter followup, 13.9 percent).

A similar pattern of increasing quit rates with increasing levels of physician

intervention was observed for continuous abstinence from smoking of greater

than 3 months reported at the time of the 6-month followup contact. Of the

advice-only patients, 5.9 percent had been completely off cigarettes for at

least 3 months at the time of the 6-month monitoring calls; the rates were

9.2 and 13.2 percent for patients in the counseling and counseling-plusnicotine-gum interventions, respectively (p < 0.005).
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Chapter 3

How soon patients stop smoking after contact with a physician provides

additional information about the immediate impact that the physician can

have on patients’ smoking behavior. The length of time between the physician visit and initial successful cessation suggested that the more intensive

the physician intervention, the greater the likelihood for early cessation.

For example, approximately 15 percent of smokers in the counseling-plusgum group reported having stopped smoking within a day of their initial

physician visit, compared to 11 percent in the counseling group and 4 percent in the advice-only group (p < 0.001).

The length of time that patients abstain from cigarettes immediately

after being seen by a physician is another measure of initial physician impact

on patients’ smoking behavior. The results of this trial suggest that the more

intensive the physician-delivered intervention, the longer the period of

abstinence after the initial contact.

A trend for an intervention effect was observed for the maintained selfreported abstinence rates at the time of the 12-month telephone followup.

That is, 6.2 percent of patients who received physician advice only reported

not smoking at both the 6- and 12-month contact points after baseline

randomization. The proportion of patients who reported not smoking for

at least 1 week prior to the telephone contact at each of these two followup

assessment points was 8.1 percent for patients in the counseling group and

10.6 percent for those in the counseling-plus-nicotine-gum condition.

No significant differences were observed, however, for the 12-month,

1-week point prevalence cessation rates among the three physician-delivered

intervention groups. Among patients randomized to the advice-only group,

15.2 percent reported being abstinent from cigarettes for at least 1 week; the

corresponding percentages for patients in the counseling and counselingplus-nicotine-gum groups were 12.9 and 16.7 percent, respectively. The

absence of a main effect is attributable primarily to an increased number of

“new stoppers” in the advice condition. It is highly probable that this higher

prevalence of new cessation in the advice condition is a crossover effect

rather than a result of the delayed impact of the brief advice-only intervention. “Crossover” means that patients in the advice-only group who continued to see their study physician probably ended up receiving more intensive

counseling between the time of the 6- and 12-month followup contacts,

resulting in higher rates of cessation.

After the residents saw their patients for the initial study contact, they

were not restricted to their original intervention condition. With the exception of the project stickers that identified patients participating in the study,

there were no identifiers placed on the patients’ charts to indicate their

original randomized condition. In spite of there being no observed trends

in 1-year quit rates related to intensity of smoking intervention, and possible

subsequent confounding between randomized groups in the subsequent use

of the various smoking interventions, it was encouraging to note the high
Smoking and Tobacco Control Monograph No. 5

202

quit rates in the advice group, suggesting a clearly positive effect of physician

advice on patients’ long-term quit rates.

Integration of the Although the integration of the physician-delivered smoking interTraining Model vention training into the residency program was not a measured trial

outcome, it was clearly necessary if the trial was to be successfully

implemented. This report, especially the last section, indicates how such

integration was facilitated. It is also of note that even after the study ended,

the residency program directors strongly supported the continued teaching

of the project protocol. All incoming medical residents at the University of

Massachusetts Medical School have come to expect such training as part of

their residency program.

What Did Not As is consistent with most population-based clinical trials, efforts

Work and Why to recruit the projected number of patients to the study fell behind

the projected schedule. This was caused by operational factors as well as the

unexpected low rate of current cigarette smoking among the populations

surveyed. Also, early in the trial it became apparent to the investigators

that they would need a multiplicity of institutional resources, recruitment

techniques, and variations in the methods by which residents would be

taught the various smoking intervention approaches. For example, the

provision of training without lunch or refreshments did not work; nor did

training sessions lasting more than an hour, as the training began to impinge

on the residents’ clinical responsibilities. In the early training aspects of the

trial, residents may have suffered information overload as the investigators

attempted to condense a lot of information into a limited timeframe. The

investigators soon realized that they had to keep the resident training simple

and understandable without presenting excessive didactic material, and they

realized the need for considerable role-playing in the three quit-smoking

intervention approaches. It is certainly likely that the cultural norms and

milieu of the residents’ environment are influential in the adoption of, or

failure to adopt, training in smoking intervention or other lifestyle intervention techniques. It is clearly important not only to obtain the support and

enthusiasm of those involved in the daily clinical training of medical

residents, but also to create a receptive and open environment in which

residents can be shown the importance of such training and foster its

encouragement among peers.

Problems With The results of this study confirm and extend current knowledge

Implementation of the beneficial impact that physicians can have on the smoking

behavior of their patients. The study demonstrated that patients who

received brief, patient-centered, behavior-oriented counseling, with or

without the prescription of nicotine gum, were considerably more likely

to change their smoking behavior than were patients who were provided

brief advice to stop smoking. The impact of these interventions on quit

rates was seen immediately after intervention and at 6 months after

randomization. It was also evident in terms of the length of time patients

were able to continue abstaining from cigarettes.
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One concern that physicians expressed about delivering smoking

interventions was that they might offend and alienate patients who are

not yet ready to quit, particularly if the physicians do more than offer brief

advice. However, in this trial the patients rated physicians as substantially

more helpful when they offered counseling or counseling plus nicotine

gum than when they simply gave advice to stop smoking. This was true

whether the patients went on to quit or not. As most smokers go through

several stages of readiness to change their smoking status (Prochaska and

DiClemente, 1983), it is important that physicians feel confident in exploring smoking issues with smokers who are not highly motivated to quit.

Patient-centered counseling is designed to minimize defensiveness on the

part of the smoker and it can be used repeatedly, thereby taking advantage

of another characteristic of usual health care—intermittent contact over

extended periods of time with a regular health care provider.

Conversely, the results of this study do not support the use of followup

telephone counseling by ancillary staff to facilitate changes in patients’ longterm smoking behavior. This result was surprising because it did not fit the

pattern observed by Kottke and colleagues (1988). Although the telephone

counselors were well-trained and skilled, no face-to-face contact had occurred

between the study patients and the counselors, and patients may have

perceived their calls as impersonal, intrusive, or unwarranted.

The results of the present study suggest also that resident physicians can

be successfully trained in the delivery of patient-centered, behavioral counseling for smoking cessation. Residents demonstrated enhancement of not

only their attitudes toward smoking cessation approaches, but also their

ability to affect favorably their patients’ smoking behavior. A further mark

of success for the training program was that it was requested by, and extended to, attending physicians working in the clinics in which the study

was carried out.

QUESTIONS Despite the encouraging results of the present study (Ockene et al.,

TO RESOLVE 1988 and 1991; Quirk et al., 1990), a number of questions remain

unanswered and warrant further investigation. Is the effectiveness of patientcentered counseling attributable to the greater amount of time spent by the

physician or to the manner of counseling? Can the counseling techniques

used in this study be taught readily in other settings and to physicians at

other levels of professional development? There are also unanswered

questions about how best to use the clinic environment to foster smoking

prevention and cessation among patients attending the clinic and how best

to prompt the resident physicians to deliver the smoking intervention.

Another major set of questions has to do with identifying the necessary

and effective followup of patients who smoke. Perhaps telephone counseling

followup would increase cessation efforts when offered by someone known

to the patient, or if the patient were able to decide whether or not to receive

such additional counseling.
Smoking and Tobacco Control Monograph No. 5

204

Although no data are available to address this question, another important

area for future research is whether this type of brief, patient-centered counseling can be used by physicians to intervene effectively with other behavioral

risk factors such as physical exercise (Harris et al., 1989) and lowering cholesterol (Report of the National Cholesterol Education Program, 1988). Given

that the authors have shown that residents can be trained to deliver effective

quit-smoking messages to their patients, it is hypothesized that physicians in

training and practicing physicians might also use such approaches in helping

patients to modify their intake of saturated fat and total fat and to find effective ways to increase their energy expenditure on a long-term basis. Finally,

the authors do not know how best to maintain the quit rates observed in

this trial, given the minimal interaction that occurred between patient and

physician.

There are a number of additional issues related to physician training.

Support from the department chairs, directors of the residency training programs and clinics, and the staffs of clinics at which the study took place was

considered essential in successfully training the residents, recruiting patients,

and carrying the study to completion. Attending physicians in the clinics

also were perceived as agents of support and sanction for the residents’

activities.

There remain unanswered questions as to whether one can assess the

stages of readiness for the adoption of training in smoking intervention in a

physician sample, and whether efforts should be aimed specifically at residents

who are seriously contemplating or eager to get such training. The receptivity

to training is expected to be quite high among such physicians, whereas those

physicians who are in a precontemplation stage for receiving and adopting

such training might be initially bypassed. Such targeting of physicians might

result in more effective and efficient recruitment, as well as training, of health

care providers in smoking cessation techniques.

The optimal timing for the various training activities involved in educating

residents in the use of such counseling techniques is unknown. Meals and

additional incentives (e.g., gift certificates or possibly continuing medical

education credits for attending physicians) should most definitely be provided

as a means to recruit and retain the parties involved. Questions also remain

as to when and if resident or attending physicians might need additional

maintenance or booster training sessions to reinforce and bolster their smoking intervention efforts. At present, the authors’ training program has been

incorporated into the medical residents’ curriculum, providing a further

institutionalization of the program.

The most effective ways to train resident physicians remain to be determined. For example, should members of a study staff train key physicians

who will in turn be responsible for training their residents (training the trainers)? Or, on the other hand, might self-training materials be used by targeted

personnel and might use of these materials be considered adequate training?
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Chapter 3

WHAT MIGHT Although, in general, it was thought that the recruitment and training

BE DONE of physicians for this trial were satisfactory, particularly as the study

DIFFERENTLY investigators accrued experience with methods that might or might

not work for recruiting the physicians and study sample, the logistics were

quite formidable. The principal investigator and project coordinator are

key to the successful recruitment and retention of physicians, and these

individuals must be highly visible and approachable. Early and continued

involvement of the director of the residency training program and the chair

of the medical department from which residents are recruited is also essential

to the successful conduct of such a trial. In addition, it is extremely important

to identify and involve key clinic staff from each of the participating clinics

at which residents practice early on, so that the residents’ role in the study

will be fostered and obstacles minimized.

With regard to the structure of training sessions, the study showed that

between 6 and 10 participants was the ideal number, so that each individual

resident could successfully role-play each of the interventions to be used. In

addition, within several months after the physician has become involved in

such a trial, regardless of the number of patients treated with the intervention,

booster training sessions should be developed to maintain a high degree of

competency for the various smoking interventions. More attention should be

directed also to the training of residents in smoking relapse prevention, as this

was a problem that affected the study’s 12-month findings.

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Cohen, S.J., Christen, A.G., Katz, B.P., Drook, C.A.,

Davis, B.J., Smith, D.M., Stookey, G.K. Counseling

medical and dental patients about cigarette

smoking: The impact of nicotine gum and chart

reminders. American Journal of Public Health 77:

313-316, 1987.

Cummings, S.R., Coates, T.J., Richard, R.J., Hansen,

B., Zahnd, E.G., Vander Martin, R., Duncan, C.,

Gerbert, B., Martin, A., Stein, M.J. Training physicians in counseling about smoking cessation: A

randomized trial of the “Quit for Life” program.

Annals of Internal Medicine 110(8): 640-647, 1989.

Ewart, C.K., Li, V.C., Coates, T.J. Increasing physicians’ antismoking influence by applying an

inexpensive feedback technique. Journal of Medical

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Handel, S.P. Change in smoking habits in a general

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Harris, S.S., Caspersen, C.J., DeFriese, G.H., Estes,

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Kottke, T.E., Battista, R.N., DeFriese, G.H., Brekke,

M.L. Attributes of successful smoking cessation

interventions in medical practice: A meta-analysis

of 39 controlled trials. Journal of the American

Medical Association 259: 2882-2889, 1988.

Li, V.C., Kim, Y.J., Ewart, C.K., Terry, P.B., Cuthie,

J.C., Wood, J., Emmet, E.A., Permutt, S. Effects of

physician counseling on the smoking behavior of

asbestos-exposed workers. Preventive Medicine 13:

462-476, 1984.

Ockene, J.K., Kristeller, J., Goldberg, R., Amick, T.L.,

Pekow, P.S., Hosmer, D., Quirk, M., Kalan, K.

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smoking intervention: A randomized clinical trial.

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Ockene, J.K., Quirk, M.E., Goldberg, R.J., Kristeller,

J.L., Donnelly, G., Kalan, K.L., Gould, B., Greene,

H.L., Harrison-Atlas, R., Pease, J., Pickens, S.,

Williams, J.W. A residents’ training program for

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Archives of Internal Medicine 148: 1039-1045, 1988.

Porter, A.M.W., McCullough, D.M. Counseling

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Prochaska, J.O., DiClemente, C.C. Stages and

processes of self-change of smoking: Toward an

integrative model of change. Journal of Consulting

and Clinical Psychology 51(3): 390-395, 1983.

Quirk, M., Ockene, J., Kristeller, J., Goldberg, R.,

Donnelly, G., Amick, T., Kalan, K. Training family

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Wells, K.B., Ware, J.E., Jr., Lewis, C.E. Physicians’

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Chapter 3

Effects of Two Realistic Interventions

To Teach Smoking Cessation Counseling

To Primary Care Residents:

A Randomized Trial1

Victor J. Strecher, Michael S. O’Malley, Victor G. Villagra,

Elizabeth E. Campbell, Jorge J. Gonzalez, Thomas G. Irons,

Richard D. Kenney, Robert C. Turner, C. Stewart Rogers,

Mary F. Lyles, Susanne T. White, Clare J. Sanchez,

Frank T. Stritter, and Suzanne W. Fletcher

PURPOSE OF The NCI Smoking, Tobacco, and Cancer Program trials of smoking

THE STUDY interventions by physicians have demonstrated that smoking cessation

counseling by physicians can help smokers quit. How best to disseminate

widely effective smoking cessation counseling and increase physicians’ use

of it remains an issue. Residency training programs offer a natural, though

standard, opportunity to teach effective smoking cessation counseling to

large numbers of physicians.

The authors developed two realistic, generalizable interventions to

increase smoking cessation counseling by primary care resident physicians:

the tutorial and the prompt. Both were based on the same minimal-contact

smoking cessation counseling protocol, one similar to those used in the STCP

Physician Smoking Trials. The tutorial used a “training of trainers” approach

in conjunction with the familiar tutorial format to teach smoking cessation

counseling to residents. The prompt used a chart-based reminder to teach

residents smoking cessation counseling by prompting and guiding them to

do counseling.

The investigators then used a randomized factorial design to determine

changes in residents’ counseling practices and their patients’ cigarette smoking after the two interventions. The trial evaluated the effectiveness of the

tutorial and the prompt across 11 residency training programs and 3 primary

care specialties: internal medicine, family medicine, and pediatrics. This

paper summarizes previously published results and examines the utility of

1 Supported by the University of North Carolina Faculty Development Program in General

Medicine and General Pediatrics (PE54004, Bureau of Health Professions, Washington, D.C.)

and by grants from the National Cancer Institute (R03-CA43994), the North Carolina Chapter

of the American Heart Association (1986-86-37-A), and the University of North Carolina Center

for Health Promotion and Disease Prevention.
Smoking and Tobacco Control Monograph No. 5

208

training in smoking cessation counseling as well as barriers that impede

implementation of such training (Campbell et al., 1991; Kenney et al., 1988;

Strecher et al., 1991).

TRAINING What constitutes a realistic intervention to increase the use of

PROGRAM smoking cessation counseling by residents in primary care training

programs? A realistic intervention should address two questions:

Background: (1) What is an effective and generalizable smoking cessation counDefining seling protocol that physicians can use in a practice setting? and

Realistic (2) What are the most effective and generalizable ways to teach,

Interventions reinforce, and remind physicians to use the smoking cessation

counseling protocol?

The smoking cessation counseling protocol that resident physicians use

with their patients who smoke should reflect the realities of clinical practice.

Busy physicians involved in ongoing patient care need simple, efficient, and

effective counseling skills. A number of studies have shown that minimalcontact smoking cessation counseling programs can be effective (Cohen et

al., 1987; Cummings et al., 1989; Janz et al., 1987; Kottke et al., 1989;

Wilson et al., 1988).

Most residency training programs likely would provide only minimal

time for residents to learn the protocol and develop their counseling skills.

Given the extensive curricula of such programs, training in smoking cessation counseling would be provided most easily through already planned

seminars or in another seminar format. Although interactive sessions would

be better for teaching counseling skills, seminars are the method of choice

in many residency programs.

An alternative to seminar teaching would be use of a prompting system

that reminds physicians to perform routine clinical and preventive procedures. By enhancing the prompt, the system could guide counseling as well

as remind physicians to perform the counseling, and physicians would learn

smoking cessation counseling by doing. Such teaching would not impose

on residency curricula. Because either manual or computer systems can be

developed and maintained in most settings, the training would also be

generalizable.

Given a seminar-based teaching intervention, it seems likely that a

faculty physician associated with the residency program or the institution

would have to do the teaching. Because the faculty physicians would probably have little or no formal training in smoking cessation counseling, a

training-of-trainers approach would be appropriate and generalizable. Physician teachers would be centrally trained in the smoking cessation counseling

protocol. Their training would be extensive, involving expertise in smoking

cessation counseling, general behavior change and relapse prevention counseling, and medical education/adult learning strategies.
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Chapter 3

Finally, teaching resident physicians to do smoking cessation counseling

presents unique challenges. Residents’ pessimism about the effectiveness of

smoking cessation counseling makes them reluctant to undertake counseling

in their busy practices. Any training approach for smoking cessation counseling must attempt to convince residents of the importance and effects of smoking cessation counseling by physicians. Residents are also adult learners who

receive instruction while actively caring for patients. Teaching must be succinct and relevant to their immediate experience.

Using these principles, the authors developed two interventions to promote minimal-contact smoking cessation counseling by physicians: a tutorial

and a prompt. A detailed description of both interventions and their development is available elsewhere (Campbell et al., 1991).

Minimal-Contact Both interventions taught physicians a minimal-contact smoking

Counseling cessation counseling protocol based on work by Strecher, by

investigators in the STCP Physician Smoking Trials, and by other researchers

in the field (Cummings et al., 1986; Gritz, 1988; Kottke et al., 1988; Ockene,

1987; Strecher et al., 1985). According to the protocol, the physician first

assessed the patient’s motivation to quit smoking. If the patient did not

express an interest in quitting, the protocol suggested that the physician

attempt to motivate the patient to quit by discussing the health, social, and

financial benefits of quitting smoking and by setting a goal toward quitting.

If the patient was motivated to quit, the physician was to explore the patient’s

obstacles to quitting, consider the use of nicotine gum, set a quit date, write a

prescription for a quit date, and give the patient self-help materials. Whether

or not the patient was motivated to quit, the protocol had the physician follow

up on the counseling.

The Tutorial The tutorial consisted of two sessions in smoking cessation counseling

that could be incorporated into ongoing residency training. The sessions

were based on seven principles of adult education adapted from Gagne and

Briggs (1979):

• Gaining the resident’s attention,

• Making clear the objectives,

• Presenting material in varied ways,

• Providing guidance,

• Having the resident practice,

• Providing feedback on performance, and

• Assessing performance.
Smoking and Tobacco Control Monograph No. 5

210

The initial 1-hour session included a 10-minute slide presentation/lecture

on smoking and smoking cessation; a 10-minute presentation of the minimal-contact smoking cessation protocol, incorporating a handout flowsheet;

a 10-minute videotape demonstrating two successful counseling interactions;

and a 20-minute group discussion and evaluation. The videotape presented

one interaction with a motivated patient and one with an unmotivated

patient. Approximately 2 weeks after the initial session, residents attended

individual or small group followup sessions to discuss their initial attempts

to counsel patients.

In both sessions, the tutorial attempted to counter residents’ pessimism

about the effectiveness of smoking cessation counseling by emphasizing that

a 10- to 15-percent quit rate among all smokers seeing a physician each

year—a success rate difficult for the individual physician to discern—would

generate nearly a half-million new nonsmokers each year and could save

thousands of lives. The tutorial for pediatric residents was identical to that

for internal medicine and family practice residents, except that pediatricians

were taught to counsel the patient’s parents rather than the patient.

A clinic director or a faculty member involved in the residency training

program conducted the tutorial at each site. The trainers were fellows in the

University of North Carolina Faculty Development Program. As part of the

program, each of the fellows had received training in smoking cessation

counseling, general behavior change, and medical education/adult learning.

The fellows and the program faculty developed the smoking cessation protocol and the two interventions, designed the randomized trial to evaluate the

interventions’ effects, and authored this study. Thus, the current study

approximates the training-of-trainers approach—although the physician

trainers in this study were probably more involved and committed to the

interventions than other faculty members would be.

The Prompt The prompt provided chart-based reminders for physicians to counsel

patients to stop smoking and to guide physicians in that counseling (Figure 1). At patient check-in, clinic nurses identified patients who were smokers. Nurses then attached a one-page flowsheet summarizing the minimalcontact counseling protocol to the front of the medical chart. The prompt

was identical to the flowsheet used in the tutorial. In pediatric residency

programs, nurses determined which parents smoked and placed the prompt

on the charts of their children.

EVALUATION The authors used a randomized factorial design to determine the

effects of the two realistic teaching interventions, alone and in combination.

To investigate the generalizability of the interventions, the investigators

tested them in 11 residency training programs representing three primary

care specialties.
211

Chapter 3

Figure 1

Smoking cessation counseling flowchart

Source: UNC Faculty Development Program. Copyright University of North Carolina, Chapel Hill; used with permission.
Smoking and Tobacco Control Monograph No. 5

212

Figure 1 (continued)
213

Chapter 3

Clinical Setting The trial took place in 11 primary care training programs: 6 in

And Target internal medicine, 3 in family medicine, and 2 in pediatrics. The

Audience programs were distributed across three university medical centers

(University of North Carolina at Chapel Hill, East Carolina University School

of Medicine, and Bowman Gray School of Medicine) and four universityaffiliated community hospitals (Charlotte Memorial Hospital, Charlotte,

North Carolina; New Hanover Memorial Hospital, Wilmington, North

Carolina; Moses Cone Memorial Hospital, Greensboro, North Carolina;

and the Geisinger Medical Center, Danville, Pennsylvania).

All residents who saw patients in the ambulatory care setting at least

one-half day per week throughout the study period were eligible for the trial.

Those who did not complete a pretest questionnaire were dropped from the

trial. Adult patients were people aged 17 to 75 who were making a return visit

to a study physician and who reported smoking five or more cigarettes in the

preceding 7 days. At the two pediatric sites, parents of patients, rather than

the patients themselves, were eligible.

Trial Design The authors used a randomized factorial design, alone and in combination, to test the two interventions (Figure 2). For the physician pretest, residents completed self-administered questionnaires to provide self-reports

on smoking cessation counseling frequency and content, their attitudes,

and their training. For pediatric residents, questions were adapted to address

counseling of patients’ parents.

After the pretest, residents were randomly assigned, by clinic half-day

session, to one of four groups: tutorial only, prompt only, tutorial plus

prompt, and control. The physician posttest was administered 6 months

after completion of the tutorials and the start of the prompts.

During the 6 months between the physician pretests and posttests, research assistants at each site used a structured questionnaire to interview

patients who smoked and who had just seen a study physician. Patients

were asked about their smoking habits and physician advice to stop smoking.

Up to 10 patients were interviewed for each physician.

Six months after the initial exit interview, telephone interviewers, who

were blind to residents’ and patients’ group assignments, obtained patient

reports on current smoking status. Patients who reported stopping smoking

were offered $15 to return to their clinic site for a short interview during

which a breath sample was obtained for biochemical verification of smoking

cessation. Patients whose breath samples had carbon monoxide concentrations greater than 8 ppm were considered smokers (Jarvis et al., 1987).

Outcomes The primary outcomes of the trial with respect to physicians were the

frequency and content of counseling practices. Frequency was measured as

the percentage of return smokers that residents counseled, and content was

measured as the number and mix of five specific techniques residents reported

using in counseling. The five techniques were setting a quit date, prescribing
Smoking and Tobacco Control Monograph No. 5

214

Figure 2

Trial design and participation by physicians and patients

* Tut, tutorial; Pro, prompt; Con, control.

Source: Strecher et al., 1991; used with permission of the authors.

a quit date, prescribing nicotine gum, giving the patient self-help material,

and providing followup. Residents were considered to have used a technique

if they said they used it often or always with their patients who smoked.

Both physician self-report and patient exit interview reports (aggregated

by physician) were used for assessing resident counseling practices. Several

secondary physician outcomes also were examined, including use of techniques

to motivate patients to quit smoking and three attitudes toward smoking
215

Chapter 3

cessation counseling: confidence, perceived preparedness, and perceived

success.

The primary patient-related outcome was the patient quit rate, measured

by the percentage of each resident’s patients who reported they had quit

smoking within 6 months of the exit interview. Biochemical testing of expired

carbon monoxide was used to verify the patients’ self-reported status as exsmokers. However, because the biochemical test verified the self-report in all

but two cases, and because the percentage of patients with biochemical verification varied by patient group, self-reported status was used as the primary

dependent variable.

RESULTS Of the 261 residents eligible for the trial, 234 (90 percent) completed

all phases of the trial, including 157 physicians in internal medicine

Physician (67 percent), 52 in family practice (22 percent), and 25 in pediatrics

Self-Reports (11 percent). Participation did not differ by study group or site. Individual sites contributed a mean of 21 residents, with a range of 11 to 44.

Pretest Results Prior to the interventions, all four groups were similar for study outcomes

and other selected characteristics. Residents reported that they advised

cessation for 63 percent to 70 percent of return patients who smoked cigarettes

but used only 0.5 to 0.7 of five specific counseling techniques (Figure 3).

About half of the residents reported that they had had smoking cessation

training of some kind in the preceding 6 months. The groups did not differ

in terms of resident specialty or year of training. Pretest results for trial

participants plus residents from two additional pediatric programs have been

published else where (Kenney et al., 1988).

Changes in After the interventions, the self-reported frequency of smoking cessation

Counseling counseling increased in the tutorial-plus-prompt and tutorial-only groups

Frequency (Figure 3). Analysis of covariance (ANCOVA) to compare the two interventions showed that only the tutorial produced significantly greater

posttest counseling frequency. After adjustment for pretest scores and

specialty, the posttest mean frequency for physicians receiving the tutorial

was significantly higher than that for nontutorial physicians (76 vs. 69 percent, p < 0.05). Counseling frequency also tended to be higher for those

receiving the prompt than for those who did not (75 vs. 70 percent), but

the difference was not statistically significant. There was no significant

interaction between the tutorial and the prompt. Nor was there any significant interaction between either intervention and physician specialty.

Changes in Self-reported counseling content followed a pattern similar to that for

Counseling counseling frequency (Figure 3). The use of ANCOVA to control for

Content pretest scores and specialty showed that the mean number of techniques

reported by tutorial physicians was double that reported by nontutorial

physicians (1.5 vs. 0.7, p < 0.001). The number of techniques reported by

those receiving the prompt was only slightly higher than those who did

not (1.2 vs. 1.0, p > 0.05). Again, there was no interaction effect for the two
Smoking and Tobacco Control Monograph No. 5

216

Figure 3

Physicians’ self-reported counseling practices*

* A, frequency: percentage of patients advised to quit. B, content: number of five techniques used.

Black bars, pretest; striped bars, posttest.

Source: Strecher et al., 1991; used with permission of the authors.
217

Chapter 3

interventions combined and no interaction between either intervention and

physician specialty.

Patient Reports During the 6-month period between the start of the interventions

and the physician posttest, 937 exit interviews were conducted with

Participation patients at 10 sites, representing 203 of the 250 randomized physicians in the trial. One family medicine site with 24 physicians was

unable to participate, and 23 of the 226 remaining physicians did not have

any patients interviewed. The mean number of interviews completed per

physician was 4.1. There were no significant differences in pretest counseling frequency, content, or attitudes between the 203 physicians with exit

interview patients and the 23 without.

The 937 patients included 736 internal medicine patients, 80 family

medicine patients, and 121 parents of pediatric patients; their mean age was

45 years. The majority of the patients were female (63 percent), and most

patients had less than a high school education (59 percent). About half were

nonwhite, and about half were married. One-third of the patients reported

they had no insurance coverage. The mean number of cigarettes they

smoked per day was 19. Most (69 percent) reported a previous attempt to

stop smoking, and 71 percent reported that they smoke a cigarette within

30 minutes of waking. The patients represented approximately 66 percent

of the smokers who could have participated in the study. Only 6 percent of

the eligible smokers refused to participate. The remaining 28 percent could

not be contacted at exit or by telephone within 3 days of the clinic visit.

Frequency and Patient exit interviews corroborated the changes indicated by physiContent cians (Table 1). The use of ANCOVA to control for physician specialty

showed that the percentage of patients reporting physician advice was

significantly higher (p < 0.05) for tutorial (62 percent) than for nontutorial

physicians (53 percent) and for prompt (62 percent) than for nonprompt

physicians (57 percent).

Patient reports also indicated changes in counseling content in the same

direction reported by physicians (Table 1). With adjustment for physician

specialty, patients reported significantly more counseling techniques used

by tutorial physicians than by nontutorial physicians (mean of 0.6 vs. 0.3,

p < 0.05). Physicians in the prompt group used slightly more techniques

than did nonprompt physicians (mean of 0.5 vs. 0.4), but the difference was

not significant. More tutorial physicians than nontutorial physicians used

each of the five techniques, but the differences were significant (p < 0.05)

only for prescribing a quit date and scheduling followup. Differences between physicians receiving the prompt and those who did not were small

and not statistically significant.

Patient vs. Though patients corroborated the physician reports to a great extent,

Physician physicians reported more frequency and content of smoking cessation

Reports counseling than did patients. Across all groups, physicians reported

giving significantly (p < 0.05) more advice (76 percent) than patients
Smoking and Tobacco Control Monograph No. 5

218

Table 1

Patient reports of physician counseling practices, by study groupa

Tutorial + Tutorial Prompt

Prompt, Only, Only, Control,

Percentage Percentage Percentage Percentage

(n=55) (n=51) (n=50) (n=47)

Counseling Frequency:

Return Patients Advised To Quitb 74% 73% 71% 58%

Counseling Content

(Mean number of five techniques (0.9) (0.7) (0.6) (0.5)

used per patient)c

Sets quitting date 12 9 7 6

Writes quitting-date prescriptionb 9612

Prescribes nicotine-containing gum 20 17 15 13

Gives self-help materials 15 10 11 13

Schedules followup visit 51 53 42 37

a All percentages are mean percentages.

b ANOVA, p < 0.05.

c ANOVA, p < 0.10.

Source: Strecher et al., 1991; used with permission of the authors.

reported receiving (69 percent). Physicians also reported using significantly

more techniques than the patients remembered (1.3 vs. 0.7, p < 0.01).

Because physicians were asked about the counseling they generally provided

and patients were asked about counseling received during one specific visit,

physician reports would likely be higher than patient reports.

Six-Month Patients without a home telephone (n=78) and patients who died, were

Patient institutionalized, or moved out of state (n=16) were excluded from the

Followup 6-month followup. Of the remaining 843 patients, 659 (78 percent)

were interviewed by phone 6 months after their exit interview, with

Participation no differences in followup rate between study groups. According to

exit interview data, excluded patients and patients lost to followup were

no different from those who remained in the trial with respect to physician

counseling frequency, the number of cigarettes smoked per day, or report

of a previous quit attempt. However, they were more likely to report that

they smoked a cigarette within 30 minutes of waking.

Patient Quit The rates of patients’ smoking cessation in the intervention groups were

Rates generally higher than those in the control group, although study group

differences were not statistically significant (Figure 4). According to selfreports, quit rates in the intervention groups ranged from 5.3 percent (tuto

rial only) to 8.2 percent (tutorial plus prompt), compared with 5.2 percent
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Chapter 3

Figure 4

Six-month rates for patients’ smoking cessation*

* Shaded bars, self-reported; black bars, biochemically verified.

Source: Strecher et al., 1991; used with permission of the authors.

for the control group. According to the biochemically verified quit rates,

intervention group rates of smoking cessation ranged from 3.4 percent

(tutorial only) to 5.7 percent (prompt only), compared with 1.7 percent

for the control group.

Self-reported patient quit rates for tutorial physicians, when adjusted

for physician specialty, were higher than those for nontutorial physicians

(4.9 vs. 3.7 percent), though the difference was not significant. For physicians in the prompt group, self-reported patient quit rates were also higher

than those for the control physicians (5.2 vs. 3.4 percent) and were not

statistically significant. Biochemically verified cessation rates followed a

similar pattern, and there were no statistically significant differences among

groups.

Patients undertook smoking cessation in spite of limited contact with

physicians. Only 45 percent of all the patients in followup reported having

seen their physician during the 6 months after the exit interview, with

67 percent of those patients reporting that the physician gave advice to

quit smoking.
Smoking and Tobacco Control Monograph No. 5

220

Quit Attempt Rates Patient quit attempt rates, the percentage of each resident’s patients

reporting at least one quit attempt during the 6-month followup

period, ranged from 58 percent (tutorial plus prompt) to 50 percent (tutorial

only) to 44 percent (prompt only); the rate for the control group was 49 percent. Adjusted for physician specialty, quit attempt rates for patients of the

tutorial physicians were higher than those for patients of nontutorial physicians (47 vs. 40 percent), though the differences were not significant. For

physicians in the prompt group, quit attempt rates were lower than those

for nonprompt physicians (40 vs. 47 percent), but the difference was not

statistically significant.

DISCUSSION Results from the authors’ randomized trial involving 234 residents from

11 training programs and three specialties demonstrated that a training-oftrainers program can be effective in enhancing residents’ practices with respect

to smoking cessation counseling. Whether used alone or in combination

with the tutorial, the prompt—a second intervention that employed a chartbased reminder—had less effect on residents’ counseling practices. Although

reporting a lower level of activity, patients tended to corroborate physicians’

smoking cessation counseling reports; however, only small changes in patients’ smoking behavior were found, and differences among experimental

groups were not significant.

The trial examined the effects of a preventive health care intervention

under conditions generalizable to most residency training programs in North

America. A training program faculty member, not smoking cessation experts,

conducted the tutorial at each site, and in-place nursing staffs administered

the prompt. Residents in the study represented 3 primary care specialties,

4 community hospitals, 3 university medical centers, 82 U.S. medical schools,

and 6 foreign medical schools. Because only 10 percent of residents did not

complete the trial, it was unlikely that self-selection by physicians affected

the results.

As far as the authors know, no previous study of training in smoking

cessation counseling has included pediatric residents. The effects of parents’

smoking on children’s health and subsequent smoking behavior make parental counseling increasingly important (American Academy of Pediatrics, 1986).

Although pediatric residents reported counseling frequency and content at

lower levels than those reported by the internal medicine and family medicine

residents prior to intervention, the pediatric residents’ response to the interventions did not differ from that of other residents (Kenney et al., 1988).

Two barriers were encountered in implementation of the intervention.

First, arranging for delivery of followup of the tutorial was difficult and required a concerted effort from the faculty. Second, integration of the prompt

form into the medical record often proved difficult. A number of sites had

stringent policies that tended to restrict the incorporation of new information

into the record. The investigators found that both of these barriers could be

overcome through the efforts of the on-site faculty member. Organizational
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Chapter 3

change is often found to result from efforts by a champion for change in the

existing system (Orlandi, 1987). Use of on-site faculty also appeared to have

a positive influence on participation by residents. Having a faculty member

who is the designated smoking counseling “expert” on site allowed residents

to easily refer to this person when they encountered interesting counseling

experiences.

A number of explanations for low rates of smoking cessation found

among patients in the experimental groups are possible. First, the patients

included in the study may have been less likely to quit smoking after

6 months than were patients in other settings. Study patients were predominantly black, female, and less educated. Smoking cessation among these

patients is less frequent (Novotny et al., 1988). Second, fewer than half of

the patients saw their physicians during the 6-month followup period; there

was little opportunity for residents to reinforce previous counseling. The

total amount of time spent on smoking cessation counseling is exceedingly

small in comparison to the time spent in more formal cessation programs

and is far outweighed by the number of social reinforcements to continue

smoking. Third, because interventions were incorporated into ongoing

training programs and residents at each site worked closely with one another,

some contamination occurred. Almost two-thirds of the residents who did

not receive the tutorial reported awareness of it, although most claimed

that such awareness did not change their counseling practices.

Another factor accounting for low cessation rates could have been the

intervention itself. Although the intervention was based on commonly

recommended smoking cessation strategies, it also was developed so as to

minimize expenditure of counseling time. This required minimizing openended probes and prolonged discussion about reasons for quitting, past

quitting history, or the involvement of significant others in quitting. In

other words, efforts to make the counseling strategy convenient for the

physician may have also diminished the effectiveness of the strategy.

The authors recommend that future cessation efforts based in physician

office practices include more attention to the role of other office staff members and to changes in the office system. Concerted, coordinated efforts

from intake nurses, physicians’ assistants, family nurse practitioners, and

other health professionals in addition to the physician should minimize

time constraints on all office staff while maximizing counseling effectiveness.

These efforts may require systematic changes in the way candidates for

smoking cessation counseling are identified, approached, and followed.

Examples of such systematic efforts have been provided by Cohen and

colleagues (1987) as well as Kottke and coworkers (1989).

ACKNOWLEDGMENTS The authors thank the patients, parents, and physicians who participated in

the trial; the nursing staffs at participating institutions for assistance with the prompting system;

Keith Cochran, Julie Curry, Rebecca Denson, Elizabeth Dickman, Gina Flemming-Maget, Sam

Hart, Mary Angela Lee, Terry Loomis, Stephen McLoughlin, Deborah Moser, Jane Raney, Ph.D.,

Scott Robson, Sharon Sugarawa, Deborah Traugh, R.N., and Zoe Wood for providing research
Smoking and Tobacco Control Monograph No. 5

222

assistance and data management; Cynthia France, Ph.D., of the Office of Research and Education

in the Health Professions, University of North Carolina at Chapel Hill, for assistance in developing the tutorial; Stan Alexander and the Television Section of the Medical Sciences Teaching

Labs at the University of North Carolina at Chapel Hill for producing the tutorial videotape;

Margaret Pennypacker, Jane Silver, and the staff of Social Research Associates, Research Triangle

Park, North Carolina, for conducting the followup telephone survey of patients; and David

Siscovick, M.D., Department of Medicine, University of Washington, for providing valuable

suggestions and ideas for the study.

REFERENCES

American Academy of Pediatrics. Report of the

committee on environmental hazards:

Involuntary smoking a hazard to children.

Pediatrics 77: 755-757, 1986.

Campbell, E.E., Villagra, V.G., Rogers, C.S., et al.

Teaching and promoting smoking cessation

counseling in primary care residencies: Description of a method. Teaching and Learning in

Medicine 3(1): 20-27, 1991.

Cohen, S.J., Christen, A.G., Katz, B.P., Drook, C.A.,

Davis, B.J., Smith, D.M., Stookey, G.K. Counseling

medical and dental patients about cigarette

smoking: The impact of nicotine gum and chart

reminders. American Journal of Public Health 77:

313-316, 1987.

Cummings, K.M., Giovino, G., Emont, S.L., Sciandra,

R., Koenigsberg, M. Factors influencing success in

counseling patients to stop smoking. Patient

Education and Counseling 8: 189-200, 1986.

Cummings, S.R., Richard, R.J., Duncan, C.L., Hansen,

B., Vander Martin, R., Gerbert, B., Coates, T.J.

Training physicians about smoking cessation: A

controlled trial in private practice. Journal of

General Internal Medicine 4(6): 482-489, 1989.

Gagne, R.M., Briggs, L.J. Principles of Instructional

Design (2nd edition). New York: Holt Rinehart

and Winston, 1979.

Gritz, E.R. Cigarette smoking: The need for action

by health professionals. CA—A Cancer Journal for

Clinicians 38: 194-212, 1988.

Janz, N.K., Becker, M.H., Kirscht, J.P., Eraker, S.A.,

Billi, J.E., Woolliscroft, J.O. Evaluation of a

minimal-contact smoking cessation intervention

in an outpatient setting. American Journal of Public

Health 77(7): 805-809, 1987.

Jarvis, M.J., Tunstall-Pedoe, H., Feyerabend, C., Vesey,

C., Saloojee, Y. Comparison of tests used to distinguish smokers from nonsmokers. American

Journal of Public Health 77: 1435-1438, 1987.

Kenney, R.D., Lyles, M.F., Turner, R.C., White, T.S.,

Gonzalez, J.J., Irons, T.G., Sanchez, C.J., Rogers, C.S.,

Campbell, E.E., Villagra, V.G., Strecher, V.J.,

O’Malley, M.S., Stritter, F.T., Fletcher, S.W. Smoking

cessation counseling by resident physicians in

internal medicine, family practice, and pediatrics.

Archives of Internal Medicine 148: 2469-2473, 1988.

Kottke, T.E., Battista, R.N., DeFriese, G.H., Brekke, M.L.

Attributes of successful smoking cessation interventions in medical practice: A meta-analysis of

39 controlled trials. Journal of the American Medical

Association 259: 2882-2889, 1988.

Kottke, T.E., Brekke, M.L., Solberg, L.I., Hughes, J.R.

A randomized trial to increase smoking intervention

by physicians: Doctors Helping Smokers, round I.

Journal of the American Medical Association 261: 2101-

2106, 1989.

Novotny, T., Warner, K.E., Kendrick, J.E., Remington,

P.L. Socioeconomic factors and racial smoking

differences in the United States. American Journal

of Public Health 78: 1187-1189, 1988.

Ockene, J.K. Physician-delivered interventions for

smoking cessation: Strategies for increasing

effectiveness. Preventive Medicine 16: 723-737, 1987.

Orlandi, M.A. Promoting health and preventing

disease in health care settings: An analysis of

barriers. Preventive Medicine 16: 119-130, 1987.

Strecher, V.J., Becker, M.H., Kirscht, J.P., Eraker, S.A.,

Graham-Tomasi, R.P. Evaluation of a minimalcontact smoking cessation program in a health care

setting. Patient Education and Counseling 7: 395-407,

1985.

Strecher, V.J., O’Malley, M.S., Villagra, V.G., Campbell,

E.E., Gonzalez, J.J., Irons, T.G., Kenney, R.D., Turner,

R.C., Rogers, C.S., Lyles, M.F., White, S.T., Sanchez,

C.J., Stritter, F.T., Fletcher, S.W. Can residents be

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Chapter 3

APPENDIX A

Smoking Intervention Communication Grida

Physician-Centered – – – – – – – – – – – – – – – – – – – – – – – – – – >Patient-Centered

Closed-Ended Open-Ended

Information Reassurance Questions Questions

Provide Advice Smoking is harmful to I believe you can stop Do you wonder if How do you think

your health. As your smoking. smoking is really smoking is related

physician, I advise you affecting your health? to your health?

to stop smoking.

Assess Motivation To be a successful You really seem to Have you thought How do you feel

ex-smoker, you need want to stop smoking. about stopping about trying to stop

to make a serious smoking recently? smoking?

commitment and make

a plan to stop smoking.

Assess Past Often there are many Being able to stop Have you ever How did it go the

Experience things you can learn for a week is a real stopped smoking in last time you

from your past accomplishment. the past? stopped?

attempts at stopping. You made it through

the hardest part.

Discuss Problems Certain situations, I believe that together Has your fear about What problems do

thoughts, or feelings we can figure a way withdrawal kept you you anticipate

usually bring on the for you to deal with from trying to stop coming up if you

urge to smoke. the problem situation. again? stop now?

Discuss Resources Choosing other It sounds like you What can you do What do you believe

behaviors to substitute expect your spouse instead of smoking will enable you to

for smoking is easier if to be supportive. after meals? be successful at

you plan ahead. stopping?

Negotiate Plan When developing a I think that’s a very When will you stop? How do you think

plan to stop smoking, realistic plan. Could you reduce the you would like to

it is important to amount you smoke to stop?

choose a “quit” date. half by the next time

we meet?

Arrange Followup I’d like to set another My staff and I are Is it okay if my nurse What kind of followup

appointment in 1 or available to you if the calls you in a week or help from me would

2 weeks with you to going gets tough. two to see how you be helpful?

follow your progress. are doing?

a It is suggested that the topics be addressed in the order shown; the order may be changed, however, to meet the

needs of the patient and physician.
Smoking and Tobacco Control Monograph No. 5

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APPENDIX B

Outline of the Advice and Counseling

Smoking Intervention Approaches

ADVICE-ONLY INTERVENTION

• Advise patient to stop smoking.

• If requested, give patient list of resources.

• Inform patient of periodic telephone contacts.

Sample Statement:

“I notice that you are a cigarette smoker. Smoking is harmful to your health. In many

cases, the harmful effects of smoking can be reversed. As your doctor, I must advise you

to stop smoking. If you are interested, I have a list of some programs for stopping smoking available in the community. Someone will be contacting you periodically by phone

to see how you are doing.”

COUNSELING INTERVENTION

• Advise patient to stop smoking.

• Use counseling technique to determine most appropriate method for cessation.

• Set agreement with patient for cessation.

• Provide booklet of stopping smoking tips.

• If requested, give patient list of resources.

• Request return visit in 1 to 2 weeks (or phone contact if unavailable) to check progress

and reinforce initial visit.

• Inform patient of periodic telephone contacts.

Sample Intervention:

“I notice that you are a cigarette smoker. Smoking is harmful to your health. In many

cases, the harmful effects of smoking can be reversed. As your doctor, I must advise you

to stop smoking.

“How do you feel about being a cigarette smoker?

“Have you thought about stopping?
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Chapter 3

“What reasons would you have for stopping?

“Have you ever stopped smoking?”

YES

• When was the last time?

• How did you stop?

• Any problems?

• How long did the problems last?

• What helped you?

• How did you feel? How did you feel

about yourself?

“Would you like to stop smoking?

“Do you think you could stop now?

“What would be possible problems or

barriers to stopping?

“What could help you?

“Would you be willing to develop a plan to

stop smoking?”

NO

• Have you ever made any other changes?

How? When? Any problems?

YES

• Write agreement plan for cessation

with patient.

• Give booklet on tips for stopping

smoking.

• Request return visit in 1 to 2 weeks (or

phone contact if unavailable) to check

progress.

• Inform patient that someone will be

contacting him/her periodically by

phone to see how he/she is doing.

NO

• Give booklet on tips for stopping

smoking.

• Request return visit in 1 to 2 weeks (or

phone contact if unavailable) to check

progress.

• Inform patient that someone will be

contacting him/her periodically by

phone to see how he/she is doing.
Smoking and Tobacco Control Monograph No. 5

226

APPENDIX C

Physician Responses to Patients’ Concerns

Patient: I am under a lot of stress, and smoking relaxes me.

Response: Your body and brain have become accustomed to the drug effects of nicotine,

so you naturally feel more relaxed when you get the nicotine you have come

to depend on. But nicotine is also a stimulant that temporarily raises heart rate,

blood pressure, and adrenaline levels. After a few weeks of not smoking, most

ex-smokers feel less nervous.

Patient: Smoking stimulates me and helps me to be more effective in my

work.

Response: Difficulty in concentrating can be a symptom of nicotine withdrawal, but it is a

short-term effect. Over time, the body and brain function more efficiently when

you don’t smoke, because carbon monoxide from cigarettes is displaced by

oxygen in the bloodstream.

Patient: I have already cut down my smoking to a safe level.

Response: Cutting down is a good first step toward stopping. But smoking at any level

increases the risk of illness. And some smokers who cut back inhale more often

and more deeply, thus maintaining nicotine dependence. It is best to stop

smoking completely.

Patient: I only smoke safe, low-tar/low-nicotine cigarettes.

Response: Low-tar cigarettes still contain harmful substances. Many smokers inhale more

often or more deeply and thus maintain their nicotine levels. Carbon monoxide

intake often increases with a switch to low-tar cigarettes.

Patient: I don’t have the willpower to give up smoking.

Response: It can be hard for some people to give up smoking, but for others it is much

easier than they expect. More than 3 million Americans stop every year. It may

take more than one attempt for you to succeed, and you may need to try different methods of stopping. I will give you all the support I can.

Patient: I wish everyone would mind their business about my smoking.

Response: It must be hard to feel like people are nagging you about your smoking. I do not

want to add to this. However, I feel as your physician I have a responsibility

to help you stay well. I also would like to be able to provide help and support. Is there anything I can do to help?
227

Chapter 4

Chapter 4

Special Practice Settings

CONTENTS Introduction

Ellen R. Gritz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Pediatricians’ Role in Smoking

Prevention and Cessation

Barbara L. Frankowski and Roger H. Secker-Walker . . . . . . . . . . . . . . . . . 232

Responsibilities of the Pediatrician . . . . . . . . . . . . . . . . . . . . . . . . . 232

Pediatricians’ Attitudes and Practices . . . . . . . . . . . . . . . . . . . . . . . . 233

Parents’ Attitudes, Needs, and Behavior. . . . . . . . . . . . . . . . . . . . . . 236

Objectives of Pediatrician Intervention . . . . . . . . . . . . . . . . . . . . . . 238

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Smoking Intervention by Providers of

Health Care for Women

Mary Sexton, Joan Stine, and Steven Cahill. . . . . . . . . . . . . . . . . . . . . . . 246

Role of the Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Effectiveness of Antismoking Intervention . . . . . . . . . . . . . . . . . . . 247

Constraints on Office-Based Intervention . . . . . . . . . . . . . . . . . . . . 249

Training Prenatal Care Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

Possible Barriers to Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

Components in Obstetrical Offices . . . . . . . . . . . . . . . . . . . . . . . . . 256

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

A Physician- and Dentist-Delivered Smoking Cessation

Intervention for Head and Neck Cancer Patients

Ellen R. Gritz, Clifford R. Carr, David A. Rapkin,

Cindy Chang, John Beumer, and Paul H. Ward . . . . . . . . . . . . . . . . . . . 259

Purpose of the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Target Audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

Practice or Clinical Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

Recruitment of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

Protocol for Advice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

Nature of the Training Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Special Resources and Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Products of the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

Barriers and Problems Overcome . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

What Worked and Why . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266

What Did Not Work and Why . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

What Would Be Done Differently Now . . . . . . . . . . . . . . . . . . . . . . 269

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Smoking and Tobacco Control Monograph No. 5

228

Medical Advice as a Communication

About Risks of Smoking and

Benefits of Quitting

Laura C. Leviton, Timothy R. Cline, and Saul Shiffman . . . . . . . . . . . . . 272

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

Purpose of the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

Target Audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274

Setting of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

Recruitment Procedure and Results . . . . . . . . . . . . . . . . . . . . . . . . . 276

Nature of Medical Advice Given . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Nature of Counseling Intervention . . . . . . . . . . . . . . . . . . . . . . . . . 280

What Did Not Work and Why . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

What Worked and Why . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

Appendixes

A. Smoking Materials for Pediatricians . . . . . . . . . . . . . . . . . . . . 287

B. Algorithms for Delivery of

Smoking Cessation Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

C. Protocol Developed by University of North Carolina

Faculty Development Program . . . . . . . . . . . . . . . . . . . . . . . . . 292

D. Self-Efficacy Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

E. Transcript From a Self-Efficacy

Counseling Session. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
229

Chapter 4

Special Practice Settings

Editor: Ellen R. Gritz

INTRODUCTION One of the major tactics used in physician- and dentist-delivered

smoking cessation advice is to tailor the risk and benefit information to the

patient’s present condition, to maximize the likelihood of capitalizing on a

teachable moment or window of opportunity. The four papers in this chapter

address specialized practice settings that provide opportunities to reach selected populations and to focus on particular disease risks associated with

tobacco use. The four target populations vary substantially. Two of the groups

represent essentially healthy populations who might also be seen by primary

care and family practitioners—pediatric patients and their parents, and women

being treated for gynecologic conditions or pregnancy. The other two populations are persons at high risk of developing potentially fatal malignancies—

former chemical workers exposed to a bladder carcinogen—and individuals

newly diagnosed with head and neck cancers.

The health care professionals treating these populations also vary

markedly in their orientation with regard to the urgency of smoking cessation

for their patients. Pediatricians are in the specialty perhaps least empowered

with regard to counseling smoking prevention for children and adolescents

and smoking cessation for parents. Obstetrician/gynecologists have a clear

message to convey to pregnant women, but less specific advice for the gynecologic patient. Physicians and respiratory therapists who perform cancer

screening for carcinogen-exposed former chemical workers can provide precisely tailored advice to their high-risk patients. Finally, the head and neck

surgeons and maxillofacial prosthodontists who treat patients with cancers of

the upper aerodigestive tract are delivering a tertiary prevention message, the

avoidance of further disease (cancer or other conditions) caused by continued

smoking. Thus, these health professionals also have an urgent mandate to

deliver clear and strong cessation messages, and have likely been doing so,

albeit in the absence of even the most rudimentary behavioral skills training.

Yet a third dimension useful for scaling the special populations of

medical and dental patients addressed in this chapter is their stage of change,

or readiness to stop smoking. Intuitively, individuals at very high risk of

developing cancer or those already suffering from it should be the most ready

to stop and most receptive to advice from the physician or dentist. However,

strong tobacco dependence, a sense of fatalism, and external factors (such as

management-labor disputes over attribution of disease risk to exposure or

to personal behavior) may weight the target population toward precontemplation. About 20 percent of women in the early stage of pregnancy quit

smoking (take action) because of nausea, perceived risk to the fetus, and

heterogeneous other factors, including low tobacco dependence and support

from significant others. Women reached later in pregnancy may be less ready
Smoking and Tobacco Control Monograph No. 5

230

to stop because of a different constellation of reasons, including concern

about excessive weight gain, past experience of having a healthy baby—in

spite of smoking during pregnancy, greater tobacco dependence, and a

smoking spouse/partner. Finally, parents of small children may contemplate

stopping smoking to provide a role model and to avoid exposing their

offspring to environmental tobacco smoke; but, on the other hand, they may

perceive these not to be urgent issues if they and their families are healthy.

Thus, patients in each specialty practice will encompass the range of stages of

change, which the practitioner must address sensitively, with tailored advice.

The goal may not always be action, but movement toward cessation, as in

the case of the former chemical workers or women of childbearing age.

The examples provided in these four sections can be generalized to many

medical and dental specialties in terms of both educating providers in the

delivery of advice and reaching patient populations with certain characteristics and/or health problems.

Pediatricians Pediatricians have a unique opportunity to influence an entire family’s

smoking behavior, by practicing primary prevention with children who have

not yet begun to smoke and by counseling parents to quit before either

they or their children suffer any smoking-related health consequences. The

surveys of Vermont pediatricians and parents reported here by Frankowski

and Secker-Walker reveal the current gap in practice and define the extent

of the need. The authors found that pediatricians were very unlikely to have

received formal training in delivering smoking cessation advice and, while

they did advise smoking parents to quit, the majority of physicians had low

levels of confidence about delivering the advice. Parents, on the other hand,

responded that it was the pediatrician’s job to talk about passive exposure,

to counsel children against smoking initiation, and even to advise smoking

parents to stop. With these findings in mind, Frankowski and Secker-Walker

describe the objectives of an intervention based in the pediatric practice, and

they provide useful guidelines for incorporating cessation advice into clinical

care.

Providers of Health With public health and medical attention focused on the

Care for Women decline in smoking prevalence called for in the Year 2000

objectives, there has been voiced concern over the slower decline in women’s

smoking rates, compared with men’s. Providers of gynecologic and obstetrical services, either in private or public settings, have a special opportunity to

deliver a smoking intervention in the context of targeted risks. Surprisingly,

there is little information on smoking cessation in the gynecologic setting.

However, Dr. Sexton and her colleagues have extensive expertise in developing and implementing pregnancy-based interventions. They discuss interesting issues such as the smoking status of the provider, the role of nurses in

the intervention, counseling materials for clients and providers, and the

reconciliation of staff time with patients’ expectations. The experience

gained from these trials will facilitate the development and implementation
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Chapter 4

of further smoking interventions for women in a variety of practices and

settings.

Head and Neck Individuals with head and neck cancer are the most seriously ill

Cancer patient population addressed in this monograph. They receive

care from highly specialized practitioners, surgeons (otolaryngologists)

and reconstructive dentists (maxillofacial prosthodontists). Gritz and her

colleagues describe the first systematic smoking intervention trial for head

and neck cancer patients, featuring advice delivered by surgeons and dentists

and tailored, self-help materials for patients and family members. Faced with

cancer diagnosis and treatment, patients are clearly at a teachable moment

with respect to smoking cessation. On the other hand, long-term, highly

dependent tobacco and alcohol use characterizes many of these patients,

imposing obstacles to cessation and potentially reducing the patients’ readiness to change. Head and neck surgeons and maxillofacial prosthodontists

are highly knowledgeable about the risks of smoking, yet they have had no

prior training in behavior skills for delivering cessation advice. The research

project described here pioneered the development of materials for patients,

the surgeon and dentist cessation training, and the identification and

recruitment of eligible patients for the trial. The issues discussed apply

to a broad spectrum of seriously ill patients as well as to medical specialties

heretofore not involved in smoking cessation counseling.

Chemical Workers Counseling an individual who is at high risk for a cancer

At Risk for because of occupational exposure and whose risk is substantially

Bladder Cancer increased by continued smoking might, at first, appear to be

easier than counseling a healthy smoker. However, the work of Leviton

and colleagues, with a population of former chemical workers exposed

to a bladder carcinogen, outlines the complex issues related to perceived

responsibility for health status, delivery of information on the risks of

smoking and benefits of cessation, readiness to change, and self-efficacy.

The target population consists of blue-collar workers who reside in a rural

area, are not highly educated, and, in general, have little interest in quitting

smoking.

The task of the physicians and respiratory therapists who conduct the

periodic bladder cancer screenings is to provide smoking cessation counseling in a manner that facilitates movement toward change and increases the

workers’ self-efficacy. Challenges involved in recruiting members of the

population to the study, training the providers in the counseling protocol,

and overcoming the multiple forms of resistance to counseling provide

valuable lessons that could be used in multiple settings and by a range

of medical and dental providers.
Smoking and Tobacco Control Monograph No. 5

232

Pediatricians’ Role in Smoking

Prevention and Cessation

Barbara L. Frankowski and Roger H. Secker-Walker

RESPONSIBILITIES Despite public awareness of the long-term morbidity associated

OF THE with initiation of cigarette smoking during childhood and

PEDIATRICIAN adolescence, nearly 5 million teenagers (12 to 17 years old)

smoke, and there are more than half a million youngsters from

Prevention for 8 to 11 who smoke (DiFranza and Tye, 1990). Each day, more

Children and than 3,000 U.S. children begin to use tobacco (Fiore et al., 1989).

Adolescents Pediatricians should take every opportunity to promote

nonsmoking among patients. It should be part of routine anticipatory

guidance at all visits. Because healthy children see their pediatrician only

every 2 years for health supervision, schools may perform this task better,

with the pediatrician as a reinforcer or a participant.

Every effort should be made to encourage smoking parents to quit because

of the negative role model they offer children. In addition, the pediatrician

should support efforts to prevent advertising of all tobacco products. The

pediatrician can also play a leading role in the elimination of advertising

campaigns that seem likely to influence young people to start smoking.

Smoking Cessation Pediatricians should play a role in advising patients who are

By Children already smoking to quit. However, most pediatricians know

And Adolescents no formal way of doing this, and thus merely tell patients, “You

should quit.” Although other health care professionals also care for children,

pediatricians are the least likely to have received training in smoking cessation counseling. Many pediatricians are unaware of community resources

to help patients with smoking cessation; however, there are few programs

for adolescents at this time.

Protecting Children Pediatricians should be aware of the effects of passive smoke on

From Passive all stages of a child’s growth, including the behavioral implicaSmoking tions of having smoking parents, and physicians have an

obligation to inform smoking parents of those effects. Surveys have shown

that 53 to 76 percent of the homes in the United States contain at least one

smoker; between 8.7 million and 12.4 million American children less than

5 years of age are exposed to cigarette smoke in their homes (Landrigan, 1986).

Between 1974 and 1987, four prospective studies and nine case-control

studies examined the possible effects of exposure to parental tobacco smoke

on the frequency and severity of acute respiratory illness in children (Fielding

and Phenow, 1988). Although different research designs were used, the results

have consistently demonstrated greater frequency of both upper and lower

respiratory problems among the young children of smoking parents than
233

Chapter 4

among children of nonsmoking parents. Wheezing and asthma appear to

be more common among the children of smoking parents (Weiss et al., 1980).

Asthmatic children of smokers reportedly experience improvement when

their parents stop smoking, in contrast to children with asthma whose parents continue to smoke (Gortmalker et al., 1982). Smoking by parents

has also been identified as a risk factor for persistent middle-ear effusions and

otitis media in young children (Kraemer et al., 1983; Stahlberg et al., 1986).

Helping Parents The Surgeon General has suggested that one of the pediatrician’s

With Cessation most important educational obligations is to encourage and help

parents to give up cigarette smoking (Koop, 1985). Pediatricians are in a

unique position to address the issues of smoking prevention and smoking

cessation at several levels. Healthy young adults who are starting a family

see a pediatrician or family practitioner more often than any other health

care professional.

Of the 3.6 to 3.7 million women who have given birth in the United

States each year since 1980, approximately 1.0 to 1.2 million smoked while

pregnant (Windsor, 1986). According to the Surgeon General, most recent

estimates suggest that about 25 percent of U.S. women smoke throughout

pregnancy, and the proportion of smokers who stop entirely during pregnancy is approximately 20 percent (US DHHS, 1990). The majority of women

who give up smoking during pregnancy start smoking again after

the baby is born (Sexton et al., 1985; US DHHS, 1990).

New parents often are motivated to make changes in their lifestyles

“for the good of the baby.” Each contact with the pediatrician could provide

an opportunity for the physician to support a smoking mother in her efforts

to quit or a recent ex-smoker in her efforts to refrain from starting again.

Women who succeed in staying away from cigarettes will then model nonsmoking behavior for their children. Equal influence should be directed

toward fathers as well. However, most pediatricians are not aware of the

literature on smoking cessation, nor do they know that there are specific

methods of giving brief, effective advice.

PEDIATRICIANS’ In the current study, the investigators used the questionnaire

ATTITUDES AND developed to survey Maine pediatricians (Frankowski and SeckerPRACTICES Walker, 1989) with minor modifications. The questionnaire contained 50 items, including demographic questions, and addressed

Methods the pediatrician’s estimate of the proportion of parents who smoke,

smoke, current activities concerning smoking advice, confidence in his or her

ability to offer smoking advice, perceived barriers to offering smoking advice,

and opportunities to offer smoking advice. The questionnaire and a stamped,

addressed return envelope were mailed to all pediatricians practicing in

Vermont; nonrespondents were sent two mailings. Of the 92 pediatricians,

72 responded. After physicians who were no longer practicing pediatrics in

Vermont (n=13) were excluded, the response rate was 72 of 79, or 91 percent.

Of the 72 pediatricians, 10 are subspecialists and the rest deliver primary care
Smoking and Tobacco Control Monograph No. 5

234

in 19 solo and 16 group practices. The pediatricians in the practices chosen

for distribution of parent questionnaires were invited to take part in a more

in-depth interview about smoking, administered by the principal investigator.

That interview included questions about what the pediatrician actually said

about smoking to patients and parents, where the information was recorded,

and what type of further training would be of interest to the pediatrician

or office staff. Eighteen pediatricians were able to take part in the in-depth

interviews (5 of 6 in solo practice and 13 of 19 in group practices), representing 25 percent of the pediatricians who responded to the questionnaire.

Results On average, the pediatricians, 32 percent of whom were women, were

43.5 years old and had been in practice for 13 years. Twenty-seven

Pediatrician percent of respondents were in solo practice, 62 percent in a partnership

Demographics or group, 7 percent in hospital-based practice, 1 percent in a community

health center, and 3 percent in other settings. Sixty-one percent were

never-smokers, 36 percent were former smokers, and 3 percent gave no

response; no one reported being a current smoker.

Effects of Passive Fifty-seven percent of the pediatricians estimated that about oneSmoke on Children third or fewer of their patients’ parents were cigarette smokers.

About 40 percent of pediatricians routinely take a smoking history

from parents, but only 11 percent record the information in the child’s chart.

Most pediatricians (64 percent) estimated that they talk to one-half or more

of smoking parents about the effects of parental smoking (passive smoke) on

their children.

Pediatricians were asked, “What are the major concerns about the effects

of parental smoking in children that you discuss with parents?” The percentages of responding pediatricians who checked each concern were as follows:

88 percent, more bronchitis and pneumonia in infancy and childhood;

83 percent, more exacerbation of asthma; 56 percent, parental role modeling

for smoking; 53 percent, lower birth weight; 39 percent, more middle-ear

infections; 17 percent, fire hazards and burns; and 7 percent, other (allergies,

competition in athletics, risk of pulmonary cancer). Figure 1 shows the

distribution of parents’ beliefs about the effects of parental smoking. Almost

all pediatricians (91 percent) felt moderately confident (39 percent) or very

confident (52 percent) about addressing passive smoking issues with parents.

Most pediatricians (94 percent) reported they advise smoking parents to

quit. The pediatricians estimated advising about two-thirds to quit and spent

an average of 4.4 minutes per parent in that activity. The estimated successful

quit rate was 12 percent.

Pediatricians were asked, “When you advise parents who smoke about

their smoking, what issues do you address?” The percentages of responding

pediatricians who checked each issue were as follows: 97 percent, hazards

of passive smoking for children; 81 percent, hazards of smoking for smoker;

77 percent, keeping smoke away from infants and young children; 54 percent,
235

Chapter 4

Figure 1

Parents’ beliefs about the effects of parental smoking

Source: Frankowski et al., in press; used with permission.

benefits of stopping smoking; 40 percent, cutting down the consumption of

cigarettes; 29 percent, quitting “cold turkey”; 25 percent, prescribing nicotine

chewing gum; 22 percent, setting a quit date; and 10 percent, other issues.

The pediatricians were also asked about the best opportunities to give

smoking cessation advice to parents (see Figure 2). The percentages that rated

various opportunities as “good or excellent” were as follows: 89 percent, visits

for acute respiratory infections; 75 percent, prenatal visits; 72 percent, wellchild visits; 65 percent, visits after delivery; 34 percent, visits for other acute

problems. Most pediatricians (93 percent) have a no-smoking policy in their

offices, 30 percent have printed materials to give smokers to help them quit,

and 26 percent had lists of smoking cessation resources available in the

community.

Only 45 percent of pediatricians felt moderately confident (25 percent)

or very confident (20 percent) about advising parents to quit. Respondents

identified several barriers to giving smoking cessation advice to parents:

42 percent cited lack of time; 25 percent said the smoking parent does not

expect such advice; 25 percent feel “ill at ease” when giving advice; 7 percent

noted lack of reimbursement; and 1 percent said, “none of my business.”
Smoking and Tobacco Control Monograph No. 5

236

Figure 2

Opportunities to give parents quit-smoking advice

Learning How Only 8.5 percent of pediatricians had received formal training in giving

To Give smoking advice, but 87 percent would be willing to learn brief methods.

Quit-Smoking Pediatricians were asked to rate opportunities to learn about brief methods

Advice for giving smoking cessation advice. The percentages rating different

methods “good or excellent” were as follows: 73 percent, 1-hour videotape; 55 percent, journal article; 52 percent, 2-hour training in office; and

41 percent, one half-day continuing medical education workshop or seminar.

PARENTS’ ATTITUDES, A second questionnaire was developed to assess parents’

NEEDS, AND BEHAVIOR attitudes about smoking. The questionnaire contained

34 items and addressed demographics, the parents’ beliefs

Methods about the effects of parental smoking on children, attitudes

about pediatrician-delivered advice about smoking, reactions to pediatriciandelivered advice, smoking history, smokers’ intentions to quit, and dietary

habits. The questionnaire was first pretested among parents in the investigator’s

practice, and then it was administered by one research assistant who distributed

the questionnaire and a consent form to all parents in the waiting rooms of

participating pediatricians’ offices. The pediatric practices were chosen randomly to include two solo and two group practices from each of three arbitrarily

defined regions: Chittenden County, northern Vermont, and southern Vermont.

Approximately 25 parents were surveyed for each pediatrician in each practice.

Source: Frankowski et al., in press; used with permission.
237

Chapter 4

Results A total of 676 parents completed questionnaires at 6 solo and 6 group

pediatric practices. Several parents who received questionnaires declined

Parents’ participation because of time constraints. The parents, 84 percent of

Demographics whom were women, had a mean age of 32 years. Six percent had not

completed high school, 33 percent were high school graduates, 33 percent had some college education, and 27 percent had 4 or more years of college.

The mean number of children per family was 2.0 (SD=0.9), with a mean age

of 5.3 years (SD=4.2).

Almost half the responding parents were never-smokers, 30 percent were

former smokers, and 21 percent were current smokers. The average number of

adult smokers per household was 0.53. Parents started smoking at a mean age

of 16.6 (SD=3.1) and smoked about one pack of cigarettes per day (SD=one-half

pack). Smoking parents had made an average of 6.6 quit attempts (SD=18.9).

The vast majority (82 percent) had tried to quit “cold turkey”; 32 percent had

tried gradual reduction; 15 percent had used self-help materials; 10 percent had

tried nicotine chewing gum; 9 percent had tried hypnosis; and 3 percent had

tried individual or group counseling. Current smokers were significantly

younger (p < 0.0001) and had significantly less education (p < 0.0001) than

former smokers or nonsmokers (see Table 1).

Attitudes About All parents were asked whether they agreed, disagreed, or were

Passive Smoke undecided about several statements pertaining to the effects of parental

smoking. Most (85 percent) agreed that smoking affected the fetus,

58 percent agreed that infants of parents who smoke got more colds and lung

infections, 23 percent agreed that children of parents who smoke got more

ear infections, 67 percent agreed that children of smoking parents were more

likely to become smokers, and 52 percent agreed that cigarettes cause onefourth of home fires. As Figure 1 shows, current smokers were less knowledgeable in all areas (p < 0.0001); former smokers and never-smokers were very

similar in their beliefs.

Table 1

Demographic characteristics of parents, by smoking status

Total Current Former NeverParents Smokers Smokers Smokers

n=668 n=142 n=199 n=327

Mean Age (years) 32.0 29.5 33.5 32.1

Percentage (Number)

Less than high school 6% (40) 15% (21) 3% (6) 4% (13)

High school 33 (223) 47 (67) 28 (55) 4 (13)

Some college 33 (223) 27 (38) 45 (90) 29 (95)

4-year college 27 (182) 11 (16) 24 (48) 36 (118)

Education
Smoking and Tobacco Control Monograph No. 5

238

The parents were asked whether they felt it was their pediatrician’s job to

talk about smoking. Almost all parents felt that the pediatrician should talk

about the effects of passive smoke on children (87 percent) and should talk to

children and teens about smoking (85 percent). About one-half the parents

felt it was the pediatrician’s job to advise smoking parents to quit (56 percent).

Current smokers were less likely to think that the pediatrician should talk

about passive smoke (p < 0.005) or talk to parents about quitting (p=0.01)

(see Figure 3). Forty percent of current smokers and 21 percent of former

smokers reported that their pediatricians had talked to them about the effects

of their smoking (passive smoke) on their child’s health.

Attitudes About Surprisingly, 48 percent of current smokers feel it is the pediatrician’s

Advice From job to advise smoking parents to quit. Twenty-eight percent of current

Pediatricians smokers said their pediatrician has talked about the effects of smoking

on their own health, and 27 percent of current smokers said their

pediatrician advised them to quit. Current smokers were asked how they

would feel if their pediatrician advised them to quit smoking. About one-half

(52 percent) said they would welcome the advice, 30 percent said it would

bother them somewhat, and 15 percent said it would not matter to them.

Fewer parents had more negative reactions: 11 percent claimed it was none

of the pediatrician’s business, 4 percent said it would make them angry, and

one parent claimed she would change to another pediatric practice (some

respondents checked more than one answer). Smoking parents were also

asked about the best opportunities to receive quit-smoking advice from their

pediatricians. The percentages that rated opportunities as “good or excellent”

were as follows: 77 percent, prenatal visit; 67 percent, acute visits for respiratory infections; 66 percent, well-baby visits; 55 percent, after delivery; and

48 percent, acute visits for other problems. As Figure 2 illustrates, smokers

and doctors agree closely on opportunities to talk about quitting smoking.

Smokers’ Current smokers were asked, “If you decided to give up smoking comIntentions pletely in the next month, do you think you could do it?” Twenty-two

To Quit percent responded definitely or probably, 35 percent responded maybe,

and 42 percent responded definitely or probably not. When asked, “Do

you intend to give up smoking in the next month?”, 7 percent responded yes,

34 percent maybe, and 59 percent no. However, when asked whether they

had any intentions of ever giving up smoking, 68 percent of smoking parents

replied yes, 23 percent maybe, and 9 percent no.

OBJECTIVES OF Pediatricians need to become aware of office-based smoking cessation

PEDIATRICIAN trials that have examined the efficacy of brief methods of delivering

INTERVENTION advice to stop smoking. Pediatricians are not familiar with the smoking cessation literature, and they often refrain from giving smoking

Education of cessation advice because they think it is not worthwhile—that a

Pediatricians 10- to 15-percent quit rate is unacceptably low. In fact, for a minimal

intervention of brief advice and limited followup, a quit rate of 10 percent is

actually what is to be expected.
239

Chapter 4

Figure 3

Parents’ attitudes about advice

Source: Frankowski et al., in press; used with permission.

A systematic method of training pediatric residents and practicing

pediatricians should be established, using the NCI manual for physicians,

How To Help Your Patients Stop Smoking (Glynn and Manley, 1990), and the

supplement, Clinical Interventions To Prevent Tobacco Use by Children and

Adolescents (Epps and Manley, 1991). Only 8.5 percent of Vermont pediatricians have had formal training in delivering smoking cessation advice, and

only 20 percent feel very confident in advising parents to quit.

A recent study showed that residents in primary care specialties (family

practice, internal medicine, and pediatrics) had positive attitudes but inadequate practice and training in smoking cessation counseling (Kenney et al.,

1988). The survey of 309 residents (66 in pediatrics) showed that the pediatric residents scored significantly lower in most areas of smoking cessation

counseling practices, and only 32 percent reported having any training

in this area (compared with 76 percent of family practice and 53 percent

of internal medicine residents, significantly different at p < 0.001). The

pediatric residents were also more likely to cite insufficient time as a barrier.

However, when pediatric residents were taught smoking cessation counseling

methods, they performed as well as the other residents (Strecher et al., 1991).

Thus, the need to teach both pediatric residents and practicing pediatricians
Smoking and Tobacco Control Monograph No. 5

240

brief methods of delivering smoking cessation advice is clear. The majority

of pediatricians (87 percent in Vermont and 84 percent in Maine) would be

moderately or very willing to learn such techniques (Frankowski and SeckerWalker, 1989).

The above-mentioned supplement, Clinical Interventions To Prevent

Tobacco Use by Children and Adolescents, is currently available. In addition

to the four A’s (ask, advise, assist, arrange), a fifth “A” heads up the list for

pediatricians: Anticipate the risk for tobacco use at each developmental stage.

The guide is divided into three sections: infancy and early childhood, late

childhood, and adolescence and young adulthood.

An effort should be made in each pediatric office to identify additional

personnel (for instance, a nurse or nurse practitioner) to receive training.

Although a brief message from the physician is a key element, other personnel can be used to answer the patient’s questions, help with followup, and

even counsel smokers on ways to quit (Solberg et al., 1990). Kottke and

colleagues (1988) have shown that advice from both a physician and a

nonphysician is more effective than from either alone. The dual approach

may not be practical for pediatricians practicing solo or in small groups, but

it should be considered in other settings. It could alleviate some of the time

constraints that concern many pediatricians.

Dealing With Pediatricians should be aware that the anticipatory guidance for preBarriers vention of smoking onset and the advice for smoking cessation are

brief and meant to be delivered in a few minutes once the methods

“Not Enough are learned. There is a growing body of literature indicating that brief

Time” advice (less than 10 minutes) can be successful (Pederson, 1982). A

1985 survey of 441 Iowa physicians indicated that almost all (95 percent) said they advise patients to stop; most said they spend less than

10 minutes giving such advice (median, 5 minutes; range, 1 minute to

30 minutes) (Ferguson, 1985). The median success rate for this advice was

10 percent, with a range of 0 to 100 percent. Success rates of this order after

physician-delivered smoking cessation advice have been reported from a

number of studies. In a meta-analysis of 39 trials of cessation advice or

counseling carried out in physicians’ offices, the average reported quit rate

in the intervention groups was 8.4 percent higher than in the control groups

(Kottke et al., 1988). Although some may consider such rates unacceptably

low, it should be remembered that facilitating even a quit attempt is significant, because the actual success rate among individuals is related to the

number of quit attempts. Even a quit rate as low as 5 percent, as reported

by Russell and colleagues for brief (2-minute) smoking cessation advice,

would produce a large number of quitters if all primary care practitioners

provided such advice (Russell et al., 1979).
241

Chapter 4

“Parents Don’t Pediatricians should be aware that one-half of a sample of smoking

Expect This parents said they would welcome the advice to quit and fewer than

Advice” 10 percent would react negatively. In fact, 68 percent of smoking parents claim they intend to quit sometime. It has been estimated that up

to 80 percent of smokers want to quit (Mason and Lindsay, 1983), and only

about 7 percent of current smokers in 1986 predicted they would “definitely”

be smoking in 5 years (US DHHS, 1990). However, in a 1987 survey of

patients seen in various university-based, outpatient clinic settings, only

58 percent of healthy smokers and 50 percent of smokers with smokingrelated symptoms noted that they had been advised by their physicians

to stop smoking (Ockene et al., 1987). A survey of 5,875 Michigan adults

showed that, of smokers who had seen a physician in the previous year,

only 44 percent reported they had ever been told by a physician to quit

smoking (Anda et al., 1987). Physicians should not underestimate their

influence: The single most important reason people have for quitting

smoking is concern for their health. Those who quit for health reasons

or in response to physician advice are more likely to make repeated attempts

and to maintain abstinence from cigarettes (Orleans, 1985).

“Feel Ill at Ease Pediatricians will feel more confident about giving the advice when

Giving Advice” they have had formal training and when they are made aware that

parents feel it is part of the pediatrician’s job to offer advice.

Incorporating In the authors’ survey of Vermont pediatricians, about 40 percent

Smoking Advice reported they routinely take a smoking history from parents of each

Into Office Visits patient, but only 11 percent record the information in the child’s

chart. In a national mail survey of 779 pediatricians in 1987, about

Smokers in the 65 percent reported asking about smoking at the 0- to 5-year wellHousehold child visits, and as many as 80 percent reported asking about smoking if the child is 13 or older (Nader et al., 1987). The same survey

showed that only 50 percent of pediatricians felt that cigarette smoking was

a “very important” topic to discuss at well-child visits from 0 to 5 years. In

family practice and internal medicine, flagging a smoker’s chart in some way

increases the chances that the physician will remember to provide followup

smoking cessation advice at subsequent visits (Cohen et al., 1989; Solberg et

al., 1990).

New Baby, Because pediatricians come in contact with a great number of young

Smoking Parents adults who may not be routinely seeking health care for themselves

and because parental smoking directly affects their children, the

argument is strong for pediatricians to deliver brief smoking cessation advice

to parents. Perry and Silvis (1987) have outlined methods pediatricians can

use to promote nonsmoking or encourage attempts to quit for parents,

children, and adolescents; they stress that pediatricians need to learn the

skills involved and need to motivate themselves to use these skills. Perry

and Silvis suggest encouraging parents to quit smoking and/or refrain from

smoking near the child. The pediatricians should (1) ask about parents’
Smoking and Tobacco Control Monograph No. 5

242

smoking habits; (2) motivate themselves to promote cessation and a consistent

no-smoking message; (3) motivate parents to quit smoking through discussion

of immediate risks to the child; and (4) reinforce ex-smokers to stay away from

cigarettes.

The methods that these authors suggest are very similar to the “four A’s”

method recommended in the NCI manual. The pediatrician should:

• Ask parents about smoking in the household, the car, or in day care

settings. At sick visits, ask about tobacco exposure. Remember that

silence by the physician may be interpreted by parents to mean that

smoke exposure is not a significant health risk.

• Advise all parents who smoke to stop. Talk about the effects of passive

smoke.

• Assist interested smoking parents in developing an effective smoking

cessation strategy. Set a quit date and provide self-help materials or

referrals.

• Arrange followup for parents, which can take place at the child’s next

regularly scheduled well visit. Mark the child’s chart with the parents’

smoking status as a reminder to ask at all visits.

Respiratory Although it may be more difficult because visits are sporadic, the

Problems pediatrician is obligated to inform parents that cigarette smoke is

And Smoking usually one of the causative factors in a child’s respiratory illness. It

Parents is especially appropriate to emphasize passive smoke issues for infants

and children who have problems with recurrent upper or lower respiratory infections, recurrent ear infections, or reactive airway disease. In many

cases, the parent who does not accompany the child to the office is the

smoker, and a simple phone call from the pediatrician to give information

and make a direct plea to the parent to quit smoking may be a powerful

motivator. If the parent can be coaxed into setting a quit date, the pediatrician can schedule a followup visit for the child at about the same time to

check on child and parent simultaneously. If available, other office personnel

can spend more time with the parents.

Child or There is a unique opportunity for the pediatrician because frequently

Adolescent children and adolescents who smoke do not receive proper health care.

Who Smokes An extra effort should be made to ask, advise, assist, and arrange:

• Ask about tobacco use at every visit. It may be easier to use a previsit

questionnaire.

• Advise all tobacco users to stop. Inform smokers that it is easier to stop

now than later. Personalize the message and mention reduced athletic

capability, cost, odor, and fire hazard.
243

Chapter 4

• Assist tobacco users in stopping. Help set a quit date and provide selfhelp materials. Plan a way to enlist friends to help. Consider having

the child or adolescent sign a contract to quit. Rehearse how to say no.

Encourage participation in programs that promote the development of

skills to solve problems, set goals, make decisions, and counter negative

peer pressure. Encourage exercise and social activities incompatible

with tobacco use.

• Arrange a followup visit within 1 to 2 weeks after the patient’s planned

quit date; discuss progress and problems. Arrange a second followup

visit within 1 to 2 months.

Anticipatory Perry and Silvis (1987) suggest that physicians promote nonsmoking by

Guidance emphasizing (1) harmful physical consequences, (2) the habit-addictive

nature of cigarette smoking, (3) advertising techniques that mask the real

effects of smoking, and (4) smoke-free environments at home and at the

doctor’s office. For adolescents, Perry and Silvis suggest promoting nonsmoking by emphasizing (1) immediate physiological and social consequences,

(2) ways to deal with pressures to smoke, (3) commitment to nonsmoking,

and (4) the use of alternatives.

The NCI pediatricians’ supplement suggests that the following ideas may

be appropriate for well-child visits of patients aged 5 through 12:

• Anticipate. Include the children in discussions about smoking and

tobacco use. Remind parents that tobacco use often begins in grade

school.

• Ask the child whether smoking is being discussed in school or among

friends. Ask whether the child smokes or whether friends, parents, or

other important adults in the child’s environment smoke.

• Advise the child about immediate negative effects of tobacco use. Remind the child that most adolescents do not smoke. Advise smoking

adults about passive smoke and their image as role models. Discourage

use of candy cigarettes.

• Assist the child in assuming increasing responsibility for his or her

health and behavior. Compliment the child on nonsmoking behavior

and discuss refusal skills.

• Arrange more frequent followup visits for children experimenting with

tobacco products.

For adolescents, the NCI manual suggests the following:

• Anticipate. Adolescents who are deviance-prone, who show a relative

lack of interest in conventional goals, and who overestimate smoking

prevalence among adults and teens are at greater risk for tobacco use.
Smoking and Tobacco Control Monograph No. 5

244

Adolescent females are particularly vulnerable. Peer modeling is one of

the most important factors in choosing to use tobacco.

• Ask adolescents at every visit whether they smoke and whether their

friends use tobacco.

• Advise. Congratulate non-users and advise them to resist using tobacco. Discuss the benefits of not smoking.

• Assist. When appropriate, encourage participation in programs that

promote the development of skills to solve problems, set goals, make

decisions, and counter negative peer pressure. Give adolescents information about smoking cessation that they can share with smoking

friends.

• Arrange followup at appropriate intervals for health care maintenance;

make yourself available at other times if necessary.

CONCLUSION Pediatricians should come to view smoking cessation advice as part of

the routine anticipatory guidance delivered at all health supervision visits.

For this to happen, pediatricians first need to learn the techniques that have

been shown to be helpful. Second, they need to overcome their personal

barriers to offering the advice. Pediatricians need to know that most smoking parents consider it the pediatrician’s job to offer such advice and would

actually welcome this help from their children’s physicians. The barrier of

time becomes less of an issue when the pediatrician learns the brief yet

effective method of ask, advise, assist, arrange. When possible, other office

personnel can be trained to offer further advice on stopping smoking. When

other office personnel are not available, the pediatrician can provide appropriate written materials for smoking parents and patients.

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Anda, R.F., Remington, P.L., Sienko, D.G., Davis, R.M.

Are physicians advising smokers to quit? The

patient’s perspective. Journal of the American

Medical Association 257: 1916-1919, 1987.

Cohen, S.J., Stookey, G.K., Katz, B.P., Drook, C.A.,

Smith, D.M. Encouraging primary care physicians

to help smokers quit: A randomized controlled

trial. Annals of Internal Medicine 110(8): 648-652,

1989.

DiFranza, J.R., Tye, J.B. Who profits from tobacco

sales to children? Journal of the American Medical

Association 263(20): 2784-2787, 1990.

Epps, R.P., Manley, M.W. A physician’s guide to

preventing tobacco use during childhood and

adolescence. Pediatrics 88(1): 140-144, 1991.

Ferguson, K.J., Pomrehn, P.R., Caplan, R.M. Help

your patients kick the cigarette habit. Iowa

Medicine 75(11): 495-497, 1985.

Fielding, J.E., Phenow, K.J. Health effects of

involuntary smoking. New England Journal of

Medicine 319: 1452-1460, 1988.

Fiore, M.C., Novotny, T.E., Pierce, J.P., Hatziandreau,

E.J., Patel, K.M., Davis, R.M. Trends in cigarette

smoking in the United States: The changing

influence of gender and race. Journal of the

American Medical Association 261(1): 49-55, 1989.

Frankowski, B.L., Secker-Walker, R.H. Advising

parents to stop smoking: Opportunities and

barriers in pediatric practice. American Journal of

Diseases of Children 143: 1091-1094, 1989.

Frankowski, B.L., Weaver, S.O., Secker-Walker, R.H.

Advising parents to stop smoking: Pediatricians’

and parents’ attitudes. Pediatrics, in press.
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Glynn, T.J., Manley, M.W. How To Help Your Patients

Stop Smoking: A National Cancer Institute Manual for

Physicians. U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, National Cancer Institute. NIH Publication No. 90-3064, 1990.

Gortmalker, S.L., Walker, D.K., Jacobs, F.H., RuchRoss, H. Parental smoking and the risk of childhood asthma. American Journal of Public Health 72:

574-579, 1982.

Kenney, R.D., Lyles, M.F., Turner, R.C., White, T.S.,

Gonzalez, J.J., Irons, T.G., Sanchez, C.J., Rogers,

C.S., Campbell, E.E., Villagra, V.G., Strecher, V.J.,

O’Malley, M.S., Stritter, F.T., Fletcher, S.W.

Smoking cessation counseling by resident physicians in internal medicine, family practice, and

pediatrics. Archives of Internal Medicine 148: 2469-

2473, 1988.

Koop, C.E. The pediatrician’s obligation in smoking

education (editorial). American Journal of Diseases of

Children 139(10): 973, 1985.

Kottke, T.E., Battista, R.N., DeFriese, G.H., Brekke,

M.L. Attributes of successful smoking cessation

interventions in medical practice: A meta-analysis

of 39 controlled trials. Journal of the American

Medical Association 259: 2882-2889, 1988.

Kraemer, M.J., Richardson, M.A., Weiss, N.S.,

Furakawa, C.T., Shapiro, G.G., Pierson, W.E.,

Bierman, C.W. Risk factors for persistent middleear effusions: Otitis media, catarrh, cigarette smoke

exposure, and atopy. Journal of the American Medical

Association 249: 1022-1025, 1983.

Landrigan, P.J. Involuntary smoking: A hazard to

children. Pediatrics 77: 755-757, 1986.

Mason, J.O., Lindsay, G.B. A positive approach to

smoking prevention and cessation. Western

Journal of Medicine 139(5): 721-722, 1983.

Nader, P.R., Taras, H.L., Sallis, J.F., Patterson, T.L.

Adult heart disease prevention in childhood:

A national survey of pediatricians’ practices and

attitudes. Pediatrics 79: 843-850, 1987.

Ockene, J.K., Hosmer, D.W., Williams, J.W., Goldberg,

R.J., Ockene, I.S., Biliouris, T., Dalen, J.E. The

relationship of patient characteristics to physician

delivery of advice to stop smoking. Journal of

General Internal Medicine 2: 337-340, 1987.

Orleans, C.T. Understanding and promoting smoking

cessation: Overview and guidelines for physician

intervention. Annual Review of Medicine 36: 51-61,

1985.

Pederson, L.L. Compliance with physician advice to

quit smoking: A review of the literature. Preventive

Medicine 11: 71-84, 1982.

Perry, C.L., Silvis, G.L. Smoking prevention:

Behavioral prescriptions for the pediatrician.

Pediatrics 79: 790, 1987.

Russell, M.A.H., Wilson, C., Taylor, C., Baker, C.D.

The effect of general practitioners’ advice against

smoking. British Medical Journal 2: 231-235, 1979.

Sexton, M., Hebel, J.R., Fox, N.L. Postpartum

smoking. Paper presented at the International

Conference on Smoking and Reproductive Health,

San Francisco, October 15-17, 1985.

Solberg, L.I., Maxwell, P.L., Kottke, T.E., Gepner, G.J.,

Brekke, M.L. A systematic primary care office-based

smoking cessation program. Journal of Family

Practice 30: 647-654, 1990.

Stahlberg, M., Ruuskanen, O., Virolainen, E. Risk

factors for recurrent otitis media. Pediatric and

Infant Diseases 5: 30, 1986.

Strecher, V.J., O’Malley, M.S., Villagra, V.G., Campbell, E.E., Gonzalez, J.J., Irons, T.G., Kenney, R.D.,

Turner, R.C., Rogers, C.S., Lyles, M.F., White, S.T.,

Sanchez, C.J., Stritter, F.T., Fletcher, S.W. Can

residents be trained to counsel patients about

quitting smoking? Results from a randomized trial.

Journal of General Internal Medicine 6: 9-17, 1991.

U.S. Department of Health and Human Services. The

Health Benefits of Smoking Cessation: A Report of the

Surgeon General. U.S. Department of Health and

Human Services, Public Health Service, Centers

for Disease Control, Center for Chronic Disease

Prevention and Health Promotion, Office on

Smoking and Health. DHHS Publication No. (CDC)

90-8416, 1990.

Weiss, S.T., Tager, I.B., Speizer, F.E., Rosner, B. Persistent wheeze: Its relation to respiratory illness,

cigarette smoking, and level of pulmonary function

in a population sample of children. American

Review of Respiratory Diseases 122: 697-707, 1980.

Windsor, R.A. An application of the PRECEDE model

for planning and evaluating health education

methods for pregnant mothers. Hygie 5(3): 38-44,

1986.
Smoking and Tobacco Control Monograph No. 5

246

Smoking Intervention by Providers of

Health Care for Women1

Mary Sexton, Joan Stine, and Steven Cahill

ROLE OF Health care practitioners can significantly reduce cigarette smoking

THE PROVIDER among women. In addition to initiating health care contacts related

to medical problems, healthy women are urged to seek even more preventive

health care and on a more regular basis than are men; so the number of health

care contacts during which it is possible for providers to address smoking is

quite high.

During the course of a year, women seek obstetrical and gynecological

services that include prenatal care, family planning, and screening for cervical

and breast cancers, from family physicians, gynecologists, and other providers.

For example, there are 56 million contacts a year by obstetricians and gynecologists (Nelson and McLemore, 1988). Clearly, obstetrical and gynecological

practices represent a special opportunity for impact on smoking among

women, particularly pregnant women. Yet, obstetricians and gynecologists

have not availed themselves of the smoking intervention training provided by

the National Cancer Institute. Only 3 percent of 1,568 physicians who have

been trained by NCI are obstetricians or gynecologists (Marc Manley, personal

communication). The physician’s participation in formal training is a step

that can lead to the development of office-based smoking intervention.

Not only do health care practices represent an opportunity to reach

smokers, but the increasing health risks of women dictate an obligation to

do so. Most providers already give a brief message with one or more specific

health risks of smoking. The message usually centers on the health of the

baby if the woman is pregnant. What is often missing, though, is a standardized protocol that goes beyond giving a health message and that systematically follows the patient’s progress at each visit.

The provider can and should adopt the same view and attention toward

smoking as toward other medical risks. This focus would convey to the

woman a deep and continuing concern over the increased risk that the provider recognizes and would set the framework for development of a treatment

plan. In treating acute or chronic disease problems, the provider clearly sees

an obligation to give the best medical advice and treatment possible,

1 The preparation of this manuscript benefited from work partially supported through a cooperative

agreement with the Centers for Disease Control.
247

Chapter 4

regardless of how the patient might respond, and the same clarity of

professional obligation can be extended easily to treatment consisting of

antismoking counseling for smokers.

Patients believe that providers should actively address and discuss the

issue of smoking. This was borne out by the authors’ recent experience in

the Smoking Cessation and Reduction in Public Prenatal Clinics project.

As part of the development of the antismoking intervention approach for

the project, focus groups of clients seen in prenatal public health clinics

were assembled early in the project to delineate key issues about smoking

and quitting. The women emphasized the importance to them of the clinic

staff’s actively giving support to decisions and efforts to quit. After intervention was completed, a survey of the project participants was conducted

(regardless of whether they had quit or continued to smoke). Again, the

importance of the staff’s involvement emerged from the responses. When

asked what would help smokers, the women most often suggested that the

staff talk with and support clients in their efforts to quit.

With trained physicians implementing a standardized protocol for

smoking intervention for their patients, it should be possible to achieve a

greater impact on female smokers. The effectiveness may be even greater

than reported thus far because of the greater pervasiveness and continuity

of the intervention when conducted in health care settings as part of patient

care rather than as part of research and demonstration activities.

EFFECTIVENESS Although there is an absence of published information on

OF ANTISMOKING antismoking intervention for nonpregnant smokers in the

INTERVENTION gynecological care setting, the effectiveness of antismoking

intervention for pregnant smokers has been assessed in diverse health care

settings. Table 2 shows that antismoking interventions can produce a

significant increase in the percentage of pregnant smokers who quit.

Not all the intervention studies shown, however, nor others reported

in the literature, have achieved a statistically significant difference in quit

rates. Furthermore, not all studies have included biochemical validation

(the cotinine values for the public prenatal clinics project mentioned above

are not yet available), and validation results could diminish the reported quit

rates and reduce the differences achieved. Nevertheless, the studies, taken as

a whole, clearly indicate that quitting by female smokers can be increased.

Among studies reporting significant increases, the differences achieved vary

by as much as twofold. In the study by Windsor and colleagues (1985), in

which a 12-percent difference in quit rates was observed, for example, the

intervention consisted of one brief message from a health educator and

instruction on the use of a self-help booklet.

In the Sexton and Hebel study (1984), in which a 23-percent difference was

observed, the intervention consisted of personal contacts and followup by

phone and mail over the entire course of the pregnancy (Nowicki et al., 1984).
Smoking and Tobacco Control Monograph No. 5

248

Table 2

Quit rates from randomized clinical trials for pregnant smokers

Quit Rates

Experimental Control

Group Group

Public Clinic

Alabama (Windsor et al., 1985) 14% 2%

Marylanda 24 18

Private Setting

Maryland (Sexton and Hebel, 1984) 43 20

Health Maintenance Organization

California (Ershoff et al., 1989) 26 17

National Health Care Setting

England (MacArthur et al., 1987) 9 6

a SCIP (three-state research and demonstration project). Preliminary data without biochemical validation.

Smokers from both the private sector and the public clinic sector were included.

Smokers from the public clinic had quit rates as high as those receiving services

from private providers, which suggests that when smokers are given assistance,

they will respond, in spite of substantially disadvantaged life circumstances.

It is worth noting that by the time they register for prenatal care, about onefourth of the smokers have already stopped, leaving the heavier and more

addicted smokers continuing the behavior. Even so, the provision of assistance

after the woman registers for prenatal care results in higher rates of cessation.

The importance of reaching female smokers through their health care contacts

increases when the considerable postpartum relapse of smokers who quit during

pregnancy is taken into account. A continuing focus on the problem of smoking

by all providers might assist women in sustaining the quitting they achieve on

their own or with assistance during pregnancy.

A broad range of smoking intervention approaches and resources have

been used, as illustrated in Table 3. Published information on the specifics

of each intervention has been used as a basis for the description, which should

be viewed with some caution since it may have been incompletely described.

All studies have included some type of materials, and almost all have provided

for one-to-one counseling. Most have reported having more than one intervention contact.

A clear picture of the amount of time spent on smoking intervention does

not emerge from the information. Somewhat surprisingly, only one study has

reported explicit involvement of the physician to assist with the intervention,
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Table 3

Description of interventions, by published study

Provider Type of Number of Time Quit Rate Number

Messagea Materialsb Counselingc Contacts (hr)d Differencee in Study

Ershoff et al., 1989 HE P,S,O I 1 < 1 14% 242

Windsor et al., 1985 HE S,O I 1 < 1 12 309

Nowicki et al., 1984 HE P,O I > 1 > 1 23 935

MacArthur et al., 1987 MD, N P I 1 NR 3 982

Loeb et al., 1983 HE P,O I,G > 1 > 1 1 963

Aaronson et al., 1985 HE S,O I 1 NR – 58

Langford et al., 1983 N P I 1 < 1 0 116

Danaher et al., 1978 HE P G > 1 > 1 – 11

a MD, physician; N, nurse; HE, health educator.

b P, pamphlet; S, self-help guide; O, other.

c I, individual; G, group.

d NR, not reported.

e Percentage difference between intervention and control groups; no control group reported in Aaronson et al.

and Danaher et al.

beyond what he or she “usually” does. The information suggests that, in

the future, the intervention for pregnant smokers could be strengthened by

medical personnel’s assuming a more prominent role in its implementation.

CONSTRAINTS ON The routine of a medical office usually has little free time or

OFFICE-BASED flexibility. The procedures for patient care fall into a wellINTERVENTION defined set of interlocking activities. The introduction of a

new or expanded activity, such as a standardized antismoking protocol,

must take into account the constraints that the office routine and staff

impose. The ones that are most likely to be faced are described below.

Office Time The experience with the project in public prenatal clinics showed that

several factors impinged on the intervention’s being implemented. A balance

had to be forged between maintaining a predictable office routine and spending time in counseling patients. As part of the project planning process, the

project staff met with prenatal care nurses in public clinics. The nurses were

quick to point out that the intervention should be developed with the realization that only a small amount of staff time would be given, since other activities were already extremely demanding. Emerging from the focus groups of

patients, on the one hand, was a message that the staff relationship was an

important one to patients in quitting. On the other hand, the reality was that

staff time was limited. Thus, the project intervention had to focus on the

patient’s taking a lot of responsibility for her own plan of cessation activities.
Smoking and Tobacco Control Monograph No. 5

250

Interval Between The infrequency of clinic visits, even for prenatal patients, meant

Visits that the staff could not be available on an as-needed basis or even

weekly during the time that smokers would be quitting. During the time

when the smoker prepares to quit and during the early process of withdrawal

from smoking, the individual can benefit most from very frequent contact—

daily or even more often—with a support person. It was thus important for

the clinic staff to get the patient to find support beyond that which the staff

could give.

Skills The public prenatal clinic nurses consistently expressed that training

would be needed to enhance their overall counseling skills; in particular,

they wanted guidance on how to deal with resistant clients. Most of the

staff felt the need for reassurance that they could successfully fulfill the

responsibilities given. The authors have met few staff members who felt

sufficiently trained and experienced in antismoking intervention.

The public prenatal clinic project intervention was developed within

the constraints outlined above. In recognition of limited staff time, the time

required by the clinic staff was about 5 to 10 minutes for the initial contact

and about 3 minutes for the followup contacts. The intervention itself had a

substantial self-help component, in which the patient assumed responsibility

for the development and implementation of a specific and personal plan for

quitting smoking and avoiding relapse. The patients were told that the selfhelp materials should be used at home, and they were given guidance by the

nurses in how to do that. To address the issue of sustained support, the selfhelp booklet included a section on how the smoker could develop the skills

to achieve ongoing support from family and friends. To reinforce the selfhelp material, an audiotape and posters for the refrigerator were developed.

To address the need for upgrading counseling skills, formal training was

provided to the clinic staff.

TRAINING Essential steps in the successful implementation of an office-based

PRENATAL intervention for the Smoking Cessation and Reduction in Public

CARE NURSES Prenatal Clinics project included not only the development of an

intervention that could actually be implemented in a busy prenatal clinic,

but also gaining the staff’s cooperation in implementing it. The project

staff believed that time spent in training would build confidence in and

familiarity with the intervention protocol as well as enhance the cooperation

of the staff. While in the majority of sites the antismoking intervention was

conducted by the prenatal care nurses, some clinics had very dedicated

health educators who did most of the counseling. For simplicity, though,

the following discussion refers to nurses as the recipients of the training.

The project training may have been more of a challenge than would usually

be expected because of the large number of nurses involved, and even more

so because the decision to implement the intervention had come from the

top down, and in a few instances the clinic nurse had little input to that

decision.
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Since the nurses had expressed uncertainties about their interactions

with the smoker or recent quitter, the intervention encounters were designed

to be highly structured and predictable. The training itself focused on a

standardized, minimal intervention protocol with the understanding that

there was opportunity for expansion. All materials needed for implementation were provided and included those for the exclusive use of the staff.

A Nurses Guide (State of Maryland, 1989), described below, was developed,

as was a form, part of which was used to record smoking status and part

of which was a checklist to record specific intervention activities.

Training There were five participating intervention counties in the project, with

Structure the larger ones having multiple prenatal care sites. Since the end of the

project, public prenatal care nurses in all the Maryland counties have been

trained with essentially the same intervention protocol, but with fewer

followup contacts after the initial training session. Training for the Smoking

Cessation and Reduction project was arranged for each county separately, to

minimize travel time for the staff, and took place as regularly scheduled inservice meetings to prevent disruption of clinic schedules. Because the public

prenatal clinics study was a research and demonstration project conducted

with some support from the Centers for Disease Control, it was possible to

provide several training contacts. The initial training was for one-half day

with a followup session scheduled after the staff had time to gain experience

with the intervention. Clinics were phoned each month and visited quarterly during the 2-year project. At those times, any problems the staff

experienced with intervention could be discussed.

At the initial training session for the project, some background information was provided. An overview of the scientific evidence of the risks of

smoking for the fetus during pregnancy, the newborn, and the child was

presented, and examples of possible clinical problems seen in smokers were

discussed. A summary of reported quit rates achieved in intervention studies

was presented. After the introductory material, the rest of the training

session was focused on the study intervention.

The smoker’s self-help booklet had discrete modules that explicitly

considered the patient’s stage of readiness to quit, using a Prochaska and

DiClemente (1983) approach with different modules on precontemplation,

contemplation, and relapse. The training of the nurses emphasized how the

booklet could be used with all smokers, regardless of their interest or readiness to quit. A separate self-help booklet with almost identical content was

developed for recent quitters; it emphasized maintenance of the nonsmoking

behavior.

The training of the nurses centered on interaction with the smokers (and

recent quitters), using the self-help booklet as the focal material. This focus

was to provide consistency of messages and approaches between the nurse’s

interactions and those in the self-help booklet used at home. Moreover, the

nurse’s use of the self-help booklet to organize the interaction provided a

transition to its use by the client.
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252

To further provide guidance to the counseling exchange, nurses were

given a Nurses Guide, the content of which was the same self-help booklet

provided the patient but expanded to include a brief supplemental section.

The added section contained general counseling techniques, a step-by-step

standardized counseling protocol for the nurses to follow if they wished, and

responses to reasons commonly given for not quitting smoking.

The first two pages of the Nurses Guide contained material on how to build

a positive relationship with the client, most of which was given as examples

of listening and supportive techniques for maximizing the provider/client

relationship, such as the one on how to increase confidence and expectations

for success:

Technique Purpose To Achieve Purpose Examples

Expressing To increase Express confidence. “With your husband’s

confidence confidence Be sincere and support, I believe you

and understanding; avoid will quit smoking.”

expectations “if, maybe, might,”

or “I think you can

quit.”

Just as the self-help guide provided modules to be used by the smoker,

depending on her stage in the cessation process, so the Nurses Guide included

examples of three standardized protocols (for women who do not want to

quit, for women who want to quit, and for recent quitters). Each protocol

had the same five counseling steps:

• Assess the level of current smoking and interest in quitting.

• Give strong advice to quit, along with one or more benefits of cessation.

• Problem-solve by identifying potential problems and seeking feasible

solutions.

• Contract by summarizing the stage the smoker is in with regard to

quitting and getting the patient to agree to one or two concrete

behaviors (goal), regardless of how simple.

• Follow up by assuring the patient that there will be followup at the next

appointment.

Specific information was given under each counseling step. For women

who do not want to quit, under step 3, “Problem-Solve,” the nurse following

the steps would (a) identify potential problems and (b) seek “do-able” solutions. A list of possible solutions was given as examples: “Read the self-help

manual, listen to the audiotape, put up the posters, think about quitting.”

The nurse could suggest these or substitute others, as appropriate.
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The third short section of the supplement included specific reasons the

smoker might give for not quitting, along with specific responses that the

nurse could use. If the smoker said, “I get pleasure from smoking,” the nurse

could respond, “You will get pleasure from quitting, too—improved taste and

smell, and better smelling breath, clothes, and hair. But you get more than

pleasure; you are freed of any concern over how smoking could harm you

and your baby.”

The Nurses Guide included references to specific pages of the booklets as

illustrations or further examples of the messages that the nurse could give

for each step of the counseling protocol. The client could follow along in

her own self-help booklet as the nurse pointed out the specific content. The

nurse could embellish the content of the intervention booklet as much or as

little as desired, while maintaining the core protocol, and could always turn

to the Nurses Guide for further multiple and specific messages and directions.

Thus, the materials and approach developed for use by the nurse could be

used throughout all the prenatal care sites, regardless of the different levels

of skills and motivations found in the staffs from clinic to clinic.

In addition to the Nurses Guide, a one-page form was developed and

given to the nurses so that a simple but consistent record of the patient’s

smoking status and intervention could be maintained. At each visit the

nurse was expected to record the number of cigarettes the patient had

smoked in the preceding 24 hours, the patient’s status with respect to willingness to quit (if still smoking), the intervention topics discussed at the

visit, the problems or barriers to achieving the goal, and the goal for the

next visit. This form provided a continuous record that could be used at

successive visits even if a different nurse saw the patient.

As a part of the nurses’ training, role-playing was demonstrated by two

trainers. Volunteers were then asked to participate to further illustrate how

the counseling protocol could be implemented. The role-playing showed

how resistance could be addressed. It was emphasized that the provider

should always leave the door open for future counseling by avoiding an

argumentative approach and acknowledging that people change their minds,

and that if the client became interested, there would be a chance to discuss

quitting techniques in the future.

The training concluded with a discussion of the smoking status of the

nurses and how that might affect their effectiveness in counseling smokers.

No one was asked individually about smoking status, but often the nurses

would volunteer whether they were current smokers, quitters, or neversmokers. The discussion not only led to suggestions, such as using another

behavior—for instance, weight control—around which to identify personal

involvement in making changes, it also engaged the nurses in envisioning

how they would interact with smokers. It proved to be a very lively and

fruitful part of the training session.
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POSSIBLE BARRIERS There are a number of issues that may present barriers to the

TO EFFECTIVENESS development and implementation of an effective office-based

intervention. These barriers are not necessarily overcome through developing or choosing a strong intervention protocol and training staff to use it.

Reimbursement All medical office staffs, but especially those in the private sector,

have to be mindful of the cost of patient services. The amount of time and

effort that providers spend on antismoking counseling will depend, to some

extent, on whether reimbursement is available and specifically linked to that

counseling.

Provider Attitudes The authors’ experience suggests that reimbursement is not

And Characteristics the primary barrier to office-based intervention. The attitude

of providers sometimes produces a stumbling block to assisting the smoker,

even when reimbursement is not an issue. It has been observed that, for a

number of reasons, some providers do not enthusiastically embrace the idea

of counseling, even when the intervention is minimal. Some of their own

characteristics get in the way of assisting the smoker, as described below:

• Futility of effort. Patient compliance is a general problem for the health

care practitioner, regardless of what the provider recommends. In reality,

some smokers will not change within any given timeframe, and it cannot

be predicted with much certainty which individual smokers will change.

Most experienced interventionists view smoking cessation as a process

and assume that any assistance is one more input to move the smoker

along in a progression of changing behavior that has the ultimate goal

of an achievement of quitting. Nevertheless, a significantly higher proportion of smokers will stop smoking when assistance is given; according

to current information, a 10- to 20-percent increase in quit rates can be

achieved from intervention. As techniques improve, the effect may be

even larger. Even very modest increases in quit rates are enough to make

a significant impact on smoking-related morbidity and mortality. To

avoid disappointment and feelings of futility, the provider should accept

the reality that antismoking counseling will not be effective with every

smoker but will be effective enough overall to improve health. It is

helpful to set realistic expectations of success and avoid the feeling that

the effort is meaningless.

• Burnout. A few prenatal care providers have expressed that an effort to

change the smoker’s behavior is wasted time because the smokers “are

not going to change.” Some nurses in training sessions were burned

out with their jobs. Just as some patients will not respond to assistance,

some few providers will not be responsive to opportunities to increase

their counseling effectiveness. For those unusual individuals, the mind

set prevents even a reasonable consideration of what is proposed. Where

it is possible, staff members who believe they cannot make an impact

and who resent having to provide counseling should not have direct
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counseling contact and responsibility, but should be asked to contribute to antismoking intervention only in indirect ways.

• Ambivalence. Some health care providers are ambivalent about smoking cessation counseling because smoking falls outside traditional

medical problems, and it is, in the end, the patient who controls the

success of the outcome. The provider is unable to apply to smoking

the familiar technical skills and knowledge that define medical expertise. Since the highly skilled training from which the provider’s prestige and professional standing stem is of little applicability, the health

task itself is given less worth, despite evidence to the contrary. Such

ambivalence can be addressed with training and a consistently applied

antismoking protocol that is viewed as an integral and essential component of good patient care.

• Smoking status. The provider who smokes is especially likely to be

in conflict and be defensive about the importance and effectiveness

of antismoking intervention. Included in the prenatal clinics training

described above was an explicit discussion of how a provider’s smoking

status, regardless of what it is, might influence his or her attitude and

effectiveness as a smoking cessation counselor. This broader approach

was a good way to take the spotlight off staff members who smoke. For

example, current smokers themselves said that patients might perceive

that providers who smoke are not credible. These providers were

encouraged to consider the appropriateness of their being actively

involved in the intervention and to exercise the option of no direct

responsibility if they could not overcome their barriers.

Most providers of prenatal care, however, even smokers, felt they could

seriously and sincerely work with pregnant smokers, quite possibly

because of the open discussion in training and because their peers

supported their involvement. The providers who had never smoked

found that they should be prepared to address the client’s challenge

to the provider’s lack of empathy. These providers were encouraged

to think of other behaviors that required them to make significant

lifestyle changes. The provider who had successfully quit could draw

on the experience but, at the same time, needed to avoid becoming

overzealous and personalizing the change process too much.

The trainers found it helpful to identify and discuss barriers during the

planning and training phases of the intervention and felt that more time

should have been given to the discussion. Often the staff expressed helpful

suggestions, and the group interaction helped build staff commitment to the

intervention and overcome some of the attitudes. Overcoming barriers can

be a real challenge, but if the barriers remain, they weaken or completely

undermine the intervention efforts.
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256

COMPONENTS From the experience in Maryland with three large antismoking

IN OBSTETRICAL programs for (a) about 1,000 prenatal patients in private practice,

OFFICES (b) about 2,000 smokers in State-funded maternity clinics, and

(c) about 1,000 smokers in a high-risk university clinic, giving attention to

several components appears to be important in the development of an

effective antismoking intervention in an obstetrical/gynecological setting.

The points highlighted below relate more to structuring the setting and

the intervention than to the content of the intervention. The reason is not

that the content is unimportant, but that examples of content can be more

readily found than can guidelines for how to structure the intervention.

While some points are overlapping, the components identified are those

relating to structuring the office and those that concern structure of the

intervention.

Office Structure Components of the medical office structure for smoking intervention are as follows:

• Have a smoke-free office. The message that health and smoking are

incompatible should be conveyed by behavior as well as word. When

members of the office staff smoke or condone patients’ smoking in the

office, it undermines the strength of the health message.

• Include the physician. A message from the physician is seen as a

credible one and sets the stage for a systematic and serious approach

to antismoking intervention from all of the office staff.

• Include as many other staff members as possible. All of the office staff can

contribute to intervention efforts, and it is important that they do so.

Even indirect support, such as adhering to a no-smoking office policy,

gives a consistent message in words and behavior from one staff

member to the next.

• Prepare the staff. Professional consulting skills should be sought and

utilized maximally. Nutritionists, social workers, and health educators,

while seldom available in other ambulatory settings, are often resources

in HMO and public clinic settings. Staff members from human service

disciplines, such as these, usually have formal training in the knowledge, skills, and techniques of behavioral change, which enables

them to provide more intensive antismoking intervention to patients.

They are also a valuable resource for training other staff members;

they are often eager to accept the primary responsibility for developing

antismoking intervention in the office setting. If no trained staff is

available, smoking intervention training can be obtained from outside

agencies such as NCI, health voluntary organizations, and State

agencies.

• Use chart notes. Chart notes about the assessment of smoking and

recommendations to the patient should be routine and should become

part of the patient’s medical record.
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Intervention Components of the intervention structure are as follows:

Structure

• Use a standardized protocol. In some settings, services are organized so

that the patient may see not only different physicians but also different

nurses over the course of several visits. Many guidelines for use by the

provider have been developed. As part of implementing the smoking

intervention, choosing a specific guide, such as NCI’s How To Help Your

Patients Stop Smoking (Glynn and Manley, 1990), will assure that a

uniform core approach is taken with every smoker and recent quitter.

After gaining experience, the office staff will be able to tailor the

approach to individual smokers. The chart notes on the assessment

and treatment progress of the smoker provide a history of activities

and may be the only means of tracing the course of the medical risk

factor of smoking, and of the patient’s progress in quitting.

• Address smoking at every visit. Smoking should be systematically addressed by the provider at every visit. Encourage any progress on the

part of the patient. Expressing optimism that she will one day be ready

to quit precludes a completely negative message.

• Assess smoking status. Smoking status of the patient is almost always

included at least once in the chart notes. The provider should determine and record the amount of smoking at the initial visit and at every

subsequent visit, just as for any other risk factor. It is the continuity of

assessment that most providers can improve. If the smoking status of

the patient is routinely assessed and recorded, the patient will be aware

of this effort, and the importance that the physician attaches to this

risk factor will be elevated. At the same time, the patient’s awareness

level regarding her behavior is increased. Assessment of the risk factor

can itself be an intervention activity (Mahoney et al., 1979) and is

certainly necessary for a systematic approach to intervention.

• Reinforce the message to quit. The provider message can be reinforced in

ways that take only a small amount of personnel time: by self-guided

booklets, by audiotapes, videos, posters, and a no-smoking office

policy. The more systematic, pervasive, and varied the antismoking

intervention is, the more likely that quit rates will increase.

A minimal approach, consisting of (1) assessment and recording of

smoking status and intervention activities at every visit, (2) a brief smoking

message from the provider at every visit, (3) provision of self-help materials,

and (4) referrals to already existing community programs, takes few resources. Voluntary agencies (e.g., American Lung Association, American

Cancer Society, American Heart Association) or even hospitals can be found

that will provide additional services if needed, and to which smokers or

recent quitters can be referred. Training of staff members can usually be

obtained from some of these same agencies. If it is not feasible to arrange
Smoking and Tobacco Control Monograph No. 5

258

training by outside agencies, self-training can be developed because of the

vast array of materials now available. Beginning with a minimal approach

and expanding it as resources warrant would seem to be possible for any

office providing health services to women and would greatly increase the

number of female smokers who are reached.

REFERENCES

Aaronson, N.K., Ershoff, D.H., Danaher, B.G.

Smoking cessation in pregnancy: A self-help

approach. Addictive Behaviors 10(1): 103-108, 1985.

Danaher, B.G., Shisslak, C.M., Thompson, C.B., Ford,

J.D. A smoking cessation program for pregnant

women: An exploratory study. American Journal of

Public Health 68(9): 896-898, 1978.

Ershoff, D.H., Muller, P.D., Quinn, V.P. A randomized trial of a serialized self-help smoking

cessation program for pregnant women in an

HMO. American Journal of Public Health 79(2): 182-

187, 1989.

Glynn, T.J., Manley, M.W. How To Help Your Patients

Stop Smoking: A National Cancer Institute Manual for

Physicians. U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, National Cancer Institute. NIH Publication No. 90-3064, 1990.

Langford, E.R., Thompson, E.G., Tripp, S.C. Smoking

and health education during pregnancy: Evaluation of a program for women in prenatal classes.

Canadian Journal of Public Health 74(4): 285-289,

1983.

Loeb, B.K., Waage, G., Bailey, J. Smoking intervention in pregnancy. In: Proceedings of the Fifth

World Conference on Smoking and Health (volume 1),

W.F. Forbes, R.C. Frecker, and D. Nostbakken

(Editors). Ottawa, Ontario: Canadian Council

on Smoking and Health, 1983, p. 389.

MacArthur, C., Newton, J.R., Knox, E.G. Effect of

antismoking health education on infant size at

birth: A randomized controlled trial. British

Journal of Obstetrics and Gynecology 94(4): 295-300,

1987.

Mahoney, M.J., Arnkoff, D.B. Self-management.

In: Behavioral Medicine: Theory and Practice,

O.F. Pomerleau and J.P. Brady (Editors). Baltimore:

Williams and Wilkins, 1979, pp. 75-96.

Nelson, C., McLemore, T. National Medical Care

Survey. U.S. Department of Health and Human

Services, Public Health Service, Centers for Disease

Control, National Center for Health Statistics,

1988.

Nowicki, P., Gintzig, L., Hebel, J.R., Latham, R.,

Miller, V., Sexton, M. Effective smoking intervention during pregnancy. Birth 11(4): 217-224,

1984.

Prochaska, J.O., DiClemente, C.C. Stages and

processes of self-change of smoking: Toward an

integrative model of change. Journal of Consulting

and Clinical Psychology 51(3): 390-395, 1983.

Sexton, M., Hebel, J.R. A clinical trial of change in

maternal smoking and its effect on birth weight.

Journal of the American Medical Association 251(7):

911-915, 1984.

State of Maryland, Department of Health and Mental

Hygiene. Nurses Guide To Quit and Be Free. 1989.

Windsor, R.A., Cutter, G., Morris, J., Reese, Y., Manzella, B., Bartlett, E.E., Samuelson, C., Spanos, D.

The effectiveness of smoking cessation methods

for smokers in public health maternity clinics: A

randomized trial. American Journal of Public Health

75(12): 1389-1392, 1985.
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A Physician- and Dentist-Delivered

Smoking Cessation Intervention for

Head and Neck Cancer Patients2

Ellen R. Gritz, Clifford R. Carr, David A. Rapkin,

Cindy Chang, John Beumer, and Paul H. Ward

PURPOSE OF The research described in this paper differs from the other studies

THE PROJECT reported in this monograph with respect to both the patient population and the health care providers. Although the great majority of smoking

cessation interventions for physicians and dentists have been designed for

primary care practitioners, who see generally healthy patients, there have

been no systematic trials with specialized surgeons and dentists treating

cancer patients. In general, quit-smoking rates of medical patient populations have increased with severity of disease (US DHHS, 1984). Thus, one

would predict a high cessation rate in a cancer patient population with

smoking-related tumors. Indeed, a 2-year continuous abstinence rate of

47 percent was recently reported for patients with stage I non-small-cell

carcinoma of the lung (Gritz et al., 1991b).

Patients with squamous cell carcinomas of the head and neck present

a natural group for intervention. In many cases, surgery and/or radiation

therapy can provide definitive treatment, and the 5-year relative survival

rate is approximately 51 percent for malignancies of the oral cavity and

pharynx and 67 percent for larynx cancers (US DHHS, 1990). The period

of diagnosis and treatment of smoking-related tumors is an optimal time

for smoking intervention, presenting a teachable moment when motivation

for cure and prevention of further disease is heightened. Head and neck

surgeons and maxillofacial prosthodontists who treat this cancer patient

population have not previously been involved in smoking cessation research,

so there is an opportunity to extend training into new areas of specialty.

The study described here is part of the UCLA Cancer Control Science

Program, a program project grant with the theme of enhancing adherence to

cancer control regimens. Recently completed, the prospective, randomized

trial developed, implemented, and evaluated a provider-delivered smoking

cessation intervention for patients with head and neck cancers (Gritz et al.,

1990 and 1991a). The main goal of the study was to compare the smoking cessation rates of treatment and control groups at 1 year after the

intervention.

2 This research was conducted with support from National Cancer Institute grant number CA-43461.
Smoking and Tobacco Control Monograph No. 5

260

The study intervention was designed to maximize the likelihood of

behavioral change as a result of the cancer diagnosis and treatment and to

capitalize on doctor-patient bonding to reinforce and sustain the smoking

cessation effort (Becker, 1974; Burling et al., 1984; Burt et al., 1974). The

structure and components of the study intervention were modeled after

methods established as effective in NCI-sponsored physician smoking

cessation trials (Glynn and Manley, 1990). Delivering personalized, faceto-face advice in multiple interactions and using multiple intervention

modalities (e.g., a target quit-date contract signed by both provider and

patient, in addition to repeated advice) comprised the most successful

components of smoking cessation interventions in medical practice (Kottke

et al., 1988). In addition to patient behavior, the provider’s own beliefs and

attitudes, smoking status, motivation and efforts in patient counseling, and

adherence to the cessation protocol were important influences on outcome

(American Cancer Society, 1981; Ewart et al., 1983). The current study

assessed these provider beliefs and behaviors and, through a standardized

training module, attempted to develop, enhance, and sustain effective

provider counseling skills.

TARGET Providers in this study consisted of 103 head and neck surgeons and

AUDIENCE 7 maxillofacial prosthodontists (26 attending physicians and 84 residents).

Subjects were accrued from 10 clinics at participating southern California sites:

3 university hospitals (including both the head and neck and the maxillofacial

clinics at UCLA, the main site); 3 Veterans Administration Medical Centers;

2 Los Angeles County hospitals; 1 health maintenance organization; and

1 armed services hospital.

PRACTICE A total of 389 eligibility checklists were completed on patients with

OR CLINICAL newly diagnosed squamous cell carcinomas of the head and neck.

SETTING The study sites represented a broad spectrum of facilities providing

surgical and followup care to this patient population in the southern

California region.

Study subjects had varying treatment regimens that entailed medical

care by multiple providers—head and neck surgeons, maxillofacial

prosthodontists, and radiation oncologists—in as many different clinics.

The three most typical paradigms for treatment were surgery only, surgery

followed by radiation therapy, and radiation therapy only. Subjects were

also seen by different providers within the same clinic, particularly at

university and VA hospitals. Much of the subjects’ care was provided

by residents under the supervision and guidance of attending physicians.

RECRUITMENT Patients older than 18 with newly diagnosed squamous cell carcinoOF PATIENTS mas of the head and neck were eligible for the study. Participating

providers completed an eligibility checklist on each patient to determine

whether a second tier of enrollment criteria was met: (1) life expectancy of

more than 1 year; (2) tobacco use within the past year; (3) absence of gross
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Chapter 4

psychopathology; (4) medical followup by local providers; (5) ability to speak

and read English; and (6) agreement to undergo treatment.

Study interviewers reviewed medical records and operating room schedules and attended morning rounds and tumor conferences to ensure that all

eligible patients were identified. After confirming a diagnosis of squamous

cell carcinoma, providers introduced the study to eligible patients. All patients

willing to participate were contacted by a study interviewer, who arranged a

baseline interview prior to the start of medical treatment. Patients provided

written, informed consent to participate in the project at the start of the

baseline interview.

Approximately 57 percent of the 389 patients with newly diagnosed

squamous cell carcinomas of the head and neck identified were eligible for

enrollment (n=221), and 84.2 percent of those were randomized (n=186).

Not using tobacco in the 12 months preceding diagnosis was the predominant

basis for exclusion from enrollment, accounting for 57.1 percent (n=96) of

the 168 ineligible patients. Sixty-three (65.6 percent) of these 96 ineligible

patients had stopped smoking more than 1 year prior to diagnosis, and the

remaining 33 (34.4 percent) were classified as nonsmokers. The smoking

histories of seven of the latter were unknown, and so they were conservatively

assumed to be nonsmokers. Thus, the overall rate of current tobacco use

among both eligible and ineligible subjects was 75.3 percent (n=293), and

the overall rate of ever-use of tobacco was 91.5 percent (n=356).

The 186 randomized patients were predominantly male (73.7 percent)

and in the sixth decade of life or older (average age was 58.5 years). Whites

constituted 72.6 percent of the sample; 18.8 percent were black, 6.5 percent

Latino, 1.1 percent Asian, and 1.0 percent other. Approximately one-third

of subjects (33.9 percent) had not completed high school; 14 percent were

college graduates. Although 57.8 percent had an annual family income

under $15,000, 17.3 percent fell into the $40,000-and-over category. Finally,

51 percent were married or living with someone.

The primary site of disease was the oral cavity or pharynx for 60.9 percent

and the larynx for 39.1 percent of patients. At diagnosis, 31.1 percent had

early stage disease (stages I and II). Total laryngectomies were performed on

24.7 percent of patients; 28.5 percent were treated with radiation only; and

46.8 percent had surgery other than total laryngectomy (which was followed

by radiation in some cases).

At diagnosis, 12 percent of patients were former smokers (had quit 1 to

11 months earlier) and 88 percent were current smokers (had smoked within

the past month). Overall, this was a moderately addicted group of long-term,

heavy smokers; they had been smoking an average of 39.7 years and had a

mean score on the Fagerstrom tolerance scale of 6.6 (11 maximum).
Smoking and Tobacco Control Monograph No. 5

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PROTOCOL The research protocol defined delivery of smoking cessation advice

FOR ADVICE in both usual care and experimental intervention conditions. As

Table 4 shows, there was a range of conditions in which advice (initial

advice to stop smoking, initial advice to maintain abstinence, or booster

session advice) was given. Algorithms were developed for delivery of advice

in each condition. Each of these advice algorithms, detailed in Appendix B,

could be completed in the course of a provider-patient discussion lasting

approximately 7 minutes. Providers learned and practiced delivering advice

(see “Nature of the Training Program,” below).

Initial advice was delivered to surgical patients 2 to 3 days prior to hospital

discharge and to radiation patients prior to the start of treatment by attending

(faculty) and chief resident physicians and dentists.

The usual care condition consisted solely of the delivery of the standardized

usual care initial advice—risks of smoking behavior and benefits of cessation

during continuing medical care. Providers were told to follow their usual

practices.

The experimental intervention was designed to be integrated into regular

medical care, as well. The initial advice session, as in usual care, consisted

of standardized, strong advice to quit smoking. This advice was enhanced

by greater interaction in determining the patient’s receptivity to attempting

cessation; expressing confidence in the patient’s ability to stop; discussing

craving and the withdrawal syndrome; negotiating the target quit date and

joining the patient in signing the written contract; and assuring the patient of

ongoing support for smoking cessation during treatment and followup care

(Appendix B). The initial advice was further reinforced with targeted, written,

self-help and social support materials for the patient and spouse or caregiver,

and the formal smoking cessation contract (see “Products of the Project,”

below). For the first year after treatment, head and neck cancer patients return

monthly for followup visits. Six monthly booster sessions for smoking cessation were administered during these followup medical appointments. In

addition, six postcards with smoking cessation maintenance tips were mailed

monthly to intervention subjects from the office of their provider.

Table 4

Classification of smoking cessation advice sessions

Initial Advice Booster Sessions

(All Patients) (Intervention Patients Only)

Current and former smokers—usual care group Abstainers and slippers

Current smokers—intervention group New relapsers (since last visit)

Former smokers—intervention group Reduced- and full-consumption

smokers
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NATURE OF Training was conducted at the provider’s site, often as part of a

THE TRAINING tumor conference. Providers included faculty and house staff.

PROGRAM Training was conducted in a single 2-hour session and included

a baseline questionnaire, a didactic presentation about the study, a videotape

of advice, and role-playing. Training began with administration of a baseline

questionnaire eliciting providers’ knowledge, attitudes, and beliefs about

smoking behavior (their own and patients’) and about smoking cessation

in head and neck cancer patients. Behavioral and pharmacological aspects

of tobacco dependence, study aims, and the methodology of the randomized

trial were then explained. Providers were encouraged to ask questions about

their individual roles and theoretical and methodological aspects of the

study, or to express concerns about implementation of the research protocol

at their facility.

To become familiar with the contents of the smoking cessation advice

that was to be delivered in usual care and experimental intervention conditions, providers were shown videotaped vignettes in which a surgeon delivers

smoking cessation advice across the range of conditions. The videotapes

were constructed to be direct models for providers to replicate, exemplifying

application of an algorithm to each advice condition. Algorithm outlines

preceded and followed each vignette on the videotape.

After the videotaped vignettes were shown, printed advice algorithms

were distributed, and providers were asked to break into dyads for role-play

of delivery of advice to “patients” (see Appendix B for usual care and experimental, advice-giving algorithms). Each dyad member was asked to enact the

role of both provider and patient, in turn, giving and receiving advice in as

many conditions as possible. Although a few providers were initially hesitant

to engage in the unfamiliar task of role-play, nearly all became engaged in

the process quite rapidly. Project staff members observed the dyads and

provided feedback. Training concluded with a discussion of the role-play,

involving all providers and offering an opportunity to raise final questions.

Additional training sessions were conducted for new residents, typically

at 1-year intervals. Continual monitoring of audiotaped provider-patient

interactions allowed the research staff to identify providers who needed

brushup training. Such supplemental training was also provided on rare

occasions when providers themselves requested it.

SPECIAL RESOURCES Creation of training videotapes required special resources.

AND PROCEDURES Preproduction work consisted of scripting, casting and

recruitment, and rehearsal. For the sake of simplicity,

Videotapes economy, and the intended feeling of the video vignettes

(realistic yet light), it was desirable to have a considerable amount of improvisation. To this end, no formal scripts were created. Instead, advice algorithms were used as the basis for improvising vignettes spanning the range

of advice conditions. This approach simplified rehearsals and ensured that

video vignettes were faithful to what providers themselves would do when
Smoking and Tobacco Control Monograph No. 5

264

delivering advice to real patients: express themselves as naturally as possible

while following a particular advice algorithm.

Casting required one provider and a small number of persons willing

to role-play patients. Real patients were not used because of logistical complications—contacting them, screening for suitability, obtaining consent—

and because of the ready availability of research staff and other volunteers.

The director of the university video laboratory was enthusiastic about playing

a patient and was extremely supportive and helpful in producing the tape.

Other “patients” were recruited from the project staff. The provider delivering advice on the videotape is a UCLA faculty member and a colleague of

many providers at other study sites. He was selected because of his demeanor

and his interest in the project.

All six vignettes were taped in one 3-hour session. Editing was done

by university video lab staff in consultation with the research team.

Videographics displaying algorithm outlines were inserted before and

after each vignette.

Guidelines Special procedures were aimed primarily at making it easy for

And Reminders providers to implement their tasks with patients and/or to assure

For Advice that they did so in accordance with requirements of the study.

Provider training has already been described. Providers were encouraged

to keep copies of advice algorithms. Self-help booklets (described below)

relieved providers of any need for detailed knowledge of quitting or abstinence strategies. Special stickers were designed and printed, and these were

placed on the covers of hospital charts of participating patients. Project staff

members reminded providers immediately before and during clinics about

which patients required advice. Providers were also reminded when telephone boosters were required. Provider-patient interviews were audiotaped

for several reasons: (1) to provide documentation that providers were

actually giving advice according to protocol (e.g., to document that intervention advice was not contaminating usual care); (2) to ensure that providers experienced a degree of motivation-accountability in their advice-giving

(especially useful with residents); and (3) as noted above, to allow the

research staff to identify providers who were in need of brushup training.

Patient Special procedures were also required to follow some research subjects.

Tracking Some patients, especially those living out of state, and those in low

socioeconomic groups, had addresses that were difficult to obtain (or that

frequently changed) or had no phones and were otherwise difficult to track,

contact, and interview. Project interviewers developed impressive persistence

and ingenuity in obtaining data from these patients.

PRODUCTS The components of the smoking cessation intervention are designed to

OF THE be individually and collectively exportable. The components include

PROJECT standardized, strong advice to stop smoking; targeted, written, self-help

and social support materials; a contracted quit date; booster advice sessions;

and postcards with maintenance tips. Written materials include three
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booklets: the first for stopping smoking (Team Up To Stop Smoking); the

second for maintaining abstinence (Team Up To Stay Off); and the third a

social support booklet for the patient’s spouse, family member, or other

caretaker (Team Up To Help a Friend).

The booklets are written specifically for head and neck cancer patients

and contain smoking cessation information that takes into account patients’

medical, physical, and psychological condition. The two smoking cessation

booklets feature illustrated descriptions of the connection between patients’

smoking and their cancers; the value of quitting and special opportunity to

quit now; simple, direct instructions on how to stop smoking; information

about coping with high-risk situations for relapse; a discussion of alcohol use

and the relapse risk associated with drinking; and a supportive discussion of

the stress that smoking cessation creates for the patient. The social support

booklet, directed to patients’ significant others, describes effective strategies

to aid the patients in their effort to stop smoking and stay off cigarettes.

These materials are grounded in the premise that, during this critical

period of cancer treatment and recuperation, positive social support must

be delivered to the patient in a variety of interpersonal contexts in which

smoking is likely to occur. Psychological issues relating to head and neck

cancer and disturbances of affect and physical functioning are empathically

addressed.

The stop-smoking and stay-quit contract is printed on an official-looking

document. It consists of a pledge to quit or stay off cigarettes as of an agreedon date and spaces for both the patient’s and the provider’s signatures, and it

is embossed with two hands clasped in a symbolic gesture of support between

the provider and patient. The contract is a three-part, no-carbon-required

form, with one copy each for the patient, the provider, and the study staff.

The six monthly postcards, which give tips for stopping smoking and

maintaining abstinence, are signed by a member of the provider’s staff.

The postcards are mailed in conjunction with monthly booster sessions.

The training videotape described above is completely self-explanatory and

could be used in any medical or dental setting where patients with head and

neck cancers are treated. It is 30 minutes long but can be shown in segments

consisting of the initial advice session and the three types of followup sessions (abstinence, relapse, and continuing smoker).

BARRIERS A number of unanticipated administrative, provider, and subject

AND PROBLEMS barriers prevented easy implementation of the protocol. AdminisOVERCOME trative barriers included the lack of participation by radiation

oncologists and difficulty in maintaining continuity of care. The protocol

originally was designed to include radiation oncologists among the providers.

Resistance to participation was encountered at two sites, principally because

of infrequent contact between radiation oncologist and patient and the

lack of regular followup once radiation therapy is completed. Therefore,
Smoking and Tobacco Control Monograph No. 5

266

the protocol was adapted to have smoking cessation advice delivered to

radiation-only patients by the referring surgeon or, when appropriate, by a

participating dentist.

Continuity of care is frequently a problem in tertiary care facilities.

Patients are often treated or followed concurrently by multiple providers,

including head and neck surgeons, radiation oncologists, and maxillofacial

prosthodontists. As a consequence of resident rotations, VA patients and

clinic patients at university hospitals frequently have multiple providers

within the same clinic as well. Thus, the provider-patient bond becomes

more tenuous than in a private-practice setting. In our study, this was

disadvantageous because provider-patient bonding was hypothesized to be

important for maximizing the impact of the smoking cessation intervention.

Although study providers as a group were very helpful, a few were not

willing to follow the research protocol closely. Contrary to protocol, some

attending physicians wanted to routinely delegate advice-giving to residents

and necessary paperwork to project interviewers. Persistent explanations

of the rationale for these aspects of the protocol were helpful with those

providers. Surgical residents are oriented primarily toward learning complex

operating techniques and amassing experience with disease diagnosis and

treatment. Because of the psychosocial nature of this study, it was often

perceived as their lowest priority. Thus, constant supportive urging by

attending physicians and study staff was necessary.

Patient adherence to trial procedures exceeded our expectations. In

addition to participating in advice-delivery sessions, patients were interviewed at baseline and at 1, 6, and 12 months after the initial advice session.

Surviving patients then participated in annual interviews thereafter. However, there was a small segment of subjects who were very difficult to follow.

The reasons included mobility, mostly among the Veterans Administration

patients; homelessness, applying not only to VA but also to county hospital

subjects; and family interference. Occasionally, relatives on whom the

subjects were dependent, either for communication (because they were

speech impaired) or for transportation, thwarted access to the subjects such

that further participation was precluded. It was difficult to discern, in these

situations, how closely the protectiveness of relatives reflected a subject’s lack

of interest in study participation.

WHAT WORKED The study staff made every effort to understand thoroughly the

AND WHY timing, implications, and impact of medical treatment delivered

to head and neck cancer patients. Project staff members attended

Understanding rounds and tumor conferences to become immersed in the providThe Milieu ers’ milieu; tracked patient movement from clinic entry (and from

previous physician referral, when appropriate) through treatment and

followup; and interviewed patients, providers, and staff at participating

clinics. These activities facilitated the design of an intervention that was

easily integrated into standard medical care, as well as tailoring the smoking
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Chapter 4

cessation materials to the needs and concerns of head and neck cancer

patients.

Two important adjustments to the intervention were made because

of this groundwork. First, the timing of the smoking cessation advice was

moved from the second clinic appointment, usually when patients were

informed of their cancer diagnosis, to 2 or 3 days prior to hospital discharge

for surgical patients. After being informed of their cancer diagnosis, most

patients were so absorbed in their cognitive and emotional efforts to begin

to cope with their situation that they were unable to assimilate smoking

cessation advice. As a part of standard care, surgeons warned all of their

patients of complications that can result from continuing to smoke prior to

anesthesia. Most patients stopped smoking, at least briefly, for that reason,

or because of hospital policy. When they had recovered sufficiently from

their surgery and were ready to leave the nonsmoking hospitals, patients

were able to attend to long-term concerns, including smoking cessation

and its health implications.

Second, patients receiving radiation therapy as the initial treatment

modality were often not seen by their primary surgical provider for at least

6 weeks. This could have allowed those patients to return to their routines,

including smoking, without the benefit of smoking cessation advice. Thus,

the advice was delivered to these patients prior to the first radiation therapy

appointment.

Quality Study interviewers took many precautions to ensure that all head and

Control neck cancer patients with newly diagnosed squamous cell carcinomas

were identified as potential subjects. They attended tumor conferences and

hospital rounds; reviewed operating room schedules for types of surgery

that are specific to head and neck cancer; checked medical records of clinic

patients; and maintained as much of a presence as possible in the participating clinics. Although the protocol called for providers to identify eligible

patients through eligibility checklists, the research staff often assumed the

responsibility for screening clinic records of new patients and completing

the checklists in consultation with physicians. Additional paperwork was

deemed burdensome to the providers.

Delivery of control and intervention advice by participating providers

was persistently monitored to ensure protocol adherence and to prevent

subject contamination. First, a subject’s file was marked with a sticker once

he or she was randomized. Second, intervention materials (including advice

guidelines, three smoking cessation booklets, and a quit-smoking/stay-off

contract) were presented by a staff interviewer to each provider just prior to

delivery of intervention advice. Third, providers were asked to audiotape the

delivery of initial advice in both conditions and the delivery of the intervention booster sessions. The study staff reviewed the tapes for adherence to the

advice guidelines and gave feedback to providers. Finally, all subjects were

asked to complete exit checklists after the initial advice was delivered.
Smoking and Tobacco Control Monograph No. 5

268

Provider Training Perhaps the single most important factor predisposing to

And Involvement success in provider involvement was the leadership role taken

by the Chief of Head and Neck Surgery and the Chief of Maxillofacial

Prosthodontics at UCLA. Although participation in this research was

technically not required of all faculty and residents, the enthusiastic support

and continuous encouragement of those two prominent clinicians clearly

facilitated acceptance and support of the study. Without the sponsorship

and collegial stance taken by those two individuals, the project probably

would not have sustained the involvement and interest of the other providers. It is noteworthy in this regard that not a single surgeon or dentist

(faculty or resident) refused to participate in the trial.

Success with respect to provider involvement included several additional

dimensions: suitability of intervention and supplementary materials to the

clinical environment; education of providers with respect to behavioral

research strategies and designs (which may differ significantly from biomedical research strategies); receptivity of providers to training in delivery of

smoking cessation interventions; and motivation of providers to follow

research guidelines in implementing the experimental smoking cessation

intervention and the usual care condition.

As described earlier, providers were trained to deliver a cogent smoking

cessation message (Appendix B) in a timeframe quite compatible with a

typical provider-patient interaction, usually 7 minutes or less. Dispensing

supplementary materials (contract, booklets, and postcards) proved to be

easy and required little time.

Education of providers included orientation to the overall research

strategy and to providers’ roles and tasks. Providers responded well to

training sessions, often participating energetically in the dyadic role-plays.

Responses to questionnaires administered during training sessions indicated

that providers were well aware of the morbidity associated with patients’

continued use of tobacco. Providers saw themselves as important and practical sources of advice to quit smoking.

Provider behavior after training was generally consistent with the impression that they were motivated to assist patients’ smoking cessation efforts

and to conform to the requirements of the research protocol. The house

staff and attending surgeons and dentists worked cooperatively with research

staff, integrating aspects of the protocol with their clinical routines. Tape

recordings of control and experimental interventions indicated that providers succeeded in avoiding contamination across conditions. This was particularly important because the design of the study required all providers to

administer both types of intervention (only patients were randomized).

Overall it seems clear that, in the context of a sharply and economically

presented rationale and training, and when equipped with appropriately

designed materials, even very busy providers will function effectively as

sources of a behavioral intervention in smoking cessation research.
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Patient Experience gained in this trial suggests that intervention with head

Participation and neck carcinoma patients, a potentially difficult patient population

(with long-term histories of tobacco and alcohol use), is quite feasible.

Nearly 85 percent of eligible patients were successfully enrolled. The patients

proved to be cooperative participants, even during periods of illness and

hospitalization, in this long-term research effort. As an example of the

altruism expressed by many patients, about 10 participation checks were

returned with explicit directions to donate the funds to the research study.

WHAT DID Provider training required more time than the physicians and dentists

NOT WORK wanted to devote to that activity. Multiple training sessions were

AND WHY necessary at some sites because large numbers of providers were unable

to attend preplanned sessions, even though these coincided with tumor

conferences. Future training sessions should be shorter and more compatible

with provider schedules.

Booster sessions and followup interviews were timed to coincide with

medical followups to minimize subject burden. Frequently, the standardized

scheduling was not maintained, and study interviewers had to adjust

followup schedules accordingly. It was desired that all patients receive

smoking cessation advice at designated times, that is, a fully standardized

intervention. However, diversity of treatment regimens and nonstandardized

medical followup required that flexible scheduling and telephone boosters be

introduced into the protocol. Thus, it proved difficult to maintain the

planned schedule for booster sessions. Telephone boosters were instituted

to ameliorate the problem, especially for radiation patients who were also

being treated by the dentists. Providers were asked to limit the number of

telephone boosters to two of the six prescribed sessions.

WHAT WOULD This section discusses how the current research paradigm would

BE DONE be adapted to a nonresearch, clinical environment. Modifications

DIFFERENTLY fall into two categories: (1) the physician and dentist training and

NOW counseling role, and (2) the patient intervention.

The importance of support from the most senior and powerful clinicians

(“top down”) has been discussed, but it was important also to engage cooperation from the interns and residents on the medical-dental teams

(“bottom up”). The latter, young physicians and dentists, were responsible

for delivering much of the counseling. They had to be convinced of the

intervention’s importance (both biomedically and behaviorally), of their own

effectiveness (self-efficacy), and of the value of acquiring such skills in their

surgical or dental residency (rather than detracting from their development

of operating technique or basic scientific research).

In the present study, providers’ cooperation was won with time and

the repeated exhortation and example of the senior clinicians. Counseling

skills should be framed as valuable contributions to well-rounded dental and

surgical training during the training session. As one of the division chiefs

often states, “We want to be physicians as well as surgeons.”
Smoking and Tobacco Control Monograph No. 5

270

Head and neck surgeons and maxillofacial prosthodontists are extremely

busy clinicians who, in hospital settings, see many patients in the course of

half-day clinics. Thus, the fact that the counseling interventions were timelimited (7 minutes or less, on the average) was very appealing. However,

paperwork, such as determining patient eligibility for the intervention,

tracking smoking status, remembering to schedule return appointments,

and sending reminder postcards, was perceived as too burdensome. Nurses

or medical clerks could easily assume these tasks. Second, compressing

training sessions into a single hour, as was done eventually out of necessity,

fits the tumor conference paradigm better than the original 2-hour structure.

Repeated and individual review of counseling algorithms, as appropriate

patient interviews arose, led to better provider retention and performance.

Finally, the number and spacing of booster advice sessions can easily be

accommodated to the actual scheduling of medical or dental followup

appointments and need not occur on a set monthly basis for 6 months.

The patient intervention would benefit from several modifications.

The first involves emphasizing the usefulness and importance of the targeted

self-help booklets. Patients tended to dissociate the receipt of these materials

during their time as inpatients from their home recovery activities, which

was certainly not the intent of the intervention. For example, it is unclear

how many significant others ever received the third item, the social support

booklet. It would be better for clinicians to be certain to hand the booklet

directly to a family member or caretaker and to deliver the advice and the

two patient booklets in the presence of that support person.

Consequent to initial advice, booklets should be actively used in booster

sessions. Mailed followup support material, such as postcards, should be

tailored to the patient’s current smoking status so as to be maximally relevant and personalized. The intervention developed in this study was

designed with the direct collaboration of clinicians, specifically with these

providers and their patients in mind. Because of this close working relationship, relatively few modifications would be required for a generalized dissemination of the intervention.

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Becker, M.H. The health belief model and sick role

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Burling, T.A., Singleton, E.G., Bigelow, G.E., Baile, W.F.,

Gottlieb, S.H. Smoking following myocardial

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Burt, A., Thornley, P., Illingworth, D., White, P.,

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Ewart, C.K., Li, V.C., Coates, T.J. Increasing

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Glynn, T.J., Manley, M.W. How To Help Your Patients

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Smoking and Tobacco Control Monograph No. 5

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Medical Advice as a Communication

About Risks of Smoking and

Benefits of Quitting

Laura C. Leviton, Timothy R. Cline, and Saul Shiffman

INTRODUCTION To gain maximum effect from medical advice to quit smoking,

it is important to understand the process by which medical advice causes

smokers to consider cessation and to take actions to quit (Evans, 1986).

A medical or dental professional’s advice to quit can provide motivation,

whereas an intervention (on-site counseling, referrals to other resources)

can provide the patient with tools and skills to quit. A study sponsored by

the National Cancer Institute is focusing on three elements of this process:

making the health risks personal, emphasizing the benefits of quitting, and

increasing patients’ perceptions that they are capable of quitting. Although

other aspects of medical advice may also facilitate smoking cessation, these

seem to be key aspects.

PURPOSE The project was implemented in a rural area of Pennsylvania and origiOF THE nated as an effort to provide a service to a cohort of former chemical

PROJECT workers who have been exposed to a bladder carcinogen (Leviton et al.,

1991; Marsh et al., 1991). Because of the chemical workers’ increased risk

of bladder cancer, both the risks of smoking and benefits of quitting are

greater for these smokers than they are for smokers in the general population. However, the workers were not uniformly aware of this fact before

the study started.

Access to the cohort members presented an important opportunity to

study the combined effects of several forces. Medical or dental advice in this

context should have greater importance for patients because the professional

is giving essential information about patients’ personal risk for smokingrelated disease, in combination with information about patients’ self-efficacy,

or their ability to quit smoking and thus avoid disease. Although the

cohort’s situation is unique, the same kinds of intervention could be given

by medical and dental professionals to different kinds of smokers who run

increased risk of disease because of the combination of smoking and other

factors.

The major outcome measure in this study is not smoking cessation but

progress toward smoking cessation (Horn, 1976; Leventhal and Cleary, 1980;

Pechacek and Danaher, 1979). Even when medical advice does not lead to

immediate smoking cessation, it may well lead to progress along the road to

quitting and may help to tip the balance in favor of quitting. In fact, the

guidelines provided by NCI explicitly tailor medical advice about smoking
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Chapter 4

cessation to the smoker’s stage of self-change. Smokers proceed through at

least five such stages: (1) precontemplation, in which they do not seriously

consider quitting and or even give it much thought; (2) contemplation, in

which they begin to consider quitting; (3) short-term quitting, in which

smokers have recently quit but may yet relapse; (4) relapse, in which quitters

have returned to smoking but may try cessation again; and (5) long-term

maintenance of cessation (DiClemente, 1986; DiClemente and Prochaska,

1985; DiClemente et al., 1985; Prochaska et al., 1988). In recent research,

a preparation stage is added, in which smokers are getting ready to take

action (Prochaska et al., 1992).

The project differs from the larger studies in this volume, in that it was

mounted to test several hypotheses about health professionals’ advice. The

authors predict that advice to quit has different effects on progress toward

quitting, depending on the participants’ level of health risk attributable to

smoking and the way in which each smoker interprets risks and benefits.

The level of risk is varied through comparison of smokers at high risk of

bladder cancer because of occupational exposure with other smokers residing

in the same area who are at relatively low risk. The interpretation of the risks

and benefits is varied through different types of counseling for smokers, one

of which is aimed at increasing self-efficacy, that is, improving the smokers’

perceptions that they are capable of quitting.

Hypothesis 1 The investigators predict that a medical professional’s advice will,

on average, lead to greater progress toward cessation among high-risk

smokers than among smokers at lower risk. Health messages that imply

greater danger are generally more effective in changing behavior and attitudes than messages that do not (Leventhal, 1970; Sutton, 1982). However,

when people know they are vulnerable to a health threat, various negative

reactions can result (Leventhal and Watts, 1966). The health message may

induce feelings of helplessness, anger, and other reactions that impede the

adoption of healthful behavior (Leventhal et al., 1980). Such reactions are

likely to impede progress through the stages of smoking cessation. Smokers

may be less likely to seek out new information on quitting or to take actions

to quit. People perceive themselves to be vulnerable to cancer and other

smoking-related diseases for many reasons. A secondary goal of this project

is to discover whether any negative effects of medical advice emerge,

especially for smokers at higher risk, and how those might be avoided.

High-risk smokers are more likely than others to feel vulnerable to

disease. Although high-risk smokers are more likely than others to quit after

receiving medical advice, most of them do not do so (Burt et al., 1974;

Pechacek, 1979; Pederson, 1982; Rose and Hamilton, 1978). Some of them

may be defeated by barriers such as nicotine addiction, but others may not

even try to quit or think about quitting. The more sensitive measures of

progress toward smoking cessation can give us this information.
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Hypothesis 2 Second, the investigators predict that, although smokers may not

progress all the way to long-term quitting, medical or dental advice to quit

will move them along in the process. Medical advice can move smokers

from precontemplation to contemplation of quitting by encouraging a

reevaluation of personal health risks and benefits of quitting. If high-risk

smokers start to contemplate quitting, the perceived benefits of quitting

will be greater than those for smokers at lower risk, and therefore high-risk

smokers are more likely to decide to quit.

Medical advice can also assist in moving the smoker from contemplation

to action by providing a rationale or motivation to act (Rogers, 1975). If

high-risk smokers have reached the stage of action, they have greater motivation and a stronger rationale for quitting (Leventhal et al., 1980; Rogers,

1975; Sutton, 1982).

Setting a quit date and providing nicotine gum give the smoker cues to

action (Eraker et al., 1985). Whether the smoker quits for the long term or

relapses depends less on medical advice, as such, and more on factors such as

the development of coping skills (Shiffman, 1985) and overcoming nicotine

addiction (Fagerstrom, 1982). In the medical and dental practice settings,

advice to quit can be followed by counseling on these factors.

Hypothesis 3 Third, the investigators predict that smokers who receive self-efficacy

counseling will make greater progress toward cessation than those who

do not receive such counseling. The latest generation of medical advice

protocols often includes efforts to increase self-efficacy (e.g., Janz et al.,

1987). Self-efficacy has been found to be an important predictor of lifestyle

changes in general (Bandura, 1990b) and of smoking cessation in particular

(DiClemente, 1986; Prochaska et al., 1985). Most important, research has

revealed that it is possible to instill greater perceived self-efficacy through

counseling in a variety of settings (Bandura, 1990a and 1990b; Gilchrist and

Schinke, 1983; Maddux and Stanley, 1986).

TARGET The study is being conducted in a 50-mile radius around Lock Haven,

AUDIENCE Pennsylvania, a community of approximately 12,000 people in the

Allegheny Mountains of rural north central Pennsylvania. Two groups

participated: former chemical workers at high risk of bladder cancer and

similar smokers, resident in the same area, who are at lower risk of bladder

cancer. The former chemical workers participate in a program sponsored

jointly by the National Institute on Occupational Safety and Health, the

Agency for Toxic Substances and Disease Registry, and the Pennsylvania

Department of Health. The plant at which these workers were exposed

began operation in 1944 and went bankrupt in 1981. The workers come

to the Lock Haven Hospital for screening at least once per year, more

often if screening reveals a suspicious or positive result. As of this writing,

82 percent of the living cohort members have enrolled in screening and

more than 90 percent have returned for repeat screening (Marsh et al., 1991).
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The workers were exposed to beta-naphthylamine (BNA), one of the

most powerful chemical carcinogens. The resulting increased risk of bladder

cancer, which persists for many years after exposure, ranges up to 87 times the

risk in the general population (Case et al., 1954; Schulte et al., 1985). Preliminary evidence suggests that smoking and BNA exposure have a multiplicative

effect on risk (Schulte et al., 1985). Quitting smoking would presumably

lower future risk for developing bladder cancer, regardless of the relation

to BNA.

More than 80 percent of the former workers still reside within a

50-mile radius of Lock Haven. Of these, 48 percent are current smokers,

and 68 percent have a high school education or less. The majority are bluecollar workers and have lived in rural communities most of their lives. As

with the rest of the community, they generally have little interest in quitting

smoking.

The project recruited smokers at lower risk who were similar in background to the worker cohort members through visits to 14 blue-collar

worksites. The coordinator of the screening program approached the

worksites and convinced management to offer the intervention on site.

Workers signed up for appointments on specific days.

SETTING OF Medical advice and counseling components were provided in two

THE STUDY settings: at a small hospital in Lock Haven and at 14 worksites in

the same general area. The hospital is the setting for the bladder cancer

screening program for the former chemical workers. Worksites at which

lower risk smokers were recruited included roadwork and home construction

sites and a variety of factories and mills. The entire team, including the

medical professional, clinic coordinator, interviewer, and counselor, visited

the sites on given days. Intervention took place in areas set aside for that

purpose, and workers signed up for prearranged times to receive advice and

counseling.

Medical advice was provided by three physicians and one respiratory

therapist. Their participation was based on their availability at the time of

the participants’ appointments. A respiratory therapist was included to

increase the investigators’ flexibility in implementing the study, and because

her expertise in smoking-related disease carried some professional authority

that was somewhat similar to that of the physicians. An important element

for the analysis of outcomes will be to compare participants who received

advice from physicians with those who received advice from the respiratory

therapist, to examine whether professional identification made a difference.

Counselors included an elementary school teacher trained in the American Lung Association’s smoking cessation program, a social worker, and four

psychology students from the nearby college. In this rural area, professional

cessation counselors were not available; however, all counselors participating

in the study were carefully trained and supervised by an experienced smoking
Smoking and Tobacco Control Monograph No. 5

276

cessation counselor. We believe that the diversity of counselors is a strength

of the counseling intervention. If individuals with minimal experience can

be trained to administer self-efficacy intervention, the method is more easily

transportable to medical settings in the community.

Training of the counselors was done in several stages. The supervisor

conducted all training from his base in Pittsburgh during the course of five

visits to Lock Haven. The initial orientation to the counseling sessions was

geared to changing the counselors’ mindset about counseling. All of the

counselors had been taught that counseling meant giving an individual whatever he or she needed to assist the process. However, it was necessary to make

the distinction between such counseling and adherence to a research protocol

based on certain prescribed methods—in this case, a focus on enhancing selfefficacy, or an attention placebo. The trainer pointed out to counselors that

departures from the self-efficacy material would actually dilute the expected

effects of intervention.

The concept of self-efficacy was presented to the counselors and discussed

at length. They were introduced to the sequence of steps in the counseling

session (see below). Finally, the trainer and counselors role-played the various

counseling protocols. They role-played both the counselor and the smoker

being counseled.

Counselors then practiced the self-efficacy intervention on friends who

smoked, and they tape-recorded the sessions. The tapes were then mailed to

the trainer and were brought into the next training session for group supervision and feedback. When the trainer and the counselors were confident that

they had mastered the counseling method, each trainee counseled a pilot

participant, and the sessions were videotaped. The group of counselors

then critiqued the videotapes, together with the supervisor.

When they were judged to be proficient in the counseling protocols,

the trainees began counseling the study participants. Each session was taperecorded and mailed to Pittsburgh. The supervisor monitored the recordings

to guard against departures from the protocol. When necessary, the supervisor

telephoned the counselors to point out departures from the protocol or to

point to missed opportunities to reinforce participants’ feelings of self-efficacy.

RECRUITMENT From the start, the project team was aware of the difficulty of

PROCEDURE generating interest in smoking cessation among little-educated,

AND RESULTS rural, blue-collar workers. Recruitment yielded 255 current smokers,

short of the project’s goal of 300. Participants were 75.1 percent men and

24.9 percent women. The mean age of participants was 42 years, and mean

of education was 12.7 years. Married participants constituted 74.5 percent

of the sample.

For the former chemical workers (higher risk smokers), medical advice

and counseling were to be given at the time of their screening for bladder

cancer. However, many were not interested in hearing what a medical
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Chapter 4

professional had to say about smoking. Although the coordinator of the

bladder cancer screening program had developed good relationships with the

workers and had successfully recruited them into bladder cancer screening,

her efforts to recruit them into a smoking cessation intervention were less

successful. We projected that 108 of the workers residing in the area would

take part; of these, 43 men participated in the smoking intervention. At

various worksites we recruited 5 additional men who had been exposed to

BNA at another nearby plant, accruing a total of 48 smokers at higher risk of

bladder cancer. The remaining 207 participants, or 81.6 percent, were

smokers at lower risk of bladder cancer than the chemical workers.

There may be several explanations for the meager participation among

the worker cohort. To be in the study, workers had to sign a separate consent

form, which provided them with an opportunity to say no to the project.

Although the screening program gets good participation, it still requires

effort from the screening coordinator to cajole the workers into getting their

repeat screenings. In many cases, the screening coordinator was fairly sure

she would lose a worker from the screening program if she pushed too hard

for the smoking program.

This project was less successful in recruiting precontemplators than

in recruiting smokers at the stages of contemplation or action. Because

precontemplators do not choose to expose themselves to information about

the dangers of smoking and benefits of quitting—for example, to listen to

what a medical professional has to say—it is likely that they would refuse to

participate. A higher percentage of precontemplators might be encountered

in usual medical and dental practice settings because all smokers visiting the

setting can be exposed to such advice, whether or not they choose to participate in a study. The dentist or physician has a foot in the door already.

In surveys of the general population, a fairly large percentage of

smokers are at the stage of precontemplation. Prochaska and colleagues

found that, across studies and populations, 50 to 60 percent of smokers

are precontemplators, 30 to 40 percent are contemplators, and only 10 to

15 percent are ready to quit (Prochaska et al., 1992). There is no reason to

believe that Lock Haven smokers differ much from the national trend, and

some reason to believe that a higher percentage are precontemplators,

because of local norms and a high smoking prevalence. Nevertheless, only

43 of the participants, or 16 percent, were precontemplators; that is, they

reported that they had not given any serious thought to quitting smoking

(17.3 percent of the high-risk smokers and 15.7 percent of low-risk smokers).

Contemplators were defined as those who reported that they seriously

thought about quitting before the intervention but had not quit for longer

than 24 hours during the previous year. They constituted 105, or 39 percent,

of the participants (42.0 percent of the high-risk smokers and 38.4 percent of

low-risk smokers). The remaining 120 smokers, or 45 percent, had quit for

more than 24 hours at some time during the previous year (40.7 percent of
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278

high-risk smokers and 45.9 percent of low-risk smokers); that is, they had

been short-term quitters and had relapsed recently. Clearly this intervention

has attracted primarily the smokers who were thinking about quitting and

were seeking help.

A third explanation for the workers’ lack of participation relates to

the history of their common health problem. Strong political pressure from

the workers was necessary to create the bladder cancer screening program

(Leviton et al., 1991). In the course of that struggle, some opponents told

the chemical workers that they did not deserve a screening program because

they contributed to their own problems by smoking. Many former workers

still recall this altercation with anger and would resist participating for that

reason.

NATURE OF The three physicians and the respiratory therapist had received brief

MEDICAL training in the use of medical advice to quit smoking. All had seen

ADVICE GIVEN a training videotape developed by investigators at Stanford University (Cummings et al., 1989a and 1989b). The tape presented examples of

physician advice interventions, tailored to the needs of smokers who were

at the precontemplation, contemplation, and action stages of quitting. All

had access to a flowchart developed by the University of North Carolina’s

Faculty Development Program, which indicates how to tailor advice to

the smoker’s stage of change. (See Figure 1 in Chapter 3.) The nature of

physician advice was kept deliberately simple. Each element and its role

in the study are outlined here.

Personalizing The physician or respiratory therapist was informed in advance of

Risks and each participant’s risk status and readiness to quit smoking. The

Benefits professional first gave a brief description of the effects of smoking

on health and the benefits of quitting. If a participant was identified

Protocol as a high-risk smoker, the professional added that smoking increased

the risk for bladder cancer and that quitting smoking increased the

chances of staying healthy.

Comment One goal of the study was to examine whether advice by a medical

professional causes smokers to reassess their own personal risk for health

problems. For many years, it has been clear that knowledge alone is not

sufficient to induce people to change their behavior (McGuire, 1985). Although smokers may understand in general the risks of smoking and benefits

of quitting, they may not yet have come to believe that they run a personal

health risk. In contrast to nonsmokers, smokers tend to underestimate the

health risks of smoking and to discount their personal risk (Shiffman, 1987).

A medical professional’s advice is likely to affect smokers by personalizing the health risks and benefits (Weinstein, 1988). When smokers quit,

they often cite health concerns, and these are often precipitated by a specific

circumstance, such as having an acute illness or knowing someone who has

cancer (Shiffman, 1987). In a similar fashion, advice from a medical professional may constitute a precipitating event for the smoker.
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Chapter 4

Averting The medical professionals were urged not to use scare tactics, to avoid

Dysfunctional any form of fear imagery, and to speak with participants in the same

Reactions way that they would with their other patients. For higher risk smokers, all members of the project team checked for anxious or fearful

Protocol reactions that could affect participants’ ability to use the counseling

that followed. The study coordinator was careful to ask about anxiety

in a followup phone call within 48 hours. If individuals expressed anxiety,

the study coordinator was to spend time with them to discuss the meaning

of the information that the physician and counselor had given.

Comment The high-risk smokers in the study are not similar to the kind of patient

that may walk into any office practice. They are vulnerable to disease

because of exposure to a potent chemical carcinogen. They may be especially

likely to experience dysfunctional reactions as a result of receiving information about their risk. Each of the dysfunctional reactions could impede

progress toward smoking cessation. A helpless reaction is especially likely

if smokers perceive quitting as too difficult or if they take a fatalistic attitude

toward their risk for disease (Peterson and Seligman, 1984). Also, smokers

could avoid thinking about the risk information, as they have done when

faced with other bad news about health (Folkman and Lazarus, 1980).

Smokers do avoid information on the dangers of smoking (Brock and

Balloun, 1967), and those who quit and then relapse into smoking discount

their personal risk of health problems (Gibbons et al., 1991). Finally, some

smokers may respond by coping with emotions rather than problem-solving

or planning to eliminate the feared consequence (Leventhal, 1970). Such

reactions may explain smokers’ resistance to medical advice. To minimize

such reactions, improvements in risk communication are needed.

Making Progress If smokers were ready to quit, the medical professional set a quit

Toward Cessation date and indicated that the study coordinator would telephone

the participant within 48 hours. If participants were not ready

Protocol to set a quit date, the medical professionals nevertheless urged

them to set a quit date when the study coordinator called in 48 hours.

Finally, the medical professional checked for contraindications for

nicotine gum and, if none were found, offered a prescription for the gum

(under supervision of a physician), regardless of the participant’s readiness

to quit. Participants were told that they would see a counselor in a few

minutes who would show them how to use the gum.

Comment As mentioned above, setting a quit date can move the smoker to the

stage of action; other smokers are at the preceding stages. Research on

the stages of change indicates that there may be a brief window of time in

which a person is ready to make a change. If circumstances interfere, the

opportunity passes. Moreover, we have no reason to expect that the opportunity will be available for all smokers at the time they receive medical or

dental advice to quit. However, providing nicotine gum and other resources

to help the smokers quit will help them to follow through, if and when the

opportunity occurs.
Smoking and Tobacco Control Monograph No. 5

280

Recommendations Medical and dental professionals should stress the benefits

For Advice of quitting as well as the risks of smoking; it always helps to

emphasize the positive. People interpret health risks in a positive or a

negative way, depending on how the issue is framed (Fischoff, 1988; Nisbett

and Ross, 1980). The smoker’s cup may be described as half full (you can

prevent illness by quitting) or half empty (you run a risk of disease by

smoking). The medical or dental professional can influence the way the

patient interprets risk.

Professionals who provide advice to quit smoking need to distinguish

between communication about risks and benefits and communication that

arouses fear. The former is positive, because it provides information about

a danger that can be avoided through smoking cessation. However, information about a danger may or may not induce the emotional reaction of fear.

The best means of avoiding negative reactions to medical advice is to

provide concrete means to overcome or avoid the danger (Leventhal et al.,

1980; Rogers and Mewborn, 1976). Giving the smoker increased skills to

quit, and confidence to use those skills, will help greatly. Simply providing

a prescription for nicotine gum, without a demonstration of its use, is less

likely to impart needed skills. Simply referring a patient to counseling

resources is even less likely to ensure that the patient will come to possess

skills to quit smoking.

Personal contact and continued communication are often found to

be essential when communicating with people about increased health risks

(Leviton et al., 1991). Misconceptions can be corrected, and anxiety alleviated, through such contact. In the same way, a physician’s or dentist’s

communication about the risks of smoking and benefits of quitting would

ideally be followed by contact between the smoker and other staff, who

could assess anxiety and alleviate it if needed.

NATURE OF The counseling intervention consisted of three components:

COUNSELING (1) instruction on the use of nicotine gum (if the participant was

INTERVENTION interested in the gum); (2) use of a self-efficacy intervention, an

attention placebo, or no special counseling; and (3) directing participants’

attention to self-help materials. After intervention, counselors left the room,

permitting participants to independently select self-help materials; choice

of these materials (as a behavioral measure of information-seeking) constitutes one of the dependent variables of the study.

Nicotine Gum The counselor explained the use of nicotine gum and used ordinary

Demonstration chewing gum to demonstrate, because experience suggests that

patients do not generally receive appropriate training in how to use

Protocol the gum. Participants received a sheet of simple instructions and

practiced, again with a piece of regular gum. The counselor rein

forced each participant’s mastery of using the gum and emphasized that,

should the participants decide to quit, they now possessed an important

resource to help the process.
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Chapter 4

Comment The nicotine gum constitutes a central feature of the intervention, in

that it is a tool provided to smokers to assist them in avoiding the dangers of smoking and achieving the benefits of quitting outlined in the medical advice component. A prescription is provided even to those who may not

be ready to quit, on the assumption that providing a tool for quitting will

hasten the day when they may take action.

Self-Efficacy The second phase constituted the comparison of self-efficacy intervenCounseling tion, attention placebo, or no special counseling. Participants were

randomly assigned to these three conditions, and counselors were blind

Protocol to the condition to which participants were randomized, up to this

point. The self-efficacy intervention and attention placebo occurred in

the context of assessing participants’ past experience in attempting to quit.

These two conditions were identical in terms of counselor questions for

the participant and differed only in that the self-efficacy counseling gave

participants feedback about their ability to quit smoking.

An outline of the self-efficacy counseling is given in Appendix D. Overall, the counselors asked questions about the participants’ past experience in

quitting and in other behavior changes. They reinforced coping strategies

that participants had applied successfully. They reinforced other skills and

abilities that could be transferred to the smoking cessation task. They

pointed to barriers the participants mentioned, suggested other strategies

the participants might use to overcome those barriers, and emphasized that

participants had the ability to use those skills.

Participants were first asked about their most recent attempt to quit

and then about their most successful attempt to quit. If the participants

had never attempted to quit, they were asked about the last time they had

simply coped with not smoking (when it was prohibited or a cigarette was

not available). If they had not coped well, they were asked about attempts

to change other behaviors related to health.

For each of these experiences, the counselors strongly emphasized

the participants’ success in refraining from smoking (or otherwise changing

behavior). The counselors noted the strategies the participants had used at

the time. They then asked participants to identify, in each experience, the

barriers that prevented them from quitting for good.

Throughout, the counselors strongly reinforced the fact that participants

possessed the coping skills and abilities they needed to quit smoking. These

abilities were evidenced by their prior attempts to quit, previous health

behavior changes, or experience in refraining from smoking.

Counselors summarized these experiences and reframed them as success

experiences, indicating that the participants had the abilities required to quit.

The counselors then summarized the barriers to quitting that smokers had

identified as situations that would make it difficult to resist smoking. The

counselor then turned to pamphlets that addressed those barriers (see below).
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Comment Smokers may have reason to doubt their ability to quit when they are

offered medical advice. The quitting situation may not be familiar, and

self-efficacy is relatively low under these conditions (Bandura, 1977 and

1986). In addition, smokers may have tried to quit smoking in the past and

perceive their relapse as a failure caused by lack of ability. Finally, a medical

profes-sional’s information about the dangers of smoking may cause some

fear or alarm. Emotional arousal contributes to doubts about self-efficacy

(Maddux and Stanley, 1986).

Fortunately, self-efficacy perceptions can be changed. People can be

persuaded that they have the ability to change health-related behaviors,

and this does encourage them to change (Maddux and Rogers, 1983). People

who provide models of effective behavior (all those smokers who needed

several attempts to quit) can also instill greater self-efficacy and enhance

behavior change (Bandura, 1990b; Gilchrist and Schinke, 1983). Personal

experience of success also enhances self-efficacy, and skills training to maintain cessation increases the likelihood that personal efforts will meet with

success (Maddux and Stanley, 1986). Reframing the prior attempts to quit

as successes, rather than failures, will work as long as the smokers are directed

to overcoming the barriers that caused them to relapse.

Self-Help In the third phase, counselors directed participants’ attention to selfMaterials help materials. Some of the self-help materials were of a general nature,

including both American Lung Association and American Cancer Society

Protocol self-help books. In addition, however, there were eight pamphlets that

focused directly on the barriers participants were likely to identify: urges

and temptations; withdrawal symptoms; stress; crisis situations; family

members, friends, and coworkers who smoke; weight gain; social situations;

and boredom.

Comment The pamphlets on barriers related directly to the situations that had prevented participants from quitting in the past. Participants’ self-efficacy

in quitting smoking should be directly enhanced by knowledge that skills

are available to help them succeed (Maddux and Stanley, 1986). Taking and

reading the relevant pamphlets can set the stage for further contemplation

or for action to quit smoking.

Self-Efficacy Appendix E is a transcript from a self-efficacy counseling session, which

Counsel is used to give practitioners a feeling for the types of information that

smokers provide and the kinds of feedback that counselors give to reinforce

self-efficacy. In practice, it is preceded by training in the use of nicotine gum

and followed by access to self-help materials specifically focused on barriers

to quitting that the patients identify. The transcript also affords a glimpse

of the kinds of participants seen in this study.

Recommendations In the context of medical advice, counseling by other staff can

For Counseling follow on the actual communication about health risks and

benefits of quitting. When smokers doubt their ability to quit smoking,
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Chapter 4

they may not try. Yet their own experience provides the raw material for

changing perceptions. Smokers tend to view relapses as failures, reflecting

their inability to quit. Counseling can help them to view relapses as learning

experiences, which can help them to refrain from smoking on their next try.

Letting smokers know that other people require more than one try at

quitting helps to reinforce this message. Identifying the barriers to quitting

helps smokers to take a problem-solving approach and points the way to

skills they will require to succeed in quitting for good.

WHAT DID A major disappointment in this study was the failure to recruit a larger

NOT WORK proportion of the smokers who were at increased risk of bladder cancer

AND WHY because of their smoking. It is notable that the screening coordinator,

so trusted and liked by cohort members, simply could not get them to take

part. A very large proportion of the cohort was likely to be smokers at the

precontemplation stage of quitting. It is unlikely that they would be more

favorable to advice to quit, even if they received the advice from their own

physicians. Low education and the local norms in favor of smoking may

offer explanations for their resistance to hearing medical advice.

We have observed this problem at an anecdotal level in two other worker

cohorts: another group at risk of bladder cancer and a cohort exposed to

asbestos. Both groups were blue-collar or low-income groups; both had been

subject to accusations that they contributed to their health problems more

by smoking than by their occupational exposure.

However, participation in smoking cessation among work-exposed

groups does not have to be low. Li and colleagues screened 1,231 smokers

who worked at a Navy shipyard and who had been exposed to asbestos

(Li et al., 1984). Eighty-seven percent of the smokers agreed to participate

in a minimal smoking intervention, and 84 percent of eligible candidates

did take part. However, the investigators had secured a consent to participate

at the time of the first medical screening, and the intervention took place

1 month later, at the time the smokers received their test results. It may be

that the combination of events was sufficient to motivate a large percentage

of smokers in this context. Clearly, the workers had an incentive both to

find out all they could at the time of initial screening and to return for their

test results and the smoking intervention. By contrast, in the examples

studied by these authors, smoking cessation is provided as a later service,

after a health surveillance program has been in place for some time and the

workers have a fairly good idea of their state of health. The authors also

conclude that recruitment of such workers into smoking cessation must be

a major intermediate outcome and that careful planning and design are

imperative to carry it out.

Generally, the training and supervision of the counselors was successful.

The continued feedback on tape-recorded sessions was an important feature,

however. The recruitment of participants occurred in fits and starts, and
Smoking and Tobacco Control Monograph No. 5

284

therefore counselors did not have routine, consistent experience in delivering

the self-efficacy intervention. The most common problem was that they

occasionally missed key things that the participants said that provided

opportunities to reinforce a feeling of self-efficacy. The authors suggest

that supervision be continual, that monitoring of samples of counseling

sessions be continued, and that feedback to counselors be given promptly.

WHAT WORKED This study is at the preliminary stage of analysis. While some

AND WHY hypotheses may not be supported, a key finding is the quit rate

of 22.7 percent at 1 year. However, experience in implementing the study

leads the authors to suggest improvements for smoking interventions in

medical and dental settings. First, health risks and benefits were communicated effectively, even for those patients who are at increased risk of bladder

cancer because of conditions other than smoking. Enhancing self-efficacy

is apparently a useful way to guard against misinterpretation of the advice

and dysfunctional reactions to it. Only one high-risk smoker in this study

displayed a negative emotional reaction to the information. The study

coordinator worked with the subject in person and by telephone until she

was satisfied that he correctly understood the risk and benefit information

and was no longer acutely anxious about the role of smoking in his risk for

contracting bladder cancer.

It might be argued that the precontemplators, who did not take part

in great numbers, may well be anxious about the role of smoking in their

risk for bladder cancer. For this reason, they avoided exposure to the information that the physician had to provide. It will be interesting to examine

the interview responses of the precontemplators who did participate in the

study, to find whether they were more anxious or fearful about the risk

information than were other participants.

This study is pertinent to the issue of whether more extended counseling

to quit smoking can feasibly be delegated to other staff members in the

physician’s office. The authors’ experience indicates that it is feasible to

train people to administer a self-efficacy intervention, even if they possess

little prior counseling experience. Continuing supervision and training for

this purpose is needed, however, as the quality of counseling was found to

be uneven. The counseling protocol was adaptable to 14 work settings as

well as the hospital setting. These are important conclusions, because availability of experienced counselors is likely to vary greatly among medical and

dental practice settings.

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Bandura, A. Perceived self-efficacy in controlling AIDS.

Evaluation and Program Planning 13: 9-17, 1990a.

Bandura, A. Self-efficacy mechanism in human

agency. American Psychologist 40: 359-373, 1986.

Bandura, A. Self-efficacy mechanism in physiological

activation and health-promoting behavior. In:

Adaptation, Learning and Affect, J. Madden IV,

S. Matthysse, and J. Barchas (Editors). New York:

Raven Press, 1990b.
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Bandura, A. Self-efficacy: Toward a unifying theory

of behavioral change. Psychological Review 84: 191-

215, 1977.

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287

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APPENDIX A

Smoking Materials for Pediatricians

American Cancer Society. Special Delivery Smoke Free: Stop Smoking Book.

American Cancer Society, 1988. 88-1C-No. 2422.01LE.

Strecher, V.J. A Healthy Beginning: The Smoke-Free Family Guide for New Parents.

American Lung Association and American Academy of Pediatrics, 1988.

Strecher, V.J., Rimer, B. Freedom From Smoking for You and Your Family.

American Lung Association, 1987.
Smoking and Tobacco Control Monograph No. 5

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APPENDIX B

Algorithms for Delivery of Smoking Cessation Advice

Part 1

Contents of initial advice—usual care patient

1. Provide information concerning the risks of continuing to smoke and benefits of

cessation—smoking increases probability of recurrence, second primary cancers,

delayed and compromised healing, more illness of other types.

2. Deliver strong advice to stop smoking or stay off cigarettes.

Part 2

Contents of initial advice—current smoker, experimental patient

1. Review smoking history.

2. Provide information concerning the risks of continuing to smoke and benefits of

cessation—quitting decreases risk of recurrence, second primary cancers, more

illnesses of other types, and promotes healing.

3. Identify patient’s receptivity to smoking cessation.

4. Deliver strong advice to stop smoking.

5. State confidence in patient’s ability to stop smoking.

6. Provide self-help booklets on stopping smoking and maintaining abstinence.

7. Provide booklet to spouse/other person providing care on social support for the

patient stopping smoking.

8. Mention withdrawal symptoms and craving for cigarettes.

9 A. If [patient is] willing to quit, set target quit date and obtain patient’s signature on

smoking cessation contract.

9 B. If [patient is] unwilling to quit, suggest reduced consumption.

10. State continuing support and reassurance that you are available during followup visits

to help patient in effort to stay off cigarettes.

Part 3

Contents of initial advice—former smoker, experimental patient

1. Review smoking history—quit date.

2. Provide information concerning the risks of continuing to smoke and benefits of

cessation—quitting decreases risk of recurrence, second primary cancers, more illnesses of other types, and promotes healing.
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Chapter 4

3. State confidence in patient’s ability to stay quit.

4. Provide self-help booklets on stopping smoking and maintaining abstinence.

5. Provide booklet to spouse/other person providing care on support for the patient in

remaining abstinent.

6. Ask about problems—refer to booklets.

7. Obtain patient’s signature on staying-quit contract.

8. State continuing support and reassurance that you are available during followup visits

to help patient in effort to stay off cigarettes.

Part 4

Booster session—experimental patients:

Problem-solving guide, abstainers and slippers

1. How long has patient been off cigarettes?

2. Ask about problems—has patient slipped or is patient currently having any problems

staying quit?

3. YES NO

What are their problems (debrief)? (Go to #4)

A. Withdrawal—discuss duration

of symptoms and craving.

B. Mention abstinence violation effect

(AVE): accepting slips as normal

occurrence triggered by “high-risk”

situation; explain that person feels

like a failure after slip and gives

up entirely (relapses) instead of

continuing to cope; person expects

cigarette to be a “reward.”

C. Discuss avoiding relapse

situations/triggers.

4. State confidence in patient’s ability to stay quit.

5. Remind patient to refer to booklets on staying quit and social support for questions

regarding effective maintenance of abstinence.

6. State your continuing support and reassurance that you are available during followup

visits to help patient in effort to stay off cigarettes.
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Part 5

Booster session—experimental patients:

Problem-solving guide, new relapsers (since last visit)

1. How long was patient quit and when did he/she go back to smoking?

2. Review circumstances of relapse situation and acknowledge difficulty.

3. Determine patient’s willingness to stop smoking again.

WILLING UNWILLING

(Go to #6) (Go to #4)

4. Ask patient to state reasons for unwillingness. Counter arguments.

Is patient willing to quit?

WILLING UNWILLING

(Go to #6) (Go to #5)

5. Discuss reducing consumption. (Go to #9)

6. Mention abstinence violation effect (AVE), accepting slips as normal occurrence

triggered by “high-risk” situation; explain that person feels like a failure after slip and

gives up entirely (relapses) instead of continuing to cope; person expects cigarette to

be “reward.”

7. Provide guidelines for effective cessation and long-term abstinence:

A. Refer to self-help booklets and social support booklet.

B. Discuss need for more intensive methods/aids such as referral to smoking cessation clinic or prescription for nicotine replacement pharmacotherapy. If requested, provide referral and/or Rx.

8. Obtain patient’s commitment to stop smoking. Set new target quit date and sign

new contract. Express confidence in patient’s ability to stop smoking.

9. State your continuing support and reassurance that you are available during followup

visits to help patient in effort to stop smoking cigarettes.
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Chapter 4

Part 6

Booster session—experimental patients:

Problem-solving guide, reduced-consumption and full-consumption smokers

1. Has patient cut down at all on smoking (number of cigarettes, tar and nicotine

content of brand)?

YES (REDUCED CONSUMPTION) NO (FULL CONSUMPTION)

(Go to #3)

2. Review techniques used by patient to reduce smoking.

3. Review benefits of quitting/risks of continuing to smoke.

4. Determine patient’s willingness to stop smoking completely.

WILLING UNWILLING

(Go to #7) (Go to #5)

5. Ask patient to state reasons for unwillingness. Counter arguments.

Is patient willing to quit?

WILLING UNWILLING

(Go to #7) (Go to #6)

 6. Suggest reduced consumption. (Go to #9)

7. Provide guidelines for effective quitting methods.

A. Refer patient to self-help and social support booklets.

B. Discuss need for more intense methods/aids such as referral to smoking cessation

clinic or prescription for nicotine replacement pharmacotherapy. If requested,

provide referral and/or Rx.

8. Obtain patient’s commitment to stop smoking. Set new target quit date and sign new

contract. Express confidence in patient’s ability to quit.

9. State your continuing support and reassurance that you are available during followup

visits to help patient in effort to stop smoking cigarettes.
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APPENDIX C

Protocol Developed by University of North Carolina

Faculty Development Program

1: Prescribing Nicotine Gum

RATIONALE: Nicotine gum supplies nicotine (the possible basis of addiction) without

carbon monoxide or carcinogenic tars. Nicotine from gum is released

slowly (if gum is chewed slowly) without sharp nicotine boli produced

through cigarette smoking.

GUIDELINES FOR USE OF GUM:

– Quit smoking before using gum.

– Chew gum slowly (about one chew for every normal puff interval), keeping taste

and tingle at minimal level.

– Use for craving, about 10 to 15 pieces per day.

– Taper from gum and stop using gum after 3 months (withdrawal from gum has

been difficult for some patients).

2-4: Obstacles to Quitting

2. FEAR OF WEIGHT GAIN:

– Two-thirds of quitters gain weight; only one-third gain weight and keep a

significant amount of weight.

– Weight gain can be prevented by a modest diet and exercise.

– Patient may crave sweets; warn about this.

– Compulsive eating may suggest nicotine withdrawal; patient may respond to

nicotine gum.

3. FAILED IN PRIOR ATTEMPTS TO QUIT:

– Most successful quitters require several tries.

– Circumstances of relapse should be studied to prepare for next try.

4. NERVOUSNESS:

– May be a sign of nicotine withdrawal (see #1).

– Tranquilizers are not effective in breaking smoking habit.

RELAPSE

Indicate that most successful quitters required several tries; many people need to

LEARN HOW TO QUIT.

Analyze relapse experience (“When and where did you smoke your cigarette?”). Have

smoker develop strategy for coping with that experience.

Recycle smoker into new quit date and schedule followup.
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Chapter 4

APPENDIX D

Self-Efficacy Intervention

(preceded by nicotine gum demonstration)

1. Most folks are surprised to learn that it often takes three or more tries before a

smoker finally quits for good. Have you tried to quit smoking?

IF NO, GO TO 1-C IF YES, CONTINUE TO 1-A

1-A. Think about the most recent time you tried to quit smoking. How long were you

able to stay off cigarettes this last time?

EMPHASIZE SUCCESS

What did you do when you had the urge to smoke but didn’t?

RECORD EFFICACY INDICATORS ON LAST PAGE

AND

REINFORCE SELF-EFFICACY

What happened that got you started again?

RECORD BARRIERS ON LAST PAGE

1-B. Think about your most successful try at quitting smoking. How long were you able

to stay off cigarettes that time?

EMPHASIZE SUCCESS

What did you do when you had the urge to smoke but didn’t?

RECORD EFFICACY INDICATORS ON LAST PAGE

AND

REINFORCE SELF-EFFICACY

What happened that got you started again?

RECORD BARRIERS ON LAST PAGE

IF GOOD DATA ARE RETRIEVED, GO TO 1-D; IF NOT, CONTINUE

1-C. Think about a time when you really craved a cigarette, but decided not to have one.

What happened?

RECORD EFFICACY INDICATORS ON LAST PAGE

AND

REINFORCE SELF-EFFICACY

Point out that they were successful in handling that craving . . . they have what it

takes to control all desires to smoke.

1-D. Review and summarize all EFFICACY INDICATORS for the participant. Reiterate

how useful/helpful those qualities/abilities will be when participant tries to quit

(again).
Smoking and Tobacco Control Monograph No. 5

294

1-E. Let’s consider some of the things that might be holding you back from quitting now.

If you were to quit smoking today, which of these situations would make it really

hard for you to resist having a smoke?

CHECK OFF BARRIERS IDENTIFIED:

_____ urges/temptations

_____ withdrawal symptoms

_____ stress

_____ crisis situations

_____ family member/friend/coworker smokes

_____ weight gain

_____ social situations

_____ boredom, pass time

DIRECT PARTICIPANT TO PAMPHLETS.
295

Chapter 4

APPENDIX E

Transcript From a Self-Efficacy Counseling Session

Counselor: Most people are surprised to learn that it often takes three times or more

to finally quit smoking. Have you ever tried to quit?

Patient: When you say three times . . .

Counselor: You may have tried twice before, you know, not necessarily in this

program—any time in your life. Have you ever tried to stop smoking?

Patient: Yeah, I tried “cold turkey,” and I think the very first time right after

dinner, and I might have gone a couple of months. Oh, some crisis or

something happened, you know, and, whizzzzt.

Counselor: OK. So, in thinking about that first time you tried to quit, about how

long did you stay off the cigarettes at that time?

Patient: I think I was off maybe 6 or 7 weeks, something like that.

Counselor: Oh, that’s very good.

Patient: But you know, like I told the doctor, the biggest thing I could do is to

change my habits, because every time I get a cup of coffee I get a cigarette.

Counselor: So, what did you do when you had the urge to smoke, but didn’t at that

time, during those 6 or 7 weeks?

Patient: Boy, I tell you, that’s 25 years ago.

Counselor: You say that’s 25 years? OK. You don’t remember what you did.

Patient: No, I didn’t smoke.

Counselor: There wasn’t anything you did instead?

Patient: No, I didn’t have anything like this or . . .

Counselor: OK, but you still were motivated, and you were coping with that craving

at that point.

Patient: Yes, because I had smoked from the time I got out of high school, through

the service and everything else.

Counselor: But for 6 or 7 weeks—that’s quite a while. You were doing something else,

ignoring it or just using self-discipline.

Patient: Yeah, just using, probably more self-discipline than anything else.
Smoking and Tobacco Control Monograph No. 5

296

Counselor: Well, you did it, you know, and habits, you know, that’s what it is, a

habit. As you said, you want to change that habit. You said there was

just some sort of crisis that happened that caused you to start again.

Patient: Yeah, something probably, if I remember right it’s when Jenny’s mother

fell and broke her leg, and we were running back and forth between the

hospital, we had the young one, and one thing probably brought on

another.

Counselor: All right. Think about your most successful try at quitting smoking. Was

it only that one time that you had tried? Was that the most successful

time?

Patient: Yeah, I said to myself many times “I’m going to quit now, stop for a day,”

or something like that . . .

Counselor: But the 6 to 7 weeks was the most successful time?

Patient: That’s the most successful time.

Counselor: And again you just—something motivated you at that point—there was

obviously something important enough in your mind that you were

thinking that you wanted to quit smoking at that point.

Patient: Probably so, but like I say at this point in time I can’t—

Counselor: Can’t remember what it was? Well, perhaps you will be able to remember.

So, you did the same thing, you don’t really remember 25 years ago what

you did when you had the urge to smoke. Now the last time when you

tried to quit smoking—if you can remember—when you really craved a

cigarette, but decided not to have one, what happened?

Patient: You mean like when I quit for a day or so?

Counselor: Even for a day, yes.

Patient: Oh . . ., most of the time it would just be getting a cracker or celery or

something.

Counselor: So, you replaced it with something else? So, you realized that you needed

to replace it with something else in order to make yourself more comfortable at that time when you were having that craving.

Patient: Right.

Counselor: That’s good. Again, you have been successful, you tried about 6 or

7 weeks, and you’ve done it for a couple days—a day here, a day there?

Patient: Yeah, I was able to do that.
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Chapter 4

Counselor: So, it does prove that you can do it, if you really want.

Patient: I’m going to use the gum no matter what, anyway.

Counselor: OK, Dennis, we had talked before, it sometimes does take someone three

or more times to quit smoking. That’s because there’s a lot of barriers

when you want to quit. There’s all kinds of situations, crises, things that

just get in the way when you want to quit smoking. What are some of the

things that you feel hold you back from quitting smoking? I mean, such

as withdrawal symptoms; what are some of the things that hold you back

the most? The hardest, toughest times for you to handle.

Patient: Well, like I say, in the morning I always, the first thing, I come down, I

have coffee. It’s just the idea that you just crave it, you want it, you know,

and I think—or as you’re saying, a crisis. You got to sit down and do

something.

Counselor: Do you feel your stress might be related to that?

Patient: Yeah, sometimes stress would do it, you know, you’re having an odd day,

a bad day, something doesn’t go right, you know, and you say, oh, the

heck with it and go over here and have a cigarette. You can just as soon

say in reality I’m going to go over here and have a glass of water, you

know.

Counselor: You just kind of stop caring.

Patient: It’s a crutch.

Counselor: Now remember what I said to you before, that a lot of situations and

things can happen that lead us, that stop us from being able to give up

smoking. Right over here I have all kinds of helpful information and I’d

like you to look at them, help yourself, take as many as you like, anything

that’s especially helpful for you. Go ahead, help yourself, we have plenty

more.

Patient: OK, no problem.

Counselor: This is the same booklet right here. But I really think it sounds to me like

you’ve thought, put it together.

Patient: I guess I know what I want to do.

Counselor: I guess it’s just going to take you to make up your mind.

Patient: Yes, make up my mind.

Counselor: Like all of us. I want to thank you, and go ahead help yourself to the

brochures.
Smoking and Tobacco Control Monograph No. 5

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299

Chapter 5

Chapter 5

Dissemination, Facilitation, and

Maintenance of Office-Based

Cessation Assistance

CONTENTS Introduction

David M. Burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

Smoking Cessation as a

Clinic Quality Improvement Project

Leif I. Solberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

External Intermediary Support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304

Lessons Learned for Future Diffusion . . . . . . . . . . . . . . . . . . . . . . . . 308

The Quality Improvement Paradigm . . . . . . . . . . . . . . . . . . . . . . . . 309

Applying Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

CQI for Smoking Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319

Computerized Reminder System To Aid Physicians

In Assessment and Counseling of Patients Who Smoke

Stephen J. McPhee, Joyce Adair Bird, Don Fordham,

Jonathan E. Rodnick, and Emilie H. Osborn . . . . . . . . . . . . . . . . . . . . . . 321

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Description of the Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

Implementation of the CPRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326

Analytical Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
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Physicians’ and Dentists’ Roles in COMMIT—

The Community Intervention Trial for Smoking Cessation

Elizabeth A. Lindsay, Judith K. Ockene, Larry Berger,

Norman Hymowitz, Paul Pomrehn, and Douglas M. Wilson . . . . . . . . . 334

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Trial Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

Trial Design and Endpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Trial Organization and Intervention . . . . . . . . . . . . . . . . . . . . . . . . 336

Goals for Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336

Intervention Protocol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336

Discussion and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

Dissemination of Physician-Based

Smoking Cessation Interventions

Michael G. Goldstein, Nancy A. MacDonald,

Raymond Niaura, and Catherine Dubé . . . . . . . . . . . . . . . . . . . . . . . . . . 342

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342

Diffusion Theory and Application . . . . . . . . . . . . . . . . . . . . . . . . . . 343

Transtheoretical Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344

Physicians Counseling Smokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

Clinical Interventions in Tobacco Control:

A National Cancer Institute Training Program

For Health Care Providers

Marc Manley, Roselyn P. Epps,

Robert Mecklenburg, and Corinne Husten . . . . . . . . . . . . . . . . . . . . . . . 356

Disseminating Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

Oral Health Team Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362

Project Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368

Appendix A. Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
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Dissemination, Facilitation,

And Maintenance of

Office-Based Cessation Assistance

Editor: David M. Burns

INTRODUCTION The successful approaches used by health care providers to alter

the smoking behavior of patients are presented in the preceding chapters of

this monograph. Likewise, the enormous impact that could be achieved if

the 70 percent of smokers who see a physician each year and the 60 percent

of smokers who see a dentist each year were to receive advice and assistance

in quitting is well described. However, the majority of smokers who saw a

physician in the past year did not receive advice to quit on their last visit,

and one-half of all smokers have never heard from their physician that they

should quit. To modify the behavior of physicians and dentists will require

the application of the recruitment strategies, motivational approaches, and

training methods developed by the investigators responsible for the trials

described in the early chapters. It will require also the application of effective

methods of disseminating and institutionalizing office-based smoking cessation assistance as part of the systems by which we deliver and receive health

care. The process of moving from a research or demonstration project to

widespread acceptance of a health promotion/disease prevention program

is often the most difficult part of technology transfer in cancer control.

Chapter 5 presents what we know about disseminating and facilitating

smoking cessation assistance in medical and dental practice settings. Just

as the previous chapters delineate the importance of changing office-based

patient flow and information systems to sustain physician compliance in

regular counseling, this chapter details the kinds of changes that can be

made in systems outside the physician’s office that will encourage more

physicians to provide regular counseling as well as make their advice more

effective. The important questions of how to recruit and train practicing

physicians, dentists, and their staffs; how to sustain motivation and meet

the ongoing training necessitated by staff and practitioner turnover; and

how to use office systems and staff to enhance the effectiveness of clinicians’

advice are addressed in this chapter. These issues constitute the groundwork

for the successful institutionalization of cessation advice into U.S. medical

and dental practices.

The first section, by Solberg, deals with smoking cessation as a clinic

quality improvement project and addresses the issues of disseminating and,

more important, maintaining smoking cessation assistance in physicians’

offices. It uses the rapidly growing quality assurance effort in medical practice to both motivate and institutionalize smoking cessation advice in an
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office practice. Solberg presents a clear process for introducing smoking

counseling into a practice as part of the effort to continually improve the

quality of delivered care. Tools for monitoring the success of the effort and

for modifying it to improve its effectiveness are described. This approach

provides the ongoing feedback needed to sustain the cessation effort as well as

the documentation that third party payers need to ensure that the preventive

services they have contracted for are being delivered.

In the second section, McPhee and colleagues describe a computerized

system for reminding physicians to provide advice, track the success or failure

of the advice that is given, and provide the summary data on overall physician

behavior that would facilitate the continuous quality improvement process.

The linkage between the process and technologic solutions described in these

first two papers may well be synergistic in promoting the acceptance of officebased smoking assistance.

Regardless of the approach selected, dissemination of office-based interventions will require recruitment and training of physicians, dentists, and

their staffs on a large scale. Three approaches to this problem are presented

in this chapter, dealing with communities at three different levels: local, state,

and national. Strategies for recruitment and training of health care providers

as one component of a comprehensive community-based smoking intervention effort are described by Lindsay and colleagues, through the experiences

of the COMMIT trial. Their section describes approaches that can be effective

in communities with populations of about 100,000, and that can be incorporated into efforts directed at community mobilization for a comprehensive

tobacco control effort. A second approach to physicians, on a statewide basis,

described by Goldstein and coworkers, uses professional organizations to

recruit physicians and incorporate “academic detailing,” whereby skilled

individuals visit physician offices to motivate and train physicians and their

staffs for providing advice and assistance in smoking cessation. This approach

deals with physician-based smoking cessation as a separate project, rather than

as a part of a comprehensive tobacco control effort, but identifies realistic

methods for using outside resources to help develop and sustain smoking

cessation advice in an office practice.

The last dissemination approach, described by Manley and colleagues

in the final paper of this chapter, is the National Cancer Institute effort to

develop and implement a national training program for health care providers

to improve their knowledge and skills for helping patients to quit smoking.

The authors present approaches used to develop materials that synthesize

what was learned from clinical trials and the strategies used to recruit physicians and dentists to participate in the training. The increasing medicalization

of smoking as a health care problem and its acceptance by physicians as a

problem they must treat with each patient will lead to smoking intervention

being more and more a part of systems for health care delivery.
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Smoking Cessation as a

Clinic Quality Improvement Project1

Leif I. Solberg

INTRODUCTION Numerous studies in a wide variety of medical settings have

demonstrated that physician advice to stop using tobacco can be very effective. Individual studies (Cohen et al., 1990; Cummings et al., 1986; Glynn

and Manley, 1990; Ockene, 1987) and a meta-analysis of the controlled

clinical trials (Kottke et al., 1988) have both demonstrated the characteristics

of interventions that lead to the greatest probability of successful quitting

among tobacco-using patients who are seeing a physician for care of some

other problem. In general, these studies show that medical interventions are

most effective when they are

• Provided at nearly every encounter over the longest possible time by

both physicians and staff;

• Aimed at those interested in changing their behavior;

• Presented in a clear, supportive, and nonconfrontational manner

that concentrates on specific plans, assistance, and followup for quit

attempts;

• Supported by various easily available forms of assistance, both

behavioral and pharmacological; and

• Followed by positive reinforcement after quitting occurs.

Nearly all physicians agree that tobacco use is a very serious health

hazard. However, their patients often do not receive advice that meets the

above-mentioned criteria. In addition to the need to focus on the problems

that patients bring, there are many other barriers, such as lack of time,

reliance on the physician’s memory, lack of staff support, and an approach

that does not emphasize these criteria. Research on physician behavior

suggests that, if this situation is to be changed, organizational changes that

support office smoking cessation systems will be necessary (Battista and

Mickalide, 1990; Belcher et al., 1988; Inui et al., 1981; Pommerenke and

Weed, 1991). These systems must include the following:

• Staff involvement and support;

• Reminders to physicians to intervene during office visits;

1 Supported in part by National Institutes of Health grant no. R01-CA38361 and by Blue Plus.
Smoking and Tobacco Control Monograph No. 5

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• Brevity, so that physicians can provide advice at nearly every visit;

• A variety of assistance for patients who need it; and

• Followup without requiring physician time or memory.

It is clear that, for these actions to occur regularly, systems must be in

place that screen and label charts of all patients for tobacco use and that all

components of the system are maintained and upgraded regularly.

In addition, it may be necessary to train physicians in the importance

of conducting and how to conduct brief discussions of smoking cessation as

a part of normal office visits. However, there is reason to believe that little

more than a brief orientation may be necessary with proper office system

support.

Individual physicians, medical care organizations, and public policymakers must decide how to initiate and maintain these office systems in

primary care settings if we are to gain maximum physician impact. Although

there have been some examples of external intermediaries successfully implementing these systems in representative practices, this diffusion has required

considerable effort, experience, and resources.

EXTERNAL After demonstrating the feasibility and value of an office system to

INTERMEDIARY accomplish the smoking cessation objectives described above in one

SUPPORT clinic (Nokomis) (Solberg et al., 1990), the National Cancer Institutesponsored Doctors Helping Smokers (DHS) project team decided that the next

task was to demonstrate that typical private primary care practices would want

to (and could) accomplish the same thing. Because the DHS co-principal

investigator was also the Medical Director for Quality Assurance for a health

maintenance organization (Blue Plus) that contracted with more than

100 private primary care practices throughout the state of Minnesota, a

collaborative relationship was developed between the research project and

the HMO.

Eleven of the practices contracting with Blue Plus were selected as the

target group (on the basis of location, with no awareness of their interest in

either smoking cessation or this project). None of these practices had more

than 15 percent of their patients covered by Blue Plus.

These practices were “recruited” by the Medical Director through an

introductory letter, which was followed by a phone call and a visit. The

practices were told that they were under no obligation to cooperate, but if

they were willing, we would teach and help them to implement an office

smoking cessation system that had already been demonstrated to be feasible

and effective.
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All 11 practice groups contacted (representing 29 separate clinics)

discussed the project with us, and each agreed to try it in at least one of

their sites. Over the course of the next 2-1/2 years, 24 of these 29 clinics

initiated an office system very similar to that at Nokomis; at the end of that

period, 8 clinics were maintaining a full system and 6 were maintaining a

partial system. This represented 48 percent of the clinics.

A full smoking cessation office system consists of the following:

• Routine screening of all patients for tobacco use status at every visit;

• Labeling of all charts as either users or non-users;

• Establishing a separate smoke card for each tobacco user;

• Use of the smoke card to remind physicians to discuss tobacco use, to

document each tobacco use discussion, and to communicate to the staff

any plans made with the patient;

• Delivery of self-help booklets during office visits to any tobacco user

interested in quitting;

• Followup by brief telephone calls after quit dates;

• Provision of some type of counseling assistance; and

• Establishing a smoke-free clinic policy.

The intervention with the practices consisted of an introductory full-day

workshop and subsequent quarterly half-day refresher meetings attended by

no more than three staff members from any one clinic. Only 10 percent of

physicians in these clinics ever attended any of these workshops. In addition,

1.5 FTE (full-time equivalent) nurse coordinators from DHS visited or called

the clinics regularly, and one of the DHS physicians visited infrequently.

Clinics were provided with materials for training and distribution to patients

and were encouraged to establish a support structure including

• Establishment of a clinic-wide policy for the system;

• Identification of a staff and a physician coordinator able to provide

strong leadership for the program;

• Development of an implementation plan and start date;

• Orientation and training;

• Arrangement for necessary resources;

• Cooperation with performance audits by DHS nurses; and

• Efforts to provide feedback and spirit-building events.
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The components of the smoking cessation system that seemed to be most

difficult for clinics to establish and operate were those providing followup

and any form of assistance or counseling. The component that tended to

decay most easily once started was consistency of smoke card use, especially

by the physicians. All of this was most dependent on strong and creative

leadership by the physician and staff coordinator.

It was difficult to predict which clinics would be successful and which

would not, primarily because of the limited knowledge that the DHS team

had about each clinic during the first phases of the project. As clinic and

individual patterns of behavior became clear, it became possible to identify

the problems that interfered with successful adoption of a smoking cessation

system. We believe that most of these problems would have the same effects

on adoption of any other system (and in fact were doing so for existing

operations). The main problems were general clinic stress, the motel

syndrome, and ineffective leadership.

General Clinic Anything that caused great stress and required everybody’s attention

Stress distracted the staff from the clinic’s ability to start a new system.

For example, one large clinic that never even got started (despite original

expressions of understanding and great interest) was undergoing great

financial stress because it was losing affiliation with another HMO that

controlled many of the patients. Another large clinic got off to a fair start

but then decided to end its affiliation with an HMO and lost 25 percent of

its patients. This led to the loss of an equivalent share of physicians and

staff and, not surprisingly, to the dissolution of their smoking cessation

system. A third clinic did very well for more than 3 years but quit when

it became stressed by an increased patient load.

The Motel Although individual practice is nearly nonexistent in Minnesota primary

Syndrome care, some group practices are really solo practices in disguise. The

physicians practice in their own individual ways, sharing only billing, lab,

and call systems. Because the DHS approach requires policy and procedure

agreement if it is to be effective, it was only marginally effective in such

clinics. If one or two physicians wanted to use it between themselves and

their nurse, that was possible, but such efforts tended to be short-lived.

One dedicated physician went on very well for more than a year by himself

before quitting, and soon thereafter he left the clinic altogether.

Ineffective Each clinic needed to have at least one physician who was respected by

Leadership the others, believed this approach was important, and understood how

to foster organizational change. It was clearly not enough to find a physician

advocate who believed strongly in fighting tobacco use. If that physician was

primarily a social activist against tobacco or took an individualistic or moralistic approach, he or she was unlikely to understand or support our approach.

Beyond that, such attitudes would result in other physicians at the clinic

labeling the enthusiast as unrealistic or radical. In any case, a physician

who knew how to forge support for a group approach was essential.
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It was also necessary to have a staff person with the authority, ability,

and desire to implement the system. If any of those elements was missing,

the system tended to be less effective and to fade over time. An effective staff

coordinator could make up for the absence of an effective physician leader for

a while. However, because even such a person has very limited ability to affect

physician behavior, the staff would eventually get discouraged by the lack of

cooperation from the physicians.

One of the best clinics exemplified this problem when, after 3 years of

effective operation, the physician coordinator went on maternity leave and

eventually returned on part-time status. Although the staff coordinator

continued to be very involved, the physicians stopped using the system as

much, leading to discouragement and inactivity on the part of the nurses.

When the additional stress of an increased patient load developed, this clinic

decided to “take a break” from the system.

A minor factor in some clinics was the personal use of tobacco by

physicians or staff. We found that such use of tobacco was much less of

a problem than the user’s attitude about it. For example, although one

of the most dedicated smoking cessation workers was a receptionist who

smoked, she organized and used the smoke card system very effectively.

However, in another clinic, posters and signs mysteriously disappeared

as the staff coordinator put them up, the result, she believed, of sabotage

efforts on the part of disgruntled smoking staff members.

Clearly, it would be best to identify these problems ahead of time and

make adjustments. One detection device may be to see how other patient

care systems are functioning; another may be to require some data-gathering

task and then measure the accuracy and timeliness with which the clinic

complies.

Given the potential for these problems, one might ask whether it is

possible to set up the system that we are recommending. We believe that

the fact that 48 percent of these randomly selected typical clinics in a highstress, high-competition environment like that in Minnesota were still

operating reasonably good DHS systems 2-1/2 years after being approached

demonstrates both the compatibility and utility of the system and the

possibility of stimulating it from the outside.

After completion of the grant, Blue Plus agreed to continue the intervention on its own, hiring a 1.0 FTE nurse coordinator and a 0.2 FTE physician

expressly to continue and extend this project to its other clinics. The only

major change was to work with clinics that volunteered interest, so as to

make more efficient use of Blue Plus resources. In the subsequent 1-1/2 years,

another 13 Blue Plus clinics set up DHS systems with our help, and the previous ones continued to receive some support. In addition, six more Blue Plus

clinics would like to start, and several clinics from other HMOs have adapted

and adopted the system with minimal help from us.
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LESSONS What factors motivated these clinics to undertake a project requiring

LEARNED significant time and energy while promising no financial advantage?

FOR FUTURE In part it was undoubtedly the belief that this is an important problem

DIFFUSION that needs better methods. In the first 30 clinics, there was the additional reinforcement that they were part of a unique nationwide project

associated with the National Institutes of Health and with a sense of group

camaraderie. This latter was strengthened by fairly intense support from

the full DHS team.

That these factors were important is attested by the seemingly greater

difficulty that we have had with the subsequent clinics, despite their volunteer

participation. Most are still operating, but several have quit and others are

struggling.

All clinics have also benefited from a Hawthorne effect—attention from

people whom they respected and from a major insurer of their patients (if you

include the 25 percent of their business associated with the parent Blue Cross

and Blue Shield plan). In addition, Blue Plus has required for years that all

of its primary clinics operate quality assurance systems that institute two

improvement projects per year. However, only two or three clinics have listed

their DHS system in their required annual reports of quality projects, so they

may not have made that connection.

Thus, it appears (as in A.J. Dietrich’s New England area cancer prevention

project) that an outside organization that understands and is flexible about the

problems of primary care can stimulate and maintain organizational systems

change in typical clinics (Dietrich et al., 1990). However, in both the DHS and

the Dietrich examples, this has been accomplished by people who may not be

widely replicable. The real problem is how to stimulate internal ownership

and leadership to develop and maintain the new systems.

Although we started with the belief that it was important to tailor the DHS

system to meet the needs of each clinic and to audit to evaluate the need for

system modifications, we have come to realize that these concepts are absolutely essential. Without tailoring, the system remains something that the

clinic has borrowed from elsewhere, easy to return or discard when any problems arise. Without adjustments based on actual performance, changes will

not be likely to improve function. The problem is similar for both—unless one

does the modification and audits oneself, one doesn’t care enough about how

the system functions, and the result is decay. We now believe that, unless

there is within-clinic management of the change, the system is not likely to

be successful in the long run.

Thus, outsiders may have an important role to play in encouraging development of systems like DHS for smoking cessation and in teaching some of

the techniques necessary to develop and maintain any system, but that role is

more limited than what we had originally foreseen. However, both Tornatsky’s

work with diffusion of a new approach to mental health care (Tornatsky et al.,

1980) and Rogers’ writings about diffusion of innovations (Rogers, 1983)
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should have prepared us for that. These problems may seem to leave in limbo

the question of how to encourage widespread replication of smoking cessation

systems in clinics.

Fortunately, a new paradigm is developing in American medical care

that promises to produce major improvements in the way that health care

is delivered. What makes this paradigm particularly promising for smoking

cessation is that it serves as a map for internal leadership to follow to identify

processes requiring change and to make continuous, self-sustaining improvements.

This map includes exactly what we have learned is necessary. The map

can be specific about the process of making change without specifying the

details of the change. Moreover, because this approach requires that those

within a clinic or health care organization conduct this assessment and

improvement, it has the potential to become effective, maintained, and

widely replicated. We believe that this can be the vehicle with which to

accomplish smoking cessation aims.

THE QUALITY To understand this new paradigm, it is necessary to understand its

IMPROVEMENT origins as well as its methods. This paradigm is commonly called

PARADIGM continuous quality improvement (CQI) or total quality management.

Although at least 40 years old in most other types of business, it is only a few

years old in health care. In fact, although it began with American quality

experts (W. Edwards Deming and Joseph Juran, in particular), their concepts

found greatest initial acceptance in Japan and are credited with being the

main stimulus to the enormous gains in quality and productivity exemplified

by Japanese business (Deming, 1986; Juran, 1988; Walton, 1986). In the past

5 to 10 years, these same ideas have gained acceptance in American business

(both manufacturing and service) and appear to be capable of the same

benefits in health care.

Health care concerns in the United States have forced an increasing

number of health care leaders to look to this CQI approach as a partial answer

to their problems, a redirection that was sparked most prominently by the

appearance of a journal article in 1989 (Berwick, 1989). Berwick’s subsequent

book, Curing Health Care, is the best single exposition of this approach in

health care to date (Berwick et al., 1990).

Although CQI has grown out of quality assurance, it differs from it in

many very important ways. Quality assurance in medicine has developed

a very bad reputation among physicians. It has come to represent a search

for “outliers” (bad apples) who have poor practices resulting in low quality.

Quality assurance theory holds that, if these bad apples can be identified

and removed or corrected, we shall see quality improve; thus, it emphasizes

regulatory approaches and inspection methods.

Other businesses have learned that inspection has only a minimal effect

on quality while adding substantially to costs, creating fear and other barriers
Smoking and Tobacco Control Monograph No. 5

310

to cooperation, and reducing productivity. The new quality approach instead

assumes that the great majority of workers in any industry wish to do a good

job, but this desire is regularly interfered with by the systems within which

they work as well as by a serious lack of training and management leadership.

Thus, the focus in CQI is on continuous improvement in the processes of work

by involving the workers who best know those processes in cross-functional

teams that study and improve the processes. The emphasis is on quantitative

methods and pragmatism, which are concepts that should be very comfortable

to practicing physicians. However, it also requires close multidisciplinary

teamwork; emphasis on prevention; and especially, attention to the wishes

of the customer, which are approaches that have not been nearly as traditional

for physicians.

APPLYING In its simplest form, CQI can be best viewed as a cyclical process

QUALITY in which systematic improvements are introduced into a process

IMPROVEMENT after studying the nature and frequency of problems. The effects

of these improvements are closely monitored in quantitative ways, so it can

be determined whether the improvements are helpful. The improvements

are modified as necessary and proliferated when proven but continue to be

subject to the same monitoring for future assessment and change until an

adequate level of performance has been reached. This is known as the

Shewhart or plan-do-check-act (PDCA) cycle (Walton, 1986).

In health care, the Hospital Corporation of America (HCA) has been

particularly active and a leader in this new CQI movement. It has added to

the Shewhart cycle in a way that makes it easier to understand by calling

it the FOCUS-PDCA cycle (McEachern and Neuhauser, 1990). The acronym

comes from the following steps:

• F, find a process to improve;

• O, organize a team of people who know the process well;

• C, clarify knowledge of the process as it exists;

• U, understand the causes of variation and problems in the process;

• S, select a systematic improvement based on that understanding;

• P, plan the introduction of that improvement and how to monitor

its impact;

• D, do both the improvement (on a small scale if possible) and the

monitoring;

• C, check on whether improvement has actually occurred; and

• A, act to modify, expand, and maintain any real improvements.

The cycle is repeated as needed.
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It is easy to see how such an approach might be used in improving a

manufacturing process. However, if one understands that all work (mental

as well as physical) involves processes in which an input is converted to

an output in a series of linked steps, then it is easier to see how this might

become applicable in a service business. If it can work in the airline or hotel

business, it might be useful to at least some aspects of medical care. In fact,

some physicians are starting to feel that it might also apply to the clinical

aspects of medical diagnosis and treatment as well.

All other types of business where this has been tried have found that

applying this approach to existing processes produces large savings from

reduction in waste and rework (25 to 35 percent) as well as great improvements in customer and employee satisfaction (Berwick et al., 1990). Early

applications in health care through the National Demonstration Project,

HCA, and others suggest the same will be true (Berwick et al., 1990).

Berwick has conceptualized the CQI steps in a way that is more generic

and familiar to health professionals by suggesting four phases for them

(Berwick et al., 1990): (1) project definition and organization (F and O);

(2) diagnostic journey (C and U); (3) remedial journey (S, P, and D); and

(4) holding the gains (C and A).

Thinking of it in this way makes it clear that this CQI process is very

analogous to the way that physicians approach the medical problems of

their patients. After organizing their practice to support their work, the

physicians gather data in relation to hypothesized causes of a problem, make

a first guess at a root cause, try an intervention (treatment), monitor and

measure progress, and then modify both the tentative diagnosis and the

treatment if they don’t hold up under the scrutiny of followup observation.

CQI FOR SMOKING Let us see how an individual primary care medical practice of

CESSATION any size can apply this CQI to improve its smoking cessation

effectiveness with its patients.

F—Find a Although studies show that most physicians feel ineffective in getting

Process To their patients to quit smoking, that does not mean that they understand

Improve the problems interfering with their effectiveness (e.g., lack of awareness

of which patients smoke and lack of reliable quit-reinforcement systems) or

that they agree with approaches proven to be more effective. Therefore, it

may be necessary to first verify quantitatively that the desirable activities

are not occurring.

This can be demonstrated in a way that will also be useful for monitoring

the effects of any change by conducting a simple chart review and a survey

of patients as they leave the office (see Figures 1 and 2). Having a questionnaire filled out by each adult patient until 30 to 40 tobacco users have

responded should indicate to what extent those users report that they experienced the five criteria listed in the first paragraph of this article:
Smoking and Tobacco Control Monograph No. 5

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Figure 1

Baseline audit of tobacco cessation activities at a clinic

A. Chart Review

1. Obtain about 50 random charts of adults (age 18 and over) from patients

with a recent office visit, just before they are to be refiled.

2. Total charts reviewed: _______

3. Total charts labeled for tobacco use (problem list or any identification

on chart cover):

Labeled as user: _______

Labeled as non-user: _______

4. Review of the last progress note:

a. Total with any indication of tobacco discussion: _______

b. Total identified as current tobacco user: _______

c. Total with advice to quit: _______

B. Patient Survey

Without letting physicians and nurses know the days to be studied, pick five days

out during one month, including one of each day of the week. On these days, the

receptionist gives each departing adult patient a survey form and asks them to

complete it and deposit it in a box near the door. It is important to know how

many surveys were given out and how many were collected on each day.

• Supportive assistance to quit is given at nearly every encounter over

the longest possible time by both physicians and staff;

• Attention is directed primarily to those interested in quitting;

• Assistance is clear, supportive, and nonconfrontational and concentrates on specific plans, followup, and counseling;

• Multiple forms of assistance are available, both behavioral and pharmacological; and

• Quit dates or spontaneous quits are positively reinforced soon after

they occur.

If a more elaborate study is desired, the respondents can be followed up

by phone or mail survey 6 to 12 months later to determine their actual quit

rates. It will be the unusual clinic that finds much compliance with the

criteria, even if the physicians and staff are aware of the period during which

the study is being conducted.

Source: Solberg and Kottke, 1989; used with permission of the authors.
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Chapter 5

Figure 2

Tobacco survey

If a practice (clinic) already has accepted the need to change to a more

systematic approach, then it can postpone these studies to the U phase

(below). However, our experience suggests that unless some simple quantitative review measures are used, it is very difficult to understand the problems

and to make appropriate system modifications.

Source: Solberg and Kottke, 1989; used with permission of the authors.

1. Were you asked about tobacco use during your visit today?

______ Yes ______ No

If yes, who asked? ______ Nurse ______ Doctor ______ Other

2. Do you use tobacco every day?

______ Yes ______ No (Go to #4)

3. Were you advised to quit during today’s visit?

______ Yes ______ No (Go to #4)

If yes:

a. Was the advice friendly and supportive?

______ Yes ______ No

b. Did you agree to quit?

______ Yes ______ No (Go to #4)

If yes:

Were you offered help to quit?

______ Yes ______ No

Were you offered any followup? (such as an appointment,

phone call, etc.)

______ Yes ______ No

4. Age: ______

5. Sex: ______ Female ______ Male

Thank you very much for helping us!
Smoking and Tobacco Control Monograph No. 5

314

O—Organize Logical members of the team in most practices would be a physician,

A Team To nurse, receptionist, medical records person, and office manager. The

Improve the goal is to include a representative from each functional area that is

Process involved with the process. Knowledge of the actual work of these areas

is critical to useful contributions to the team effort. Furthermore, it is clear

that a team consisting only of physicians is not likely to produce either a

feasible solution or one that will be maintained.

C—Clarify The first step in clarification is to construct a flowchart or algorithm of

The Existing the existing process (not what is supposed to occur). The flowchart in

Process Figure 3 can be used as a starting point for whether patients receive

smoking cessation advice in their clinic’s existing, unsystematic approach

to this problem. As they clarify the existing process, the team will be able

to appreciate the degree to which the existing system depends on chance,

whim, and memory and results in variation that virtually guarantees

ineffectiveness.

U—Understand Reviewing the flowchart (Figure 3) may allow team members to

The Problems see why smoking cessation advice is ineffective. However, it will

And Causes of facilitate monitoring the effect of any future changes if this judgVariation ment is based on specific data as well. If they were not used during

the F phase (above), the patient survey (Figure 2) and additional measurements of the frequency of nurse and physician smoking comments in the

chart (Figure 1) can easily document the variability (both within and

between individuals) that is occurring in these activities.

Here it is important for the team members to understand the role that

reducing variability holds for improving results and efficiency. Although

some may be reluctant to standardize the care process, it will be difficult for

them not to see that systematic approaches involving many of the clinic staff

will be necessary. Variation beyond that which is necessary to accommodate

important differences between patients or providers should be seen as affecting both efficiency (i.e., costs) and effectiveness.

S—Select an The DHS model was designed specifically to address these criteria and

Approach for to solve the problems of variable ineffective advice. However, there

Improvement are other approaches or variations in these DHS approaches to accomplish the same goals. For example, a smoking record card can be kept with

the patient’s chart (instead of separately) or smoking patients can be referred

out of the practice for any necessary assistance with quitting. It is important

that the practice develops a sense of ownership of the approach chosen and

that it adopts some way to measure the degree to which the approach is

working. Figures 4 and 5 can be used to chart a clinic’s own system.

P—Plan To Once the team members have decided on an approach, they must

Initiate and develop a plan for introducing that approach in the practice. They

Monitor the may wish to start with only part of the approach or to apply the full

Improvement approach in only one site or section of the practice to more easily

control and assess it. However, it will be necessary to obtain support for the
315

Chapter 5

Figure 3

Flowchart for actual office smoking cessation

Patient arrives for 

appointment.

Has the smoker

quit in past year?

Minimal effect.

Does M.D. advise

quitting?

Is there

an easy way for M.D.

to arrange help 

or followups?

Does M.D.

know and believe

help and followup

are needed?

Does

patient have a clear

smoking-related

illness?

Effective encounter.

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

Minimal effect.

Won’t offer it.

Won’t do it.

M.D. is less likely

to give advice.

M.D. is less likely

to give advice.

Does

nurse ask smoking

status and note it

on chart?

Will be recorded as

nonsmoker and no 

M.D. comment.

change, both from management and from each person who will play a role

in it. It also will be necessary to identify a coordinator; to conduct orientation

and training; and to make the necessary scheduling, resources, and time

available to support it.

If the approach chosen involves a standard record form and/or labeling

system like that in the DHS system, it will be relatively easy and quick to
Smoking and Tobacco Control Monograph No. 5

316

Figure 4

Office tobacco-use cessation process flowchart

Chart pulled

for visit.

Is label for 

current or recent

(< 1 year)

use?

Use

tobacco now

or in past

year?

Congratulate. Room

patient in usual way.

N

Y

N

Y

N

Y

Label chart

as non-user.

Label chart as user and

complete Smoke Card.

Is

there a tobacco

status label on

it?

Pull Smoke Card

for chart.

Room patient

in usual way.

During rooming, ask current

use, enter on card, and

congratulate if appropriate.

Asked about use

while being roomed.

Provider addresses 

reason for visit.

Provider addresses tobacco

use and records on card

(see next figure).

Smoke Card (or chart) is put

in special place for nurse.

Nurse reviews card

(or chart) before refiling.

Is

provider entry

complete?

N

Y

Do followup or schedule

it on calendar.

Followup

needed?

N

Y

Refile card

or chart. Ask (or return to) provider.
317

Chapter 5

Figure 5

Provider-patient tobacco interaction flowchart

Previous

category on

Card?

N

Y

N

Y

Using

tobacco

now?

Ask about current quit

attitude in light of past

recorded information.

A

Provider reviews Smoke Card after

dealing with patient’s reason for visit.

N

Y

Quit

in past

year?

Y

Willing

to quit in next

month?

N

Y

Willing

to quit next

year?

Y

Need

help to

quit?

– S –

Set quit date.

– H –

Discuss and arrange help.

– L –

Give self-help booklet.

Arrange followup.

Congratulate.

1.

2.

3.

Express desire to help when ready.

Give booklet.

1.

2.

Congratulate.

Discuss followup plan.

1.

2.

Congratulate.

Record on card.

Put card (chart) in 

special place for nurse.

1.

2.

– N –

Avoid argument.

Repeat importance of

quitting.

Express desire to help

when ready.

Advise will ask again in 

6 to 12 months.

1.

2.

3.

4.

Express need to quit.

Ask questions (below).

1.

2.

set up a periodic review that will determine whether these aspects of the

improvement process are being used as desired. It is also desirable to determine the reactions of physicians, staff, and patients to the change.

D—Do the Establish a “start day” (just like a quit day for a smoker) and initiate

Improvement the carefully planned changes. Also, plan to repeat the audits at

And Monitoring regular intervals, for example, at 1, 3, 6, and 12 months.
Smoking and Tobacco Control Monograph No. 5

318

C—Check on After the change has been in effect long enough to gather data

How the Change about how the new process is working and how it is being perceived,

Is Working it is time to evaluate and plan any necessary modifications. If no

data have been collected, it will be necessary to base this entirely on anecdotes

and subjective reactions. However, the CQI approach assumes quantitative

assessments are more likely to be useful.

A—Act To If the assessment suggests that the process is functioning well, it may

Expand or be time to expand to other areas of the practice. However, if substantial

Improve changes are necessary, it may be better to defer that until one or more

The Change additional rounds of the PDCA cycle have occurred.

When periodic audits suggest that the new system is working well (usually

at 6 to 12 months), it also may be time to assess the extent to which it is

producing the desired outcome of tobacco cessation. This can be done by

reviewing the smoking records or by a simple followup of a sample of tobacco

users (as was described in the F phase). If the team is satisfied with the monitoring data, it is then ready to set up permanent responsibilities for maintenance. The team then may be dissolved or may continue to build additional

preventive services into the same system. We have expanded the DHS system

to one for all cardiovascular risks, and it can clearly be adapted to include other

preventive services. However, by this time the practice, we hope, will have

found that this approach to quality improvement works so well that it will

establish other multidisciplinary teams to improve other processes of care

(such as appointments, waiting time, test ordering, results reporting, or care

for such clinical problems as urinary infections or back pain).

CONCLUSION Clearly, the above description is too brief to provide all of the information needed to make the best use of this new paradigm of CQI in medical

practice. Each practice will have to learn much about efficient team function,

statistical quality control measures, and how to understand better the needs

and expectations of its patients and employees. Even before reaching that

stage, however, it is likely that everyone associated with such a continuously

improving practice will find it to be much more satisfying. Combining that

satisfaction with the improved efficiency that is possible should result

in a practice that is also thriving financially.

An important final question: What is going to make a clinical practice

group want to go through changes like CQI, particularly for preventive services

that may not be very profitable? The promise of thriving financially is not

likely to be provable for at least a few more years. In the meantime, additional

incentives will arise from some combination of the following:

• Idealism and the sense that preventive services are a medical

responsibility of primary care practice;

• Patient expectations and competition for patients;
319

Chapter 5

• Medical-legal risk management; for example, failure to diagnose

breast cancer early enough is already a major legal problem and

other prevention services are likely to follow soon; and

• Requirements from payers—government, employers, and insurance

companies.

Each of these forces is likely to be stimulated by comparative data

about the frequency with which preventive services are delivered in clinics.

These data will surely soon be demanded, and they are easily obtainable

from claims systems, in many cases. Although smoking cessation advice

and assistance are more difficult to review than other preventive services,

they are clearly important. Therefore, smoking intervention seems likely to

be reviewed externally, perhaps through questions of patients on the satisfaction surveys that are being used increasingly to compare health plans and

clinics.

At Blue Plus, we have already demonstrated to our satisfaction that it

is possible to stimulate the development of traditional quality assurance

systems in primary care clinics through a combination of requirements and

assistance. Most of the 120 clinic groups with which we contract now have

satisfactory or excellent quality assurance programs where none existed

5 years ago.

Moreover, many of those clinics are going well beyond our requirements

in creative ways. An increasing number of clinics also are expressing interest

in the concepts and techniques of quality improvement, and we are helping

them to make that transition through conferences and on-site visits. We

are convinced that many are now ready to use the above-described CQI

approach to establishing systems for smoking cessation and other preventive

services. Those that don’t accept this challenge and opportunity will find

themselves without long-term partnerships with us, and we shall know that

through our use of audits from claims systems and satisfaction surveys.

Like quality improvement in other businesses, it is clear that the road

to improved quality comes from two directions—from improving internal

processes and from establishing close, long-term partnerships with those

suppliers who are equally dedicated to that task. Working together, we must

increasingly provide value (i.e., cost-effective health improvement) to our

customers, and smoking cessation may be one of the most important tests of

that commitment.

REFERENCES

Battista, R.N., Mickalide, A.D. Integration of preventive services into primary care: A conceptual

framework for implementation. In: Preventing

Disease: Beyond the Rhetoric, R.B. Goldbloom and

R.S. Lawrence (Editors). New York: SpringerVerlag, 1990, pp. 466-473.

Belcher, D.W., Berg, A.O., Inui, T.S. Practical

approaches to providing better preventive care:

Are physicians a problem or a solution? In:

Implementing Preventive Services, R.N. Battista and

R.S. Lawrence (Editors). New York: Oxford, 1988,

pp. 27-48.
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Berwick, D.M. Continuous improvement as an ideal

in health care. New England Journal of Medicine 320:

53-56, 1989.

Berwick, D.M., Godfrey, A.B., Roessner, J. Curing

Health Care. San Francisco: Jossey-Bass, 1990.

Cohen, S.J., Kelly, S.A., Eason, A.A. Establishing

smoking cessation programs in dental offices.

Journal of the American Dental Association

20(Suppl.): 28S-31S, 1990.

Cummings, K.M., Giovino, G., Emont, S.L., Sciandra,

R., Koenigsberg, M. Factors influencing success in

counseling patients to stop smoking. Patient

Education and Counseling 8: 189-200, 1986.

Deming, W.E. Out of the Crisis. Cambridge, MA:

MIT-CAES, 1986.

Dietrich, A.J., O’Connor, G., Keller, A., CarneyGersten, P., Levy, D., Nelson, E., Simmons, J.,

Barrett, J., Jr., Landgraf, J.M. Will community

physicians participate in rigorous studies of cancer

control? The methodology and recruitment in a

randomized trial of physician practices. In:

Advances in Cancer Control: Screening and Prevention

Research (Progress in Clinical Biology Series,

volume 339), P.F. Engstrom, B. Rimer, and

L.E. Mortenson (Editors). New York: Wiley-Liss,

1990, pp. 373-381.

Glynn, T.J., Manley, M.W. How To Help Your Patients

Stop Smoking: A National Cancer Institute Manual for

Physicians. U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, National Cancer Institute. NIH Publication No. 90-3064, 1990.

Inui, T.S., Belcher, A.O., Carter, W.B. Implementing

preventive care in clinical practice: I. Organizational issues and strategies. Medical Care Review

38: 129-154, 1981.

Juran, J.M. Juran’s Quality Control Handbook (4th edition). New York: McGraw-Hill, 1988.

Kottke, T.E., Battista, R.N., DeFriese, G.H., Brekke,

M.L. Attributes of successful smoking cessation

interventions in medical practice: A meta-analysis

of 39 controlled trials. Journal of the American

Medical Association 259: 2882-2889, 1988.

McEachern, J.E., Neuhauser, D. The continuous

improvement of quality at the Hospital Corporation

of America. Health Matrix 7: 5-11, 1990.

Ockene, J.K. Physician-delivered interventions for

smoking cessation: Strategies for increasing

effectiveness. Preventive Medicine 16: 723-737, 1987.

Pommerenke, P.A., Weed, D.L. Physician compliance:

Review and application to cancer detection and

prevention. American Family Physician 43: 560-568,

1991.

Rogers, E.M. Diffusion of Innovations (3rd edition).

New York: Free Press, 1983.

Solberg, L.I., Kottke, T.E. Smoking cessation strategies.

In: A Practical Guide for the Treatment of Substance

Abuse, M. Fleming and K. Barry (Editors). Chicago:

Mosby-Yearbook, 1989, pp. 95-112.

Solberg, L.I., Maxwell, P.L., Kottke, T.E., Gepner, G.J.,

Brekke, M.L. A systematic primary care office-based

smoking cessation program. Journal of Family

Practice 30(6): 647-654, 1990.

Tornatsky, L.G., Fergus, E.O., Avellar, J.W., et al.

Innovation and Social Process: A National Experiment

in Implementing Social Technology. New York:

Pergamon Press, 1980.

Walton, M. The Deming Management Method. New

York: Putnam, 1986.
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Chapter 5

Computerized Reminder System

To Aid Physicians in Assessment and

Counseling of Patients Who Smoke2

Stephen J. McPhee, Joyce Adair Bird, Don Fordham,

Jonathan E. Rodnick, and Emilie H. Osborn

INTRODUCTION To overcome the barriers to physicians’ performing smoking cessation counseling, reminder interventions of several types have been developed

and tested (McPhee and Detmer, in press). Approaches during medical

encounters, termed “inreach” interventions, have included medical record

stickers, checklists and flowsheets, and computerized reminders.

In the past, reminder interventions have largely targeted physicians

(often physicians in training) in university-based practices. The current

project was directed to community-based physicians in solo or small group

practices. The study was a randomized, controlled trial to test the efficacy

of a computerized cancer prevention reminder system (CPRS) in promoting

physicians’ performance of several cancer prevention activities, including

smoking assessment and counseling about smoking cessation (Fordham et

al., 1990). The CPRS intervention was supplemented by professional and

patient educational materials.

SUBJECTS The subjects of the study were primary care physicians who were members of the clinical faculty of the Department of Medicine and Department

of Family and Community Medicine at the University of California, San

Francisco. Such clinical faculty members have nonsalaried clinical appointments in recognition of their service as volunteer preceptors for medical

students. Most have their practices in the San Francisco Bay area. Many of

the physicians had expressed an interest in collaborative research (Osborn

et al., 1991).

Physician To recruit physicians for the study, we mailed each of the 307-member

Recruitment clinical faculty a letter describing the randomized, controlled trial and

a self-addressed reply postcard, followed by a second mailing and telephone

calls as needed.

Eligibility criteria for physician recruitment were as follows: (1) Each

physician was in a full-time, private (fee-for-service) office practice of family

medicine or general internal medicine; (2) each physician was in a solo or

2 This work was supported by grant no. R01-CA46020-03 from the National Cancer Institute.
Smoking and Tobacco Control Monograph No. 5

322

small group practice (sharing an office with no more than three other physicians); (3) the physician’s office was located within reasonable distance

(defined as 75 miles) of the university and research staff; (4) only one physician in a given office practice was eligible; and (5) each physician was willing

to have a computerized CPRS installed and implemented in the office.

Eligible physicians who agreed to participate were randomized into either

the intervention or the control group.

Of the 307 physicians, 140 (46 percent) did not respond to the recruitment letters and telephone calls, 53 (17 percent) refused study participation,

and 114 (37 percent) indicated their interest in the study. Among the last

group, 39 did not meet the study enrollment criteria. Of the 75 eligible and

interested physicians, 35 subsequently declined to participate, raising the

total number of refusals to 88 (29 percent). The remaining 40 physicians

were enrolled in the study.

The investigators met with potential subjects in their practice offices.

Those meetings constituted the first of two essential steps toward gaining

consent for study participation. The investigators described the study;

discussed the benefits of the study to participants (e.g., the experimental

group would receive computers, software, and educational materials; controls

would receive software and educational materials at the end of the study);

explained the contributions requested of participants (e.g., access to medical

records, office staff time, questionnaire completion); investigated space, staff,

and patient volume and demographics; and answered physicians’ questions.

All physicians were cooperative during the meetings; they approved of the

study aims and indicated that they would like to take part. However, most

were concerned that the CPRS requirements would overburden the office

staff, and some were concerned about the space required for computer

hardware. For many, those concerns led directly to refusal, whereas others

waited to assess the reactions of their office staffs before making a decision.

Peer influence appeared to be an important factor in recruitment.

During the meetings between the project physicians and the community

physicians, the tone of the discussions was collegial, and discussions of

medical issues usually related to prevention rather than research. In the

few instances in which nonphysician investigators took part in recruitment,

more time was devoted to the logistics of collecting the medical record data

and implementing the intervention. In the latter discussions, the community physicians had greater opportunity to focus on the problems that might

arise during the intervention; thus, the recruitment efforts by nonphysicians

were less persuasive.

Medical The second essential step toward gaining physicians’ consent was

Office Staff acceptance of the intervention by the medical office staffs. Research

Recruitment staff members met with office staff members to describe the system

and discuss their participation. In most cases, however, by the time these

meetings took place, the physicians already had discussed the matter with
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Chapter 5

their staff and decided whether to participate. Therefore, nearly all meetings

with office staffs were held in practices of physicians who had decided to

participate. In only one case was it clear that the physician had left the

decision entirely in the hands of the office staff. In two cases, physicians

made independent decisions to participate, choosing to operate the CPRS

themselves rather than relying on their staffs.

Physician We enrolled 40 physicians in the study: 20 were assigned randomly

Characteristics to the cancer prevention reminders intervention and 20 to the

control group. Three-quarters of the study physicians were male. The mean

age of the physicians was 45 years, and the mean year of medical school

graduation was 1971. Of the 40 physicians, 30 were family practitioners

and 10 were general internists. Slightly more than half of the physicians

(55 percent) were in solo practice. In general, physicians recruited for the

study had a strong orientation toward preventive care (Osborn et al., 1991).

For example, 80 percent believed it was their responsibility to urge patients

to be screened for cancer, and 78 percent said they always advised their

smoking patients to quit.

DESCRIPTION The CPRS is a software program developed by the investigators for

OF THE MS-DOS-based microcomputers. The functions of the program are

INTERVENTION easily accessible through a branching menu design, and a user’s

manual takes the inexperienced user through the various features step by

step. The program provides the physician with an up-to-date report of each

patient’s screening, assessment, and counseling status as a reminder to

perform the maneuvers; also, the program provides a simplified version

of the report for the physician to give to the patient. Additional features

include the ability to generate summary reports of the percentage of patients

in the data base who are overdue for a designated cancer prevention activity

and listings of patients overdue for a designated activity. The patient listings

with addresses may be printed on mailing labels and affixed to preprinted

reminder postcards.

The printed reminder displays the list of appropriate assessment, counseling, and screening maneuvers (based on the patient’s sex, age, and smoking

status); the recommended assessment, counseling, or testing intervals; the

last performance date; the due date for each next maneuver; and the patient’s

current “due” status (see Figure 6). The patient’s smoking status is identified

on each reminder report. If a patient’s smoking status has not been assessed,

the default identification is “smoker.” The system reminds physicians to

counsel smokers, to set a quit date, and to schedule a followup visit to discuss

their progress. The physician is expected to indicate on the form whether or

not each maneuver was performed or ordered, not applicable, or refused

during the current visit. The annotated form then is used to update the

computerized data base. The patient’s copy of the reminder form includes

space for physicians to write out specific recommendations as a prescription,

such as “set a smoking quit date” (see Figure 7). This form also is intended to

remind patients to schedule future appointments.
Smoking and Tobacco Control Monograph No. 5

324

Figure 6

Physician cancer prevention reminder

Name: Andrews, Ms. Anne Sex: F

Date of Birth: 03/03/33 Age: 58

Today’s date: Wednesday, March 27, 1991 SMOKER

These reminders are based on the recommendations of the American Cancer Society for asymptomatic adults. The recommendations should be individualized depending on history

and risk factors.

Date Done Done by

Procedure Last Done Date Due Overdue? This Visit Others & Date

Pap smear 11/12/90 11/12/91 NO Y N NA R _/ _/ _/ _/

Mammography 05/05/89 05/05/90 YES-G Y N NA R _/ _/ _/ _/

Smoking counseling 11/12/90 12/12/90 YES-H Y N NA R _/ _/ _/ _/

Set smoking quit date 03/27/91 YES-I Y N NA R _/ _/ _/ _/

Schedule smoking

followup 03/27/91 YES-J Y N NA R _/ _/ _/ _/

NA, Not Applicable; R, Refused.

Key to Overdue Notes:

G. For women over 50, every year.

H. All smokers.

I. All smokers.

J. All smokers.

J.Q. Public, M.D.

450 Sutter St., Suite 250

San Francisco, CA 94138-1111

(415) 555-9000
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Chapter 5

Figure 7

Patient cancer prevention reminder

Name: Ms. Anne Andrews SMOKER

Today’s date: Wednesday, March 27, 1991

According to the American Cancer Society, the following cancer prevention activities

should be considered as part of your preventive care. If the tests or counseling have been done

by another physician or clinic, please let your doctor know.

Date If Done Today,

Procedure Last Done Date Due Overdue? Next Due

Pap smear 11/12/90 11/12/91 NO 03/27/92

Mammography 05/05/89 05/05/90 YES 03/27/92

Smoking counseling 11/12/90 12/12/90 YES 04/27/91

Set smoking quit date 03/27/91 YES 04/27/91

Schedule smoking followup 03/27/91 YES 04/27/91

Goals and Recommendations

J.Q. Public, M.D.

450 Sutter St., Suite 250

San Francisco, CA 94138-1111

(415) 555-9000
Smoking and Tobacco Control Monograph No. 5

326

The authors currently are developing further refinements and plans for

nonprofit distribution of the CPRS. In the meantime, readers who wish a copy

of the software should contact the authors.

IMPLEMENTATION We derived the initial data for the CPRS from preintervention

OF THE CPRS review of a sample of medical records and from the medical

records of patients aged 40 and older who were scheduled for

System Initiation visits during the first 2 or 3 weeks of the intervention period.

At the beginning of the intervention period, the research staff installed

computers and software, entered patient data, and oriented the intervention

group physicians and their office staffs to the CPRS.

Office Staff The appropriate staff members in each office were trained to use the

Training CPRS. Usually, only one staff person was designated by the physician,

but occasionally two were chosen for training. In each of three practices,

the trainee was a high school student, hired by the physician to implement

the CPRS after school hours. In a few instances, the physician also attended

the training sessions.

Training was conducted in two 1-hour sessions. The first session covered

basic features that would be used regularly: adding new patient names, editing

names, adding data, printing reminders, and backing up data. The second

session addressed special features that would be used occasionally, such as

generating summary reports, deleting data and names, preparing mailing

labels, indexing, and establishing individual patient exceptions. Thereafter,

telephone and on-site consulting was provided as needed. Project staff members visited experimental group offices monthly to provide supplies, inquire

about problems, and monitor implementation of the CPRS. Office staff members with no prior computer experience had some trouble with basic word

processing skills, following the branching menus, and concepts such as saving

new or edited data from the screen to the data base. However, most complaints about the CPRS by the office staffs were related to shortages of time

and personnel.

We did not provide the office staff with directions or assistance in integrating the system into the general office procedures; each office had unique

features, and therefore the staff for each practice determined its own method

and procedures for handling the system. However, we did observe that offices

with noticeably good office management and clear priorities handled these

processes most easily and had fewer complaints about the amount of time

the CPRS consumed.

Day-to-Day During the 12-month intervention period, the office staffs printed cancer

Operation prevention reminders prior to each appointment (for patients aged 40 or

older). Usually, this work was done during regular office hours (eight cases),

early in the morning before the first appointment (six cases), after hours (five

cases), or during the lunch hour (one case). Among those who did the work

during office hours, four had other duties to attend to at the same time.
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Chapter 5

After printing the physician and patient reminders, the staff person attached them to the medical records. The physician was encouraged to give

the patient reminders to the patients during each visit. Typically, reminders

were printed about four times per week, and the data base was updated

about twice per week according to physicians’ notations on the reminders.

Supplemental Physicians in the experimental group were also given a rack of

Intervention educational materials to assist them in counseling their patients.

The patient education materials included the following:

• Quit for Good (National Cancer Institute);

• Weight Control Guidance in Smoking Cessation (American Heart

Association);

• Quit for Life (University of California, San Francisco);

• Getting Ready To Get Ready To Quit Smoking (Kaiser Permanente);

• Guia para Dejar de Fumar (University of California, San Francisco;

National Cancer Institute); and

• Would You Give a Cigarette to Your Unborn Child? (National Cancer

Institute poster).

Two professional education publications were provided:

• A Clinician’s Guide to Helping Patients Change Behavior (Martin and

Coates, 1987); and

• Smoking Cessation Programs in San Francisco County, Marin County, East

Bay Counties, Sonoma County and Peninsula (University of California, San

Francisco).

Physicians were free to choose where the educational material was

placed—in their offices, in the waiting room, or outside exam rooms. A few

physicians reordered materials during the intervention period.

ANALYTICAL To assess the impact of the intervention, we measured each physician’s

METHODS assessment and counseling performance during 12-month preintervention

and intervention periods. To do so, we drew independent, random samples

of about 60 patients from each physician’s practice register at the end of the

preintervention and intervention periods and audited the medical records of

those patients. We calculated the percentage of patients each physician assessed

for smoking status, the percentage of current smokers among patients who had

been assessed, and the percentage of assessed smokers who had been counseled

to quit smoking. We calculated performance rates for both preintervention

and intervention periods and used t-tests and ordinary least squares multiple

regression to test the significance of differences in mean rates between

physicians in the intervention and control groups for each period.
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328

At the end of the intervention period, we conducted brief interviews with

the physicians and their office staffs to assess the acceptability of the system

and to document any technical or logistical problems they experienced.

RESULTS Preintervention performance rates did not differ significantly between

intervention and control physicians for either smoking assessment or smoking

cessation counseling. The mean percentage of patients whose smoking status

physicians had assessed during the preintervention period was 30.1 percent,

and the mean percentage of smokers whom physicians had counseled was

34.8 percent. The mean smoking rate among patients in the 40 practices

(for patients whose smoking status appeared in the medical records) was

36 percent.

Table 1 shows the differences in mean postintervention performance

scores between control and intervention group physicians. Performance rates

of the intervention group were significantly higher than the control group for

both smoking assessment and smoking counseling.

Results of multiple regression analyses provide stronger evidence of the

intervention’s impact on smoking assessment and smoking counseling performance (Table 2). When controlled for preintervention rates, estimated

smoking assessment rates of intervention group physicians were 10.2 points

higher than controls (p=0.02), and smoking counseling rates were 17.3 points

higher than controls (p=0.03). A more detailed description of the analytical

methods and results is provided elsewhere (McPhee et al., 1991).

Physicians’ verbal reports during the exit interviews corroborated these

findings, dispelling any concern that observed differences between the

experimental and the control group simply reflected better recordkeeping by

physicians in the intervention group. Approximately two-thirds (13 of 20)

Table 1

Postintervention performance scores, by intervention group

Mean (SD) Performance Scorea

Cancer

Prevention

Control Reminders t-test,b

n=19 n=20 p value

Smoking

Assessment 32.4 (13.9) 45.0 (16.6) 0.014

Smoking

Counseling 41.8 (22.2) 58.8 (23.0) 0.027

a Percentage annual rates.

b t-test for differences between group means.
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Table 2

Regression results: effects of interventions on performance scores

controlled by preintervention scores

Cancer

Prevention

Constanta Reminders

Smoking Assessment

 bb 15.0 10.2

 pc 0.008 0.021

Smoking Counseling

bb 39.7 17.3

p 0.000 0.027

a Intercept. b Unstandardized regression coefficient. c p value.

of the physicians in the intervention group said that they had done more

counseling about smoking as a result of the reminders: 4 of 20 indicated they

had done “slightly more” counseling, 6 had done “quite a bit more,” and

3 had done “much more” counseling.

DISCUSSION The success of the CPRS is consistent with the results of other research

studies demonstrating that physician reminders can be effective in promoting

performance of smoking cessation counseling (Cohen et al., 1987 and 1989;

Cummings et al., 1989a and 1989b).

Strengths We designed the CPRS intervention specifically to address several

Of the barriers to performance of cancer screening activities, including

Intervention physician forgetfulness and time constraints, identified in our previous

research (McPhee and Bird, 1990; McPhee et al., 1986). The positive effects

of the intervention in the present study strongly suggest that the same

problems are implicated in physicians’ limited performance of smoking

assessment and counseling.

Compared with hard-copy flowsheets, the CPRS is more costly to initiate,

because a 20 Mb personal computer and printer cost between $1,500 and

$2,500; however, the CPRS has several distinct advantages when compared

with other types of interventions. First, it is readily exportable to a variety

of practice settings. Many physicians already have microcomputers in their

offices for billing and other purposes (Schmittling, 1989); installing the CPRS

software is done quite easily. It also can be built readily into in-place computerized ambulatory medical records systems, such as CO-STAR. Second, unlike

other reminder systems (such as “smoker” stickers attached to medical records),

the CPRS can be used to prompt the performance of a variety of periodic

preventive care activities, including other assessment and counseling activities,
Smoking and Tobacco Control Monograph No. 5

330

screening tests, and immunizations (Fordham et al., 1990). Third, we have

found that the CPRS, compared with other strategies, such as an audit-withfeedback intervention, is cost-effective (Bird et al., 1990). Furthermore, because the CPRS is able to target a variety of periodic health maintenance

procedures, it will remain more cost-effective than interventions that target

only one or two activities. Fourth, the CPRS software enables physicians to

monitor their own performance of various activities. Finally, the due date

intervals of the CPRS are easily adjusted to meet new recommendations (or

the physician’s preferred standards).

Acceptability Physicians (n=17) estimated that office staff spent a mean of 2.8 hours

per week using the system. Although most physicians had been concerned

about whether their office staff would have enough time to implement the

system, at the end of the intervention period, only 3 of 20 physicians said the

system had been “very burdensome” to their staff, 4 said it was “moderately

burdensome,” and 9 said it was either “only a little” or “not at all” burdensome. Office staff members (n=14) estimated that the mean time requirement

to operate the system was 3.7 hours per week. When asked how difficult it

was to find time to maintain the system, 3 of 14 office staff members said it

was “not difficult,” 7 said it was “somewhat difficult,” and 4 said it was “very

difficult.” In spite of their perceptions of the difficulty involved, 9 of 14 said

they thought the time devoted to using the system was “definitely worthwhile,” 4 thought it was “probably worthwhile,” and only 1 said it was

“probably not worthwhile.”

Weaknesses Special features of the CPRS were used by less than one-half of the

Of the physicians. For example, only 6 of 20 physicians used the CPRS

Intervention summary option to audit their own behavior; only 8 used the mailing

label feature to mail appointment-reminder postcards to patients. At the

end of the study, 3 of the 20 physicians commented that they “didn’t know”

about the features—2 in regard to the summary option and 1 in regard to

the mailing labels. The office staffs, not the physicians, were the major users

of the system and were more familiar with the range of options. However,

our observations in the practices suggested that staff members used system

features only at the request of the physicians. Thus, the degree to which

the system was used depended to a great extent on the degree to which

physicians pressed their staff to keep the system up to date. Physicians

with the busiest practices seemed to have less time to devote to system

maintenance and seemed to experience more difficulty in consistently

implementing the system.

Eight of the twenty physicians “always” or “nearly always” offered

patients the patient reminder; six did so “occasionally,” and six “never” did

so. Physician’s comments regarding the patient reminder ranged from “patients who received it, liked it” to “patients might be confused [by it]” to “it’s

not helpful; it was mostly discarded.” It is probable that some physicians were

reluctant to share with their patients any data that reflected their own forgetfulness or deviation from compliance with established standards.
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With respect to smoking reminders, a few of the physicians expressed

annoyance that they received repeated reminders to counsel patients about

smoking, set a quit date, and schedule followup appointments. This may have

reflected doubts that their repeated counseling could be effective in helping

patients to stop smoking or their annoyance with their patients’ noncompliance. The presence of three reminder messages related to smoking cessation,

rather than only one, also may have contributed to physicians’ irritation.

Suggestions for Although it is clear that the CPRS was successful in prompting

Improvement physicians to counsel their patients about smoking cessation,

anecdotal evidence indicates that more is needed to assure that physicians

persist in those efforts. Our experience and findings suggest that bringing

physicians and staffs into the early planning process and prefacing implementation of the CPRS with additional education-intervention components—

one for physicians and one for their medical office staffs—would have enhanced the acceptability of the CPRS. In addition, it is clear that many

physicians are not convinced of the importance of their role in patients’

smoking cessation efforts. Such orientation, along with training in smoking

counseling methods, would have facilitated physicians’ acceptance of repeated

reminders as a reflection of the difficulty many patients have in quitting

smoking, rather than as comments on the physicians’ ineffectiveness or the

patients’ noncompliance. Although physicians may disapprove of patients’

smoking, their continued concern and repeated counseling are more likely

to assist the smoker in quitting than are disapproval or annoyance. Indeed,

such counseling may be more cost-effective than treating hypertension or

hypercholesterolemia (Cummings et al., 1989c). The educational component

for physicians also might include videotapes of physicians providing smoking cessation counseling to patients. For medical office staffs, additional

education might include information about cancer risks and the importance

of cancer prevention.

The planning component might bring physicians and office staff into

the process of participation at an earlier stage. In turn, this might enhance

participants’ sense of investment in the study and proprietorship of the intervention. For example, we observed that, among the busiest medical office

staffs, some were more interested in the intervention than others and that

their higher level of interest and commitment appeared to motivate them

to find time for the CPRS, regardless of their workload. Educational and

planning components such as these undoubtedly would have strengthened

the physician and staff commitment to implementing the system more fully

and consistently.

In addition, it is worth considering whether the reminders to provide

counseling would be more acceptable to physicians if there were only one

reminder related to smoking behavior. Individual patient counseling packages

containing quit-date prescription forms and followup appointment forms

could then encourage the physician to take further steps whenever a counseling reminder appears.
Smoking and Tobacco Control Monograph No. 5

332

The “audit-with-feedback” function of the summary report might have

been more successful if we had asked physicians to make this report part of

their office staffs’ regular assignments. Included in the summary is a display

of the percentage of smokers in the practice who have not been counseled by

the physician. We would expect that routine, monthly inspection of the

summary of their overall performance would have further stimulated physicians’ performance of smoking assessment and counseling.

Study This study was conducted among family physicians and general internists

Limitations in solo and small group practices. The voluntary nature of their participation may have biased the results. Also, the findings may not be generalizable to other specialties or settings. Still, these physicians are more typical

of U.S. primary care physicians than are residents in teaching hospital settings.

The novelty of the computerized reminder system may have intensified

its impact. Had the intervention period been longer, the substantial effects

we observed may have declined over time (Green et al., 1986). Still, because

of the continuity of automated updating, computerized reminder systems

may have more durable effects than written flowsheets, audit-with-feedback

interventions, or other interventions. As with any system, however, effectiveness depends on fairly consistent use. As would be expected, we found the

level of use to vary among practices. At the end of the 12-month intervention

period, 13 of 20 practices continued regular use of the system. The major

reasons given by those who stopped using the CPRS were related to changes

in the practice (they moved or took over another’s patients), staff turnover,

and shortage of staff. Two of the practices that discontinued use later indicated their interest in resuming use of the CPRS, and another had acquired an

alternative system that combined computerized reminders with billing procedures.

CONCLUSIONS The authors conclude that computerized reminders can significantly

increase physicians’ performance of smoking assessment and counseling

activities in the private office practice setting. The results of multiple regression analyses (controlled by preintervention rates) estimated the experimental

group’s rates of smoking assessment and smoking counseling to be significantly higher—both statistically and clinically—than those of the control

group.

The effectiveness of the CPRS strategy suggests that physician forgetfulness is an important barrier to smoking assessment and counseling in clinical

practice. Clearly, other barriers, such as physicians’ perceptions of their

effectiveness and their need for counseling skills, must be reduced to close

the gap between recommended and actual performance levels.

Computerized reminders have been used and tested for a variety of preventive medicine activities, especially for secondary prevention such as cancer

screening tests (McPhee and Detmer, in press). To our knowledge, this is the

first report of success with a computerized reminder system in promoting
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physicians’ smoking cessation counseling. Also, in this trial, smoking assessment and smoking cessation counseling were placed in the context of other

cancer prevention activities. The success of this approach may help to

establish smoking cessation counseling as an appropriate activity for the

primary care physician.

REFERENCES

Bird, J.A., McPhee, S.J., Jenkins, C., Fordham, D.

Three strategies to promote cancer screening: How

feasible is wide-scale implementation? Medical

Care 28: 1005-1012, 1990.

Cohen, S.J., Christen, A.G., Katz, B.P., Drook, C.A.,

Davis, B.J., Smith, D.M., Stookey, G.K. Counseling

medical and dental patients about cigarette

smoking: The impact of nicotine gum and chart

reminders. American Journal of Public Health 77:

313-316, 1987.

Cohen, S.J., Stookey, G.K., Katz, B.P., Drook, C.A.,

Smith, D.M. Encouraging primary care physicians

to help smokers quit: A randomized, controlled

trial. Annals of Internal Medicine 110(8): 648-652,

1989.

Cummings, S.R., Coates, T.J., Richard, R.J., Hansen,

B., Zahnd, E.G., Vander Martin, R., Duncan, C.,

Gerbert, B., Martin, A., Stein, M.J. Training physicians in counseling about smoking cessation: A

randomized trial of the “Quit for Life” program.

Annals of Internal Medicine 110(8): 640-647, 1989a.

Cummings, S.R., Richard, R.J., Duncan, C.L., Hansen,

B., Vander Martin, R., Gerbert, B., Coates, T.

Training physicians about smoking cessation: A

controlled trial in private practice. Journal of

General Internal Medicine 4(6): 482-489, 1989b.

Cummings, S.R., Rubin, S.M., Oster, G. The costeffectiveness of counseling smokers to quit. Journal

of the American Medical Association 261(1): 75-79,

1989c.

Fordham, D., McPhee, S.J., Bird, J.A., Rodnick, J.E.,

Detmer, W.M. The cancer prevention reminder

system. M.D. Computing 7(5): 289-295, 1990.

Green, L.W., Wilson, A.L., Lovato, C.Y. What

changes can health promotion achieve and how

long do these changes last? The trade-offs between

expediency and durability. Preventive Medicine 15:

508-521, 1986.

Martin, A.R., Coates, T.J. A clinician’s guide to

helping patients change behavior. Western Journal

of Medicine 146: 751-753, 1987.

McPhee, S.J., Bird, J.A. Implementation of cancer

prevention guidelines in clinical practice. Journal

of General Internal Medicine 5(Suppl.): S116-S122,

1990.

McPhee, S.J., Bird, J.A., Fordham, D., Rodnick, J.E.,

Osborn, E.H. Promoting cancer prevention

activities by primary care physicians: Results

of a randomized, controlled trial. Journal of the

American Medical Association 266: 538-544, 1991.

McPhee, S.J., Detmer, W.M. Office-based interventions to improve delivery of cancer prevention

services by primary care physicians. Cancer, in

press.

McPhee, S.J., Richard, R.J., Solkowitz, S.N. Performance of cancer screening in a university

internal medicine practice: Comparison with the

1980 American Cancer Society guidelines. Journal

of General Internal Medicine 1: 275-281, 1986.

Osborn, E.H., Bird, J.A., McPhee, S.J., Rodnick, J.E.,

Fordham, D. Cancer screening by primary care

physicians: Can we explain the differences?

Journal of Family Practice 32: 465-471, 1991.

Schmittling, G.T. Computer use by family physicians

in the United States. Journal of Family Practice

29(2): 198-200, 1989.
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Physicians’ and Dentists’ Roles in

COMMIT—The Community

Intervention Trial for

Smoking Cessation

Elizabeth A. Lindsay, Judith K. Ockene, Larry Berger,

Norman Hymowitz, Paul Pomrehn, and Douglas M. Wilson

INTRODUCTION The National Cancer Institute’s Division of Cancer Prevention

and Control has initiated and supported more than 60 smoking cessation

intervention trials in North America since 1980. A major goal of these trials

is to test the efficacy of delivering antismoking interventions through diverse

sectors or channels within a community, for example, worksites, health care

providers, existing clinical programs, schools, and mass media.

In 1987, NCI embarked on its most extensive effort to help large numbers

of smokers achieve smoking cessation. The Community Intervention Trial

for Smoking Cessation task is to implement community-based interventions

that have been demonstrated to help smokers, especially heavy smokers,

achieve and maintain cessation. COMMIT involves 11 matched pairs of

communities throughout North America. One community from each pair

was randomly selected for a comprehensive tobacco-use intervention (COMMIT Research Group, 1991).

Building on the extensive experiences of past and ongoing smoking

cessation studies supported by NCI, community-based heart disease prevention efforts, and other groups involved in smoking cessation, COMMIT has

combined interventions into a comprehensive program designed to have an

impact on the smoking patterns of an entire community. Through a community organization approach, citizens from the community with professional

staff support assume the major role in planning, adapting, and implementing

the interventions (Lichtenstein et al., 1990-91).

TRIAL GOALS Although the overall goal of COMMIT is to reduce community-wide

smoking in general and heavy smoking in particular, the primary hypothesis

tested in COMMIT is that implementation of a defined intervention protocol

will result in at least 10 percent higher quit rates among heavy smokers in the

intervention communities than among those in the comparison communities.

There are a number of intermediate trial goals that include

• Increasing the priority of smoking cessation as a public health issue;

• Increasing the community capacity to modify the smoking behavior of

its residents;
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Chapter 5

• Enhancing existing political and economic factors that discourage

smoking within the community; and

• Increasing societal norms and values that support nonsmoking.

TRIAL DESIGN After the initial selection of communities, three general periods of

AND ENDPOINTS activity characterize the trial: planning and mobilization (phase I,

January 1987 to December 1989), intervention (phase II, January 1990 to

December 1992), and final assessment and analysis (phase III, January to

December 1993) (COMMIT Research Group, 1991).

Evaluation Cross-sectional and cohort surveys will assess the smoking status of

Of the community members in both experimental and control communities.

COMMIT In addition, there are a wide variety of surveys and other data collection

Intervention activities that will measure impact, process, and cost of the COMMIT

interventions (Lichtenstein et al., 1990-91; Mattson et al., 1990-91).

Selection of At the beginning of this project, NCI selected 11 matched pairs of

Communities communities for participation in COMMIT: 10 in the United States

and 1 in Canada. A community was broadly defined and could include welldefined portions of major metropolitan areas or two small cities in a geographic region. Ideally, communities within pairs were to have some geographical

separation to maintain independence of intervention activities and prevent

contamination. Within a pair, communities were matched for general

sociodemographic factors, including population size, demographic profile

(e.g., proportion of females, age distribution, educational distribution),

mobility and migration patterns, extent of urbanization, estimated smoking

prevalence rates, and access to intervention channels (e.g., health care

services, number of worksites, media resources, cessation services).

The populations in the communities vary from 52,493 to 166,824, with

comparable means for pooled intervention and comparison communities.

Overall, the intervention and comparison communities are well matched

on general sociodemographic variables. Another characterization of the

matching process involved cluster analysis and respective American and

Canadian census data for eight demographic variables on which the pairs

should demonstrate agreement: racial distribution, Hispanic ethnicity,

gender by age, gender by marital status, general occupational category,

educational attainment, family income, and years resident in the current

household. This analysis verified the comparability of the households.

A baseline survey provided information on smoking prevalence and recent

quit rates for the community pairs, and we found that the community pairs

were also well matched on smoking prevalence and recent cessation behavior

(COMMIT Research Group, 1991).
Smoking and Tobacco Control Monograph No. 5

336

TRIAL ORGANIZATION The communities deliver the COMMIT intervention through

AND INTERVENTION an organizational approach in which the community volunteers and staff are heavily involved in the entire project and have considerable

input in decisionmaking (Thompson et al., 1990-91). The research institutes

and the communities work in partnership to maintain trial integrity. It is

necessary to find a balance between the research requirements for standardization of the intervention and community needs for participation and control.

COMMIT provides a standard protocol to the communities that allows enough

flexibility to accommodate local variations. There are 57 activities described in

the protocol, and these are divided into four categories: worksites and other

organizations, cessation resources and services, public education, and health

care providers. We focus here on health care providers. For a complete

description of all the activities, see Ockene et al. (1990-91); Pomrehn et al.

(1990-91); Sorensen et al. (1990-91); and Wallack and Sciandra (1990-91).

GOALS FOR HEALTH Based on the understanding of how health care providers can

CARE PROVIDERS influence smoking cessation, the following overall goals guide

activities in this channel:

• Health care providers will be aware of, promote, and play an active role

in smoking intervention efforts in the community;

• Health care providers will regard smoking cessation advice as the

minimal standard of practice; some providers will go beyond providing

advice;

• All health care facilities will adopt and effectively implement policies

for a smoke-free environment; and

• Smoking patients will more actively seek assistance from the health

care system to stop smoking.

INTERVENTION To achieve these specific goals, we developed activities and established

PROTOCOL impact objectives and timelines. Figure 8 presents the impact objectives. COMMIT surveys (Mattson et al., 1990-91) measure progress in achieving

such impact objectives, but these data are not yet available. Primary care physicians and dentists are the focus of the health care provider protocol because

they see a large percentage of smokers each year and because they are generally

receptive to doing preventive interventions. Targeted physician groups include

the primary care specialties of internal and general medicine, family practice,

obstetrics and gynecology, and osteopathy. Targeted dental offices are those

practicing general dentistry.

The protocol requires activities that educate practicing physicians and

dental health teams, involve them in promoting community-wide smoking

control activities, and establish smoke-free offices and hospitals. Figure 9

presents the required activities for this channel. Whenever possible, we promote links among other channel activities in the protocol to reinforce the
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Chapter 5

Figure 8

Health Care Provider Task Force impact objectives for 1993

effects of the protocol. For example, the smokers’ network and local cessation

program guides, both of which are primarily cessation resource activities, are

actively promoted through health care settings.

Some communities are finding that other health care professionals such as

pharmacists and occupational and public health nurses are ready and able to

reach smokers and have chosen to include them in COMMIT activities. For

example, in Brantford, Ontario, chiropractors attended training events with

family physicians, and physician leaders provided special events for public

health nurses.

Approximately 30 physician and 30 dental offices were randomly selected

in each community for a telephone survey in 1990. Office staff in these

practices were asked about office smoking policies and available cessation

resources (impact objectives 2 and 3 in Figure 8). Mailed surveys were sent

to all primary care physicians and general practice dentists to determine their

counseling cessation practices.

Physician and There are three levels of training activities provided for physicians

Dental Training and dental care teams designed to achieve the educational goals

and facilitate regular counseling of all smokers following a standard protocol.

The most advanced level of training develops leadership and educational

skills for medical and dental care teams within the intervention communities.

This train-the-trainers approach uses national training seminars to build the

1. Among heavy smokers who have visited a physician or dentist in the past

12 months, increase the percentage who report having been told to stop

smoking or asked to set a quit date by their physician or dentist.

● Sixty percent of smokers will report having been told by a physician and

35 percent by a dentist to stop smoking;

● Twenty-five percent of smokers will report having been asked by a physician

and 20 percent by a dentist to set a date for stopping smoking.

2. Increase the percentage of physicians and dentists who report setting stopsmoking dates with patients most of the time.

● Twenty-five percent of physicians and 20 percent of dentists will report setting

stop-smoking dates with patients most of the time.

3. Increase the percentage of health care facilities (e.g., doctor and dentist offices,

clinics, hospitals) that do not allow smoking by either patients or staff.

● Ninety percent of physicians’ and dentists’ offices and other health care

facilities will be smoke-free.
Smoking and Tobacco Control Monograph No. 5

338

Figure 9

Health Care Provider Task Force intervention activities

1. Train leaders for basic and comprehensive continuing education sessions for

physicians and dental health professionals.

2. Provide basic continuing education sessions for physicians.

3. Provide comprehensive continuing education sessions for physicians.

4. Provide basic continuing education sessions for dental health professionals.

5. Provide comprehensive continuing education sessions for dental health

professionals.

6. Determine strategies for motivating and training office staff.

7. Promote smokers’ network.

8. Influence training of physicians and dental health professionals.

9. Promote smoke-free policies in health care facilities.

capacity of medical and dental care teams within the communities to deliver

the other two levels of training. The objectives of these training events are as

follows:

• Developing the leadership skills of health care providers from the

community to enable them to offer education to their colleagues

regarding smoking cessation;

• Teaching the participants the recommended content and timing for

basic and comprehensive educational events and providing resources

that will help them to be effective educators in their home settings;

• Providing a variety of learning strategies that demonstrate how to

develop smoking cessation intervention skills; and

• Providing ideas for the marketing of educational events in smoking

cessation.

A central component of these train-the-trainers seminars is an actual

demonstration of the comprehensive workshop for community physicians

and oral health teams. In addition, the faculty makes suggestions for how

to plan, market, and deliver the course. It is expected that these health care

providers will work with COMMIT staff and often with local continuing

education organizations to make the courses successful.
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National experts in the clinical aspects of smoking cessation designed the

materials for the train-the-trainers seminars and serve as the instructors. The

seminars provide both information and practice in conducting comprehensive training workshops in the local communities. The leaders place particular emphasis on experiential techniques and providing feedback to participants. Intervention strategies are taught through lectures, demonstration,

practice, and videotaped simulations. In addition to the events specifically

for COMMIT leaders, NCI offers these advanced workshops in conjunction

with regional and national professional meetings, to encourage participation

by community health providers throughout the United States.

One or two physicians from each of the intervention communities

attended a national training seminar in January 1989. They learned how to

deliver both a 1-hour introductory type of session (basic training) as well as

the longer skills-development workshop. These physicians have served as

training resources in providing continuing medical education opportunities

for physicians during the 1990 program year. Parallel training was also

provided for oral health teams from each community during 1990.

Basic training is a 40- to 60-minute presentation by local health care

providers who attend the national training and by invited guest speakers.

These sessions motivate physicians and dentists to intervene with smokers

and promote interest in more comprehensive, advanced training. Basic

training emphasizes the following areas:

• The health benefits of smoking cessation;

• Importance and effectiveness of health care provider intervention;

• How to create an office environment and practice that supports

smoking cessation and maintenance;

• A brief summary of intervention strategies;

• Factors that often interfere with maintaining cessation and how to

address them; and

• Steps to further develop clinical skills in cessation counseling.

The presentations work well when they are incorporated into established

networks for professional development and continuing education, such as

grand rounds at local hospitals and regular meetings of professional organizations.

Comprehensive training offers more detailed instruction and demonstrations

of how to create and deliver effective smoking cessation interventions in

physicians’ and dentists’ offices. This training includes video demonstrations

and opportunities to practice intervention skills and build on the content of

the basic training. Attendees receive a manual instructing them in the

physician-delivered smoking intervention steps.
Smoking and Tobacco Control Monograph No. 5

340

Training for the oral health care team is similar to the physician training

but has a greater emphasis on the role of the dental assistant or hygienist.

There is also more content on prevention of smoking because dentists see

teenagers more often than do physicians. Dentists and other members of

the oral health team attend training in intervention procedures and planning

office routines. They receive an instructional manual and other resource

materials designed especially for the dental office.

There are a total of 909 primary care physicians altogether (the mean was

83 per community) and 731 general practice dentists (the mean was 66 per

community) in the intervention communities. During the 4 years of intervention, a major goal is to attract 80 percent (727) of primary care physicians

and 65 percent (475) of general care dentists to training events. All sites have

conducted health care provider training and have achieved the process

objectives expected at this stage of the trial (Ockene et al., 1990-91).

Influential Each community, through a community analysis, has identified influenActivities tial health care professionals who are interested in smoking as a community health problem. In addition to their involvement in continuing medical

and dental education, these “influentials” stimulate community change by

promoting smoke-free health care facilities; supporting new regulations—and

the enforcement of existing regulations—about the sale of tobacco to minors,

and smoking in public places, schools, and worksites; and serving as spokespeople with the media, schools, and community groups. COMMIT staff

members provide assistance to health care provider “influentials” in the form

of a training manual with learning resources; materials from Doctors Ought

to Care (a national physician group involved in innovative—and often

humorous—antitobacco activities); and materials and training in media

and legislative advocacy.

DISCUSSION AND Physicians, dentists, and other health care providers can serve as

CONCLUSIONS role models, advocate healthier environments, and encourage

smokers to quit. Given that a large percentage of heavy smokers visit a

physician and/or a dentist each year, the clinician’s role in facilitating smoking cessation is important from both clinical and public health perspectives.

The results of the COMMIT baseline evaluation survey confirm the importance of health care providers in the smoking cessation effort. Most smokers

are aware that smoking is harmful to their health and say that they would

try to stop smoking if told to do so by their physicians. The general public is

very supportive of nonsmoking norms for health care facilities, and many

smokers agree that smoking should at least be restricted in such settings.

Given these considerations, there is considerable logic to the COMMIT

protocol, including the health care channel. Key goals are to train physicians, dentists, and other health care professionals to counsel or advise

smokers to stop smoking; to set up their office practices to facilitate smoking

intervention; and to advocate smoke-free health care facilities and smokingrelated legislation.
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Health care providers affect their colleagues’ response and professional

norms through their leadership roles as members of the COMMIT community board, in the Health Care Provider Task Force, and as representatives of

their own professional societies and agencies. Not all health care providers

are participating, and there are barriers to the integration into practice of

systematic, effective smoking interventions. These barriers include time

constraints, provider skepticism that they can “really make a difference” in

getting smokers to quit, competing demands, and limited training in cessation counseling techniques. However, the educational events and materials

provided to health care professionals not only build skills in working with

smokers but also demonstrate how to integrate this work into regular office

routines. Appendix A, at the end of this chapter, provides case studies to

illustrate how three communities have implemented the COMMIT standardized protocol.

The COMMIT intervention is built on the premise that the interaction

of many activities will magnify the impact of any one approach. Mobilization of the health care community will increase the chances of achieving

the goals of COMMIT and of having a demonstrable impact on smoking

cessation.

REFERENCES

COMMIT Research Group. Community Intervention

Trial for Smoking Cessation (COMMIT): Summary

of design and intervention. Journal of the National

Cancer Institute 83: 1620-1628, 1991.

Deyo, R.A., Bass, J.E. Lifestyle and low-back pain: The

influence of smoking and obesity. Spine 14: 501-506,

1989.

Lanier, D.C., Stockton, P. Clinical predictors of outcome of acute episodes of low back pain. Journal of

Family Practice 27: 483-489, 1988.

Lichtenstein, E., Wallack L., Pechacek, T.F. Introduction to the Community Intervention Trial for

Smoking Cessation (COMMIT). International

Quarterly of Community Health Education 11(3): 173-

185, 1990-91.

Mattson, M.D., Cummings, K.M., Lynn, W.R., Giffen,

C., Corle, D., Pechacek, T. Evaluation plan for the

Community Intervention Trial for Smoking

Cessation (COMMIT). International Quarterly of

Community Health Education 11(3): 271-290, 1990-91.

Ockene, J.K., Lindsay, E., Berger, L., Hymowitz, N.

Health care providers as key change agents in the

Community Intervention Trial for Smoking

Cessation (COMMIT). International Quarterly of

Community Health Education 11(3): 223-237, 1990-91.

Pomrehn, P., Sciandra, R., Shipley, R., Lynn, W.,

Lando, H. Enhancing resources for smoking

cessation through community intervention:

COMMIT as prototype. International Quarterly of

Community Health Education 11(3): 259-269, 1990-91.

Sorensen, G., Glasgow, R.E., Corbett, K. Promoting

smoking control through worksites in the Community Intervention Trial for Smoking Cessation

(COMMIT). International Quarterly of Community

Health Education 11(3): 239-257, 1990-91.

Thompson, B., Wallack, L., Lichtenstein, E., Pechacek,

T. Principles of community organization and

partnership for smoking cessation in the Community Intervention Trial for Smoking Cessation

(COMMIT). International Quarterly of Community

Health Education 11(3): 187-203, 1990-91.

Wallack, L., Sciandra, R. Media advocacy and public

education in the Community Intervention Trial for

Smoking Cessation (COMMIT). International Quarterly of Community Health Education 11(3): 205-222,

1990-91.
Smoking and Tobacco Control Monograph No. 5

342

Dissemination of Physician-Based

Smoking Cessation Interventions3

Michael G. Goldstein, Nancy A. MacDonald,

Raymond Niaura, and Catherine Dubé

INTRODUCTION Although the vast majority of physicians recognize the importance

of smoking cessation as a disease-preventive measure, few physicians are

confident of their ability to help patients stop smoking (Ockene et al., 1988a;

Orleans et al., 1985; Schwartz, 1987; Valente et al., 1986; Wechsler et al.,

1983; Wells et al., 1984). Several factors help explain the limited involvement of physicians in smoking interventions: limited knowledge of the

effectiveness of their own counseling and advice; lack of counseling skills;

little or no reimbursement for counseling; lack of organizational support in

the office environment; and limited availability of materials to aid them and

their patients in smoking cessation efforts (Battista et al., 1986; Kottke et al.,

1987; Lewis et al., 1986; Ockene et al., 1988a; Orlandi, 1987; Orleans et al.,

1985; Valente et al., 1986; Wechsler et al., 1983; Wells et al., 1984). Therefore, it appears that deficits in primary care physicians’ knowledge, skills, and

attitudes about smoking interventions, system and organizational barriers,

and lack of incentives interact to limit the effective use of smoking cessation

interventions in primary care settings.

Phase III studies, defined by the National Cancer Institute as controlled

intervention trials (Greenwald, 1985; Greenwald and Cullen, 1984), have

demonstrated that physician behavior can be changed through training

(Lindsay et al., 1989; Ockene et al., 1988b; Strecher et al., 1991; Wilson et al.,

1988), reminders on patients’ charts (Cheney and Ramsdell, 1987; Cohen et

al., 1987; McDonald et al., 1984), computer reminders (McPhee et al., 1989),

and other techniques (Battista et al., 1986). Phase III trials have also demonstrated clearly the effectiveness of physician-delivered interventions to

achieve smoking cessation (Cummings et al., 1989a; Kottke et al., 1988;

Ockene, 1987; Ockene et al., 1991; Schwartz, 1987; Wilson et al., 1988).

However, physicians who have participated in such research were volunteers,

which limits the generalizability of the findings.

The percentage of eligible, practicing, primary care physicians who

participated in NCI-funded phase III studies of community-based physicians

ranged from 5 percent to 50 percent (Cummings et al., 1989b; Kottke et al.,

1990; Wilson et al., 1988). Thus, it is unknown whether proven physician3 Supported in part by the National Cancer Institute, Cancer Prevention Research Consortium,

grant no. P01-CA50087, to James O. Prochaska, David B. Abrams, Wayne Velicer, and Michael

G. Goldstein.
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Chapter 5

delivered smoking cessation strategies can be effectively disseminated within

a representative sample of community-based physicians. Phase IV studies

(Greenwald, 1985) that employ representative samples of community-based

physicians are needed to test the effectiveness of physician-delivered smoking

cessation interventions.

Investigators at the NCI-funded Cancer Prevention Research Consortium

(University of Rhode Island, Miriam Hospital, and Brown University) are

addressing the need for phase IV studies by testing a strategy to accelerate the

adoption and implementation of smoking intervention protocols within a

defined population of primary care physicians. The following sections discuss

the models and strategies used in the Physicians Counseling Smokers Project,

a phase IV study of physician-delivered smoking interventions.

DIFFUSION Rogers (1983) and Orlandi (1987) have described models for the procTHEORY AND ess by which innovations in health promotion, such as physicianAPPLICATION delivered smoking cessation interventions, are diffused throughout

medical care settings over time. The first phase, adoption of an innovation

in the primary care setting, occurs when physicians accept the innovation

and begin to put it to use (Rogers, 1983). The adoption of a new technique

or technology generally encompasses several steps, beginning with awareness

of the innovation and a personal interest in pursuing further knowledge. An

evaluation and trial period follows as a physician weighs the advantages and

disadvantages of the innovation against current practices. For example, in

the case of smoking interventions, the physician attempts to foresee how

additional interventions with smokers would fit with current practice and

workflow. The final step of adoption is taken when the innovation is

accepted and a decision is made to use it.

Active approaches to influencing and enhancing adoption of innovations

are termed dissemination efforts. In the medical setting, dissemination efforts

may include the use of influential physicians as change agents (Rogers, 1983).

Such physicians may influence adoption if they express support and encouragement to other physicians and serve as role models in their own practices.

Recently, Lomas and colleagues had considerable success in changing physician behavior by using local physician leaders to disseminate practice guidelines regarding cesarean sections (Lomas et al., 1991). Brief presentations to

increase awareness of the innovation at hospital staff meetings, grand rounds,

or in professional newsletters may also enhance the dissemination process.

The second phase in the diffusion process is implementation, which can

be defined as the effective use of the innovation by physicians over time. It is

obvious that the eventual success of an innovation depends on how well it is

implemented by the targeted user group (Orlandi, 1987). Successful implementation is enhanced by the use of specific protocols and materials as well as

other resources that enable physicians to integrate the innovation easily into

their office practice system (Orlandi, 1987).
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344

Orlandi (1987) described a “linkage” process to overcome obstacles to

diffusion; a linkage system serves as a bridge between the technology of health

promotion, its supporting resources, and the actual recipients of the interventions. In the diffusion of physician-delivered interventions to general medical

care settings, a linkage system might include medical societies and other

professional organizations, regional health departments, government agencies

(e.g., NCI), hospitals, health maintenance organizations, medical schools, and

voluntary organizations (e.g., American Cancer Society and American Lung

Association). The ideal linkage system contains representatives from the

resource group that developed or planned the innovation, the intermediary

providers of the innovation (i.e., physicians providing smoking interventions

and medical decisionmakers from the health care system), and the patients

who are the targets of the innovation (Orlandi, 1987). Following a collaborative model, the linkage system works toward identifying the needs, capabilities, and concerns of each group within the system. “Change agents” or new

organizational structures may be established to facilitate the linkage process

(Orlandi, 1987).

Influential physicians in the community can play an important role in the

diffusion process, especially if they are “early adopters” (Rogers, 1983). Early

adopters may serve as role models for other physicians who may initially be

less active and involved (“laggards”) (Rogers, 1983). Adoption and implementation rates may be affected also by factors such as compatibility and complexity of an innovation in comparison to current practices, the relative advantage

of an innovation over current behaviors, the ability to adopt the innovation

on a trial basis, and the degree to which results of an adopted and implemented innovation are readily visible or measurable (Rogers, 1983).

These principles of diffusion theory can be used in the design of interventions to increase the dissemination and implementation of physician-delivered

smoking cessation methods.

TRANS- The transtheoretical model of change provides a conceptual frameTHEORETICAL work for understanding the process of individuals’ behavior change

MODEL (Prochaska and DiClemente, 1983 and 1986). This model is based on

observations that individuals considering or undergoing behavioral change,

such as stopping smoking, pass through a predictable sequence of stages

(Prochaska and DiClemente, 1983 and 1986), as shown in Figure 10.

Individuals in the precontemplation stage are either unaware of the

problem or deny it, and they are not motivated to make a behavior change

in the foreseeable future. The contemplation stage is a stage of ambivalence,

when pros and cons related to change are weighed without a definite commitment to action. Individuals in the preparation stage have taken steps to

change their behavior but have not yet taken definitive action. Those who

have reached the action stage have initiated behavior change. Maintenance is

reached when an individual has successfully made a change for some time but

continues to monitor behavior to prevent slips or relapses. Prochaska and
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Chapter 5

Figure 10

Stages of change

Source: Adapted from Prochaska and DiClemente, 1983.

DiClemente (1986) found that individual smokers may take several years to

move through the stages of change, and moreover they may cycle repeatedly

through the last four stages.

Prochaska and DiClemente (1983 and 1986) have also identified specific

experiential, cognitive, and behavioral processes that facilitate movement

through the stages of behavior change. Of great importance is their finding that

the processes of change that are used by individuals vary across stages.

For example, individuals in the precontemplation stage are more likely to

use cognitive strategies, such as consciousness-raising, while individuals in

the action stage are more likely to use behavioral strategies, such as stimulus

control and counter-conditioning. On the basis of these findings, Prochaska

and DiClemente have suggested that clinical interventions to facilitate

Relapse

Maintenance

Termination

Action

Preparation

Contemplation

Precontemplation
Smoking and Tobacco Control Monograph No. 5

346

behavioral change will be most successful if they are matched to the individual’s

stage of change (DiClemente et al., 1991; Prochaska and Goldstein, 1991) and

have successfully tested this hypothesis in clinical smoking cessation trials

(Prochaska et al., 1990). The transtheoretical model of change has now been

successfully applied to behaviors other than smoking cessation, including

behavior change that requires adoption of healthy behaviors (Marcus et al.,

1992; Rakowski et al., 1992).

Physician behavior change, including the adoption and implementation

of smoking cessation interventions, may also move through stages of change

as described in the transtheoretical model. For example, physicians at the

precontemplation stage have not yet accepted the idea of adopting smoking

interventions into their office practices. Physicians in the contemplation

stage are seriously considering providing smoking interventions but have not

decided to take action, whereas physicians in the preparation stage have taken

steps to implement protocols in their office (adoption) but have not used them

regularly. Physicians in the action and maintenance stages are actively implementing smoking cessation protocols and systems.

This characterization of physician stage of change may assist those who

attempt to influence the diffusion of physician-delivered interventions. Strategies that are matched to a physician’s stage of change may be most effective

in changing the physician’s behavior and accelerating the rate of adoption

and implementation of physician-delivered smoking cessation interventions.

For example, physicians who express little or no interest in adopting smoking

intervention strategies (precontemplators) might be more likely to respond

if their awareness of the effectiveness of physician-delivered interventions

were increased. Contemplators might respond to personal contact with a

“consultant” who could assess their motivational barriers and offer potential

solutions, resources, and support. Although these actions are not likely to

lead to immediate adoption and implementation, physicians may move to

an intermediate stage that will facilitate eventual adoption of the intervention

practices. Physicians who are in the preparation or action stage are likely to

be responsive to such intervention as the offer of counseling skills training or

education in the use of smoker assessment questionnaires. Physicians in the

maintenance stage may benefit from reminders to provide smoking counseling

(e.g., chart stickers) or from reinforcement for their activity (e.g., from chart

audits and/or feedback from patient satisfaction questionnaires).

PHYSICIANS Diffusion theory and the transtheoretical model were used in the design

COUNSELING of the Physicians Counseling Smokers Project, a component of the

SMOKERS Rhode Island Cancer Prevention Research Consortium. The consortium

was funded by NCI in September 1989. Physicians Counseling Smokers was

designed to address the following specific aims:

• Assess the impact of a comprehensive, community-based intervention

on the rates of adoption, implementation, and maintenance of physician-delivered smoking cessation interventions;
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Chapter 5

• Measure the impact of the comprehensive intervention on physicians’

knowledge, attitudes, and practice behavior and on community smoking

cessation outcomes; and

• Identify individual, system, and organizational factors that predict

physicians’ adoption, implementation, and maintenance of physiciandelivered smoking cessation interventions.

The entire community of physicians providing primary care to the people

of the State of Rhode Island is the target population for the study. All primary

care physicians in one distinct Rhode Island geographic area received the

experimental intervention for a period of 15 months. Physicians in two other

geographic areas served as “untreated” controls. After 15 months, a crossover

feature was implemented and a second area was targeted for intervention,

while physicians in the third area remain “untreated” for the entire 3-year

intervention period. The intervention began in the spring of 1991. Both

physician outcomes (knowledge, attitudes, and behavior) and community

and population smoking outcomes are to be measured. The population

outcomes will be derived from a representative sample of approximately

4,200 Rhode Island smokers recruited for the Rhode Island Cancer Prevention

Research Consortium projects.

Recruitment and According to diffusion theory, adoption must precede implementaPreparation tion (Orlandi, 1987). For adoption to occur, physicians must

become aware of the innovation and its potential usefulness. Thus, an

important first step in the diffusion process is preparing members of the

population to enhance their participation in the project. In a phase IV

study (Greenwald, 1985; Greenwald and Cullen, 1984), the recruitment

strategy must maximize participation among eligible physicians to create

a representative sample and must avoid creating barriers to widespread

participation. Care must be taken to avoid placing any additional burden

on physicians by the requirements of participation in the research aspects

of the study (e.g., measurement). Recruitment and enrollment of physicians

into the study thus becomes a crucial first step in the overall strategy to

increase diffusion of smoking interventions within this population.

Several avenues were used to enhance awareness of the project in an

attempt to increase recruitment and hence participation. First, intermediary

organizations were enlisted to help create a linkage system to aid in the

recruitment of physicians (Orlandi, 1987). A physician advisory committee

was formed, according to the principles of community activation (Bracht and

Kingsbury, 1990), to generate ownership and demand for the intervention

among the leaders in the physician community. Advisory committee members

included local and state medical society leaders, hospital and health maintenance organization medical staff presidents, professional medical organization

representatives, and voluntary agency board members. The project staff met

with advisory committee members to familiarize them with the goals of the
Smoking and Tobacco Control Monograph No. 5

348

project and to solicit their input regarding the proposed recruitment and

intervention process. Support was generated among advisory committee

members for the intervention, and strategies to effectively reach and involve

other physicians were discussed.

Committee members agreed to assist in the enrollment process through

recruitment phone calls to colleagues. The demand on physician “recruiters”

was kept minimal, in that each was asked to make only a brief phone call

(2 minutes) to each person on a defined list of physicians (an average of 8 to

10 calls per physician). The recruiter was asked to state the goals of the

project briefly, endorse the project, and encourage physicians to enroll when

approached. Dietrich (1990), using a similar recruitment strategy, successfully recruited a large sample of community-based primary care physicians

for an office-based cancer prevention project.

A targeted promotional campaign was also developed to increase awareness about the project. The campaign included items in hospital medical

newsletters, mailings to eligible physicians from influential physicians (e.g.,

director of the State health department and president of the state medical

society), and announcements about the project in the state medical society

newsletters. Finally, grand rounds sessions were given in community hospitals during the recruitment period. In addition to providing an overview of

the project and presenting compelling statistics about the importance of

physician counseling for smoking cessation, each session included a short

“trigger video” that was designed to increase physician awareness of patients’

views about physician advice to quit smoking. Discussion points covered in

the session included patient and physician expectations about recommendations to quit smoking and the positive impact physicians can have on patient

decisions about health behaviors. The authors recognized the potential

problem of contaminating the baseline survey by providing this session at

grand rounds. When weighing the risk of influencing the physician baseline

by providing this brief educational session versus the potential for increased

enrollment, they decided that the grand rounds were needed to generate

demand for the project and enhance recruitment. Grand rounds were

provided in both the control and the intervention areas, decreasing the

likelihood that the baseline would be affected differentially across conditions.

During the early phase of the recruitment process, the investigators

learned several useful points. One was about the relative lack of interest

in the scientific aspect of the project among eligible physicians. In Rhode

Island, many physicians in community hospitals without university affiliations were not only reluctant but wary of being involved in a project that

was designed primarily for research goals rather than service delivery. On

the other hand, a factor that enhanced acceptance of the project (available

only because the project is research-oriented) was the potential to provide

physicians with feedback about their success in lowering smoking rates

within their own communities. An overriding concern expressed by the
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Chapter 5

advisory committee was that individual physicians might perceive that,

by participating, they would have to do much more than they would do in

typical interactions with patients. The investigators addressed this concern

by emphasizing that physicians will be provided with the best available

resources and strategies to allow smoking interventions to become a consistent, more effective part of their usual interaction with patients. It was emphasized that the research staff would also be working with office staff members

to enhance their role in providing smoking interventions to patients, which

could potentially decrease the current workload for physicians.

There were only two defined requirements for physician participation in

the project: (1) completion of an annual questionnaire assessing physician

knowledge, attitudes, and practices with respect to smoking cessation and

interventions and (2) completion of an annual audit of each office practice

to assess and document smoking cessation activities and resources that are

currently in use. Physicians are able to select their level of participation in

the intervention. They do not have to agree to use any of the protocols or

resources that will be made available to them during the intervention period.

Thus, the only requirements involved agreements to complete repeated

assessment. Although surveys are often perceived as unpopular by physicians, the absence of a requirement to accept intervention protocols enhanced physician willingness to participate. We have succeeded in recruiting

more than 80 percent of the eligible primary care physicians in the geographic areas selected for the study.

Delivery Delivery of the intervention to individual physicians is accomplished

Of the through the use of “office practice consultants,” master’s-level health

Intervention care providers with health promotion training. Rather than using only

the traditional CME format, an “academic detailing” approach will be used.

This unique educational approach has been described by Soumerai and

Avorn (1990); it extends the promotional practices used primarily by pharmaceutical sales representatives to university-based educational outreach.

Characteristics of this approach include use of focus groups to understand

the motivations of the targeted physicians, involving “opinion leaders,”

promoting active learner involvement, providing repetitive messages and

reinforcement, using brief graphic materials, and training detailers to deal

with resistant, indifferent, and less receptive physicians (Soumerai and

Avorn, 1990).

Questionnaire data and informal interviews are used by office practice

consultants to assess and “stage” individual physicians. As a result of the

assessment, office practice consultants are able to personalize the intervention for each physician’s practice. A physician-centered approach is used, in

that each physician will have an intervention tailored to his or her expressed

interest, current smoking cessation knowledge and attitudes, and baseline

stage of adoption and implementation. Brief, intermittent “detail” visits and

phone calls are scheduled with physicians to develop a plan of action for
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350

each physician, office, and staff. Printed materials developed by NCI and

major voluntary agencies are distributed by the office practice consultants,

when appropriate, to increase awareness, interest, knowledge, and activity.

To facilitate the communication process, graphic flipcharts and brief handouts

will be developed by the project staff. During four visits over a 1-year period,

the office practice consultants can develop an ongoing relationship with

physicians and office staff, negotiate plans for use of smoking cessation

interventions, address barriers, and solve problems.

To increase the diffusion of available resources, the intervention will match

individual physicians’ interests and needs to their stage of adoption and implementation of smoking cessation protocols (Prochaska and DiClemente, 1986;

Prochaska and Goldstein, 1991). For example, those physicians who have not

yet made the decision to implement office systems to identify and track smokers (precontemplators or contemplators) are given information to increase their

awareness of the effectiveness of such interventions without being asked for a

commitment to implement them. During the course of the intervention, those

physicians also are provided with a newsletter to inform them of the activity of

their “early adopter” colleagues, who have already elected to implement aspects

of the office-based smoking intervention program. Physicians in preparation

and action stages who express a desire to implement smoking assessment and

intervention systems are also provided with samples of resources and training

on how to use them effectively.

Initial assessments by the office practice consultants are aided by new

measures being developed by Prochaska and colleagues at the University of

Rhode Island, which include the physician’s stage of adoption and implementation of smoking cessation interventions. Our definition of stage of adoption

was based on the NCI protocol for physicians that incorporates the four A’s of

patient counseling about smoking (Glynn and Manley, 1990):

• Ask (all patients about their smoking status);

• Advise (all smoking patients to quit);

• Assist (smoking patients with their smoking, regardless of their interest

in quitting); and

• Arrange (followup visits with smokers).

The NCI counseling protocol was slightly modified, according to a patientcentered counseling approach (Grueninger et al., 1989), to include addressing

the agenda (i.e., smoking) at each patient visit. “Ask” was changed to “assess”

to cue the physician to assess the patient’s stage of change as well as aspects of

the patient’s smoking history. Physicians who report that they routinely assist

greater than 80 percent of their patients who smoke and arrange a followup

specifically to discuss smoking are considered to be in the action stage.
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Chapter 5

Resources to be provided to the physician may include (1) educational

materials about physician-delivered smoking interventions for physicians and

their office staffs; (2) materials and systems for smoker identification, assessment, and tracking; (3) physician self-instruction manuals (i.e., Glynn and

Manley, 1990); and (4) formal skill counseling workshops for physicians and

staff members (see Table 3).

The education of physician participants, both during office practice consultant “detail” visits and at more traditional CME sessions, will include

information on how to assess patients’ smoking history, level of nicotine

dependence, stage of change, reasons for smoking, pros and cons related to

smoking, and ways to match interventions to individual smoking patients in

light of these assessments (Goldstein et al., 1991; Prochaska and DiClemente,

1986; Prochaska and Goldstein, 1991). Training sessions for physicians in

preparation or action stages will be voluntary and offered on site at community hospitals whenever feasible. These workshops will apply state-of-thescience educational techniques aimed at improving physicians counseling

skills. Skill teaching will employ small-group methods, including role-play,

video demonstration and review, and feedback techniques successful in the

teaching of medical interviewing. In these sessions, physicians will be given

the opportunity to learn more about smoking cessation counseling skills,

practice applying these skills to simulated cases, and consider how these newly

learned skills will be applied to their clinical practice. Other office personnel

who provide primary care or patient education activities will be encouraged to

Table 3

Summary of intervention strategies for physicians

Stage of Adoption/Implementation

Precontemplation Contemplation Preparation Action Maintenance

Office Practice Consultation ✔ ✔ ✔✔ ✔

Resource and Referral Lists ✔ ✔ ✔✔ ✔

NCI Office Manual ✔ ✔ ✔✔ ✔

Information About

Reimbursement ✔ ✔✔ ✔

Information About Physician

Effectiveness ✔ ✔✔

Materials for Patients ✔✔ ✔

Materials To Identify and

Track Smokers ✔✔ ✔

Skill Training Workshop

for Physician ✔✔ ✔

Training Workshop for Staff ✔✔ ✔
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352

attend these sessions as well. Breakout groups will be employed for discussing

the special concerns of each group of professionals attending the workshop.

Evaluation Efficacy of the physicians’ intervention will be assessed through measured

Of the changes in (1) physician knowledge, attitudes, and behavior regarding

Project smoking cessation interventions and (2) community smoking outcome

measures. It is hypothesized that, after 3 years, physicians who receive the

intervention will have increased their knowledge about smoking-related

practices, developed more positive attitudes about smoking cessation, and

increased their adoption and implementation of office-based smoking interventions. Moreover, this will result in a significantly smaller proportion of

subjects who smoke in target intervention areas than in control areas. As

noted previously, population-based outcomes will be derived from a representative sample of Rhode Island smokers recruited for the Rhode Island Cancer

Prevention Research Consortium.

Presently, the investigators are in the final stages of developing the

physician measures. They include

• An algorithm to categorize physician stage of adoption and implementation;

• A measure of pros, or benefits of the provision of smoking cessation

interventions, and cons, or barriers to provision of smoking cessation

intervention, adapted from a similar measure, the Decisional Balance

Inventory, which was developed for smokers by Velicer and colleagues

(Velicer et al., 1985);

• A processes of change measure, adapted from a measure derived from the

transtheoretical model for smokers (Prochaska et al., 1988);

• Smoking-related intervention practices derived from Wells and colleagues

(Wells et al., 1986);

• A knowledge questionnaire, derived from Ockene and colleagues (Ockene

et al., 1988b); and

• A measure of physician self-efficacy.

As described previously, an annual audit of the office practice will be

performed to assess and document smoking cessation activities and resources

currently in use. The items to be assessed will include the presence of an office

smoking policy, identification of an office smoking intervention coordinator,

use of identification and tracking systems, use of patient education materials,

use of a followup system, and presence of Physicians Counseling Smokers

materials.

SUMMARY The Physicians Counseling Smokers Project, a phase IV NCI-funded

research project, was designed to assess the effectiveness of an intervention

to disseminate physician-delivered smoking cessation protocols among a
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population of primary care physicians. In designing the intervention strategy, the investigators have incorporated principles of diffusion theory

(Orlandi, 1987; Rogers, 1983), the transtheoretical model (Prochaska and

DiClemente, 1983 and 1986; Prochaska and Goldstein, 1991); academic

detailing (Soumerai and Avorn, 1990); and state-of-the-science physician

educational strategies.

The population of physicians targeted for recruitment into the study is

all primary care physicians serving adult smokers in Rhode Island. To recruit

a representative sample of the physicians (more than 80 percent of eligible

physicians in intervention areas), the authors had to develop a recruitment

strategy that would maximize enrollment and participation. Thus, among

the strategies used for recruitment are several that are derived from diffusion

theory, including development of a “linkage system,” and strategies to

increase awareness of physician-delivered smoking interventions in the

target population (Orlandi, 1987).

The intervention will disseminate the resources developed by NCI for

physicians in office practice (Glynn and Manley, 1990) and will use academic

detailers (Soumerai and Avorn, 1990), master’s-level health care providers

with experience in health promotion, to deliver much of the intervention.

Physicians will be individually assessed, according to measures developed

by the project team, and the intervention will be matched to each

physician’s stage of adoption and implementation, using the principles

of the transtheoretical model developed by Prochaska and DiClemente

(1983 and 1986).

If the intervention is effective in increasing the adoption and implementation of physician-delivered smoking cessation interventions, the investigators will be able to measure its effect on both physician behavior and patient

smoking prevalence. Because the results should be generalizable to other

community settings, a positive outcome will have much clinical and public

health significance. Moreover, the intervention strategy could be easily

adapted to diffuse other cancer prevention measures and, more generally,

other health promotion innovations within the medical care community.

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356

Clinical Interventions in Tobacco

Control: A National Cancer Institute

Training Program for

Health Care Providers

Marc Manley, Roselyn P. Epps,

Robert Mecklenburg, and Corinne Husten

DISSEMINATING Other chapters in this monograph describe the clinical trials funded

INTERVENTIONS by NCI that examined the effect of health care professionals on

smoking by patients. This section describes the training projects conducted

by NCI to disseminate the research results after completion of the above trials.

Project At the time the five clinical trials were completed, there was very little

Planning information about mechanisms to disseminate behavioral interventions

to practicing clinicians. Although the trials had demonstrated that physicians

and dentists can change the smoking behavior of their patients, there was

little in the literature about effective methods for rapid training of clinicians

in the new techniques. One trial from the United Kingdom clearly demonstrated that mailing information on smoking cessation techniques to physicians resulted in very little change in physician knowledge and, presumably,

very little change in physician behavior (Fowler et al., 1989). Given the

volume of mail that most physicians receive and the demands on their

time, such a result is not unexpected.

Experience from clinical trials in smoking cessation techniques indicated

that physicians and dentists are willing and able to incorporate effective

techniques into their practice after training in these skills. The trials showed

that clinicians appreciate how tobacco use affects their patients’ health and

that health care professionals are willing to intervene with their smoking

patients when provided with clinical techniques that are (1) effective and

(2) easily incorporated into a busy practice.

Based on the concepts derived in the clinical trials, a decision was made

to develop a training program that would provide clinicians throughout the

United States with information about smoking cessation techniques and the

skills to apply such techniques. A program for physicians and nurses began

about 2 years before a similar effort was started for dentists and other oral

health professionals.

Medical Materials An early step in the development of the training project was the

Development creation of effective training materials, which began prior to the

completion of the clinical trials. A consensus on the development process

for training materials was established while the major trials were in progress.
357

Chapter 5

The investigators held regular meetings during the trials, and issues such as

study design, comparability of data, intervention techniques, and validation

were discussed in early meetings. At the end of the trials, extensive discussions focused on the principal findings, the results that were found in more

than one trial, and the lessons that should be communicated to practicing

clinicians.

Based on these discussions, a consensus document was written: How To

Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians (Glynn and Manley, 1990). The manual, designed for primary care

physicians, nurses, and office staff members, was written as a “how to” guide,

not as a scientific paper. It addresses two subjects: how to intervene with a

smoking patient, and how to establish mechanisms in an office practice that

result in systematic, routine treatment for all smoking patients.

Five steps are described for establishing and maintaining such an office

system:

• Select a smoking cessation coordinator;

• Create a smoke-free office environment;

• Identify all smoking patients;

• Develop smoking cessation plans for patients; and

• Provide followup care.

These five steps establish a system that allows for the routine care of smoking

patients. This office organization is planned to ensure that all patients who

smoke are identified, monitored, and appropriately treated at every office

visit. Because office practices differ, the exact procedures adopted will vary.

However, it is important to involve as many members of an office staff as

possible in smoking cessation. Involvement of the office staff results in more

support for patients, increases the likelihood of patients’ success, and reduces

the amount of physician time required.

Within this framework of an office system, the NCI manual describes

brief interventions that can be used by clinicians when they are face-to-face

with a smoking patient. An intervention plan is presented and summarized

with the four A’s:

• Ask about smoking;

• Advise smokers to stop;

• Assist patients who want to stop; and

• Arrange followup care.
Smoking and Tobacco Control Monograph No. 5

358

This intervention can be initiated at any office visit. The intervention typically lasts less than 3 minutes, but it may vary with each patient’s needs and

the clinician’s skills. The recommended procedures are based both on data

from the trials discussed above and on a meta-analysis of 39 controlled trials

(Kottke et al., 1988), which showed that the most effective techniques used

more than one modality (e.g., physician advice, self-help materials, nicotine

gum), involved both physicians and other clinical staff, and involved more

smoking messages over a longer period of time.

The next step in development of the training program was the creation

of materials for teachers. The manual described above contained the basic

information for a course, but experience from the clinical trials indicated that

there were several different ways to teach this information. The development

of teaching materials required extensive input from the trial investigators, as

well as from experts in the design of training programs. The training materials

design incorporated some new materials as well as ideas that had proved useful

in the trials.

The training materials constituted a 3-hour course. Both longer and

shorter training sessions had been used in the trials, and the 3-hour time was

a compromise. A longer course would allow more time for skills development,

which would be useful for physicians who received little formal training in

behavioral change techniques. However, longer courses require more time

commitment from the clinicians who attend. A shorter course, of 1 hour or

less, is more typical in medical education and presents fewer logistical barriers;

but a period shorter than 3 hours would allow little time for skills development exercises and could consist of only a lecture. A lecture can only transfer

knowledge; it cannot teach skills.

The clinical trials indicated the value of conducting exercises that allow

clinicians to practice techniques for smoking intervention. Most of the training in the trials included role-playing exercises. Another teaching technique

frequently used was modeling of the intervention on videotape. The new

training materials incorporated both techniques. Another exercise was designed that had small groups discuss typical smoking patients as an alternative

to the role-playing exercise, because many of the course teachers would have

had no experience with conducting a role-play. The small-group exercise was

designed so that teachers with little experience in conducting exercises could

lead a discussion of common intervention issues.

Other exercises in the training materials address issues of organizing the

office and defining roles of staff members. Barriers to implementing an office

system for smoking cessation also are discussed.

Finally, the order of topics covered during the course was considered. As

mentioned above, the NCI manual included the intervention techniques (the

four A’s) within the framework of the office system approach, but this order

was changed somewhat in the training materials. The training materials
359

Chapter 5

included an introduction that briefly addressed the importance of smoking

cessation to patients’ health. The introduction also discussed the crucial role

of physicians and other clinicians in smoking cessation. Finally, the introduction reviewed the literature that demonstrated the impact of brief interventions on smoking among patients.

After the introduction, the course materials covered the four A’s. Didactic material was followed by videotape demonstration of the techniques and

then practice exercises. A short discussion of followup visits was then presented, including the importance of followup and the conduct of a typical

followup visit. A videotaped demonstration of a followup visit was then

shown. The final module of the course addressed the office system approach

with didactic materials, slides, and exercises. A brief closing section reviewed

the highlights of the course. The course materials, titled How To Help Your

Patients Stop Smoking: Trainer’s Guide (US DHHS, n.d.[a]), are contained in

a three-ring binder that includes teaching notes, slides, handouts, and the

videotape.

The final step was the design of materials to train the trainers. Courses

for trainers were considered essential because few health professionals in this

country had experience in smoking cessation techniques. A 1-day course for

trainers was designed. A longer course might have been preferable, to produce trainers who can not only discuss the didactic information comfortably,

but also conduct small-group and role-playing exercises; but, as with the

course for clinicians, a longer course presents more logistical barriers and is

likely to be attended by fewer health professionals.

The trainers’ workshop demonstrated the 3-hour course to the participants and allowed them to discuss the teaching techniques used in the

course. Approximately 6 hours of class time were allowed, so that questions

about the didactic materials and the exercises could be addressed in detail.

New materials were developed for the conclusion of the trainers’ workshop,

and issues relevant to implementing a course were discussed. The material

was designed to involve the participants in a discussion of organizing and

marketing a course to health professionals. That portion of the workshop

was designed to help trainers develop a plan of action for conducting courses

for their colleagues.

Training Activities As training materials were created, a plan was developed to

reach clinicians with the training. An initial goal was to train 100,000

physicians within 3 years. (Subsequent goals were formulated for the training of other health professionals, as discussed below.) The goal was based

on the number of practicing physicians in the United States and the proportion of primary care physicians among them.

A total of 50 workshops to train trainers are planned. With an average

attendance of 40 trainers, 50 workshops will produce 2,000 trainers nationwide. Those trainers then conduct shorter courses (1 to 3 hours) for their
Smoking and Tobacco Control Monograph No. 5

360

colleagues. If each trainer can teach 50 other physicians, a total of 100,000

physicians will have been trained (see Figure 11).

This strategy does not require the development of a new training institution but seeks to incorporate the new course into established continuing

medical education systems. To reduce the prevalence of smoking as rapidly

as possible, initial efforts will be to train practicing clinicians rather than

those still in internship and residency.

In order to reach clinicians throughout the country, NCI sought to

collaborate with medical organizations (e.g., American Medical Association

and American Cancer Society) that shared a commitment to cancer prevention and had a membership of practicing physicians or nurses. National

associations initially approached were those that have state-level components, primary care specialties, and members likely to treat patients in highrisk populations. Through their members, interested organizations were

encouraged to develop policies to sponsor, support, and promote training

for clinicians in smoking cessation techniques.

Agreements with organizations committed to smoking intervention

training were developed for implementing essential activities. Under those

agreements, NCI provided expert faculty for trainers’ workshops, as well as

all training materials (trainer’s guides and videotapes) for each workshop

participant. Participants were also given as many copies of How To Help Your

Patients Stop Smoking as needed for distribution to the clinicians they train.

The collaborating organizations were asked to promote the training to

their members and make special efforts to ensure that the training reaches

physicians who serve high-risk populations. The organizations also convened the trainers’ workshops and, most importantly, recruited the trainers.

Clinicians were sought who already had teaching responsibilities, so that this

class could be easily incorporated into established teaching institutions.

These trainers not only were willing to attend the 1-day workshop, but

also agreed to conduct classes for 50 of their colleagues. The trainers were

also asked to use the NCI training manuals and to keep NCI informed of

their progress in teaching.

Phase I—Training Trainers Phase II—Training Clinicians

50 2,000

× 40 × 50

2,000 100,000

Figure 11

Training 100,000 clinicians

Source: National Cancer Institute, February 1990.
361

Chapter 5

Discussions with the staff and leaders of professional and voluntary

associations made clear that this kind of training strategy works for some

associations but not all. The strategy requires staff time and commitment.

To assure participation by members, association leaders and staff members

must promote and organize the training efforts. In addition, the “train-thetrainers” model will not fit with every association’s continuing education

activities. Some groups already have activities that address the smoking

issue, and some associations do not have continuing education programs in

which to incorporate the NCI course.

Association Support Many medical associations and agencies, however, did adopt

the NCI training into their activities. National associations that have done

the most training have done so by encouraging the participation of their

state affiliates. In particular, the American Cancer Society and the American

Medical Association have formally encouraged their state divisions and

component societies to adopt this project. Both organizations have staff

members at the state level to work on the program, and both have local

affiliates that can reach their members. Networks that allow programs to

reach from national to state to local levels have proved invaluable in the

dissemination of the training.

Several other associations have participated in this training effort. Several medical specialty organizations, even those with less extensive state and

local organizations, conducted trainers’ workshops at their national meetings. State health departments and large HMOs were also very active. Collaborators to date include the American Cancer Society, American Medical

Association, Association of American Medical Colleges, American Medical

Women’s Association, Society of Teachers of Family Medicine, Association of

Teachers of Preventive Medicine, American College of Preventive Medicine,

National Medical Association, many state medical societies, and several large

health maintenance organizations.

Typically, a trainers’ workshop is sponsored by the state medical society

and the state division of the American Cancer Society. After the workshop,

the trainers conduct classes for their colleagues under the auspices of the

sponsoring organizations. In many cases, a state medical society will encourage or assist local medical societies as they work with the trainers to conduct

courses. The classes have been taught as special events, but usually they are

incorporated into ongoing medical education systems. The 3-hour course

can be taught in more than one session. A shorter version of the course also

is taught, often to inform physicians of the need for training in smoking

cessation and to identify those interested in more complete training.

NCI provides trainers with new teaching materials periodically. Among

these materials are new publications that discuss interventions for preventing

tobacco use among children and adolescents. The materials, developed by

NCI with the collaboration of the American Academy of Pediatrics, discuss

brief interventions for use by pediatricians and other physicians who care
Smoking and Tobacco Control Monograph No. 5

362

for children. Included in these materials are discussions of preventing

exposure of children to environmental tobacco smoke, anticipatory guidance

to prevent tobacco use, cessation by adolescents, and the role of physicians

in schools and the community.

NCI reinforces the work of the trainers by providing periodic mailings to

all health professionals they train. These mailings provide new information

on smoking cessation and prevention techniques and augment the training

with new materials and ideas. The NCI staff has also promoted the importance of smoking cessation training in articles in professional journals and

through presentations at medical education conferences.

Clinical interventions in tobacco control are most effective when practiced by more than one health professional in an office and when the intervention is incorporated into routine office procedures. Accomplishing these

tasks requires knowledge and skills on the part of physicians and nurses. For

this reason, training in these techniques is most effective when entire office

teams are trained, rather than just physicians. Whenever possible, trainers

and sponsoring organizations are encouraged to recruit office teams to attend

their classes. Nurses and others of the office staff can make the physician’s

intervention more efficient and effective, and they should receive training

for this role. However, this is not always possible, and training of physicians

alone is certainly valuable.

The training program has reached physicians and nurses in a variety of

practices. The program has been adopted by HMOs, private practices, public

health clinics in State and local health departments, family planning clinics,

and specialty clinics. The trainers have also taught the course to residents,

medical students, nursing students, and other health professionals in training. As of January 1, 1992, 34 trainers’ workshops had been conducted,

which produced more than 1,100 trainers. An estimated 40,000 health

professionals have subsequently been trained by these trainers.

ORAL HEALTH As discussed above, the first efforts to train health care providers

TEAM RESEARCH were directed at those professionals who work in primary care

medical practices, especially physicians and nurses. In 1989,

Design while the training of medical providers was under way, a similar

program for dentists, dental hygienists, and dental assistants was planned.

One study funded by NCI, as well as other trials, demonstrated that dentists

can be as effective as physicians in influencing patients to quit smoking.

Furthermore, it was recognized that oral health professionals, like medical

professionals, see a large proportion of the smoking population every year.

In addition, the oral health team routinely treats adolescents and young

adults, who often have excellent health and therefore do not have frequent

contact with physicians and nurses.
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Chapter 5

Tobacco use commonly produces or contributes to ill effects in the mouth

(Mecklenburg et al., 1992). The dental care team can show patients their own

oral health problems, thereby creating teachable moments, since tobaccorelated conditions in tissues of the mouth often occur years before serious

internal diseases become detectable. Tobacco use intervention is a reasonable

complement to the preventive services common to dental practice.

The dental profession has concerned itself primarily with patients who

use smokeless tobacco products. For example, moist snuff will produce

leukoplakia in the oral mucosa in about half of users within 6 months after

their beginning use. The oral effects of smoking are more diverse and less

frequent. Without clear guidance about scientific methods to help smoking

patients, and because of physicians’ history of concern about smoking, fewer

dentists than physicians have actively helped patients stop smoking.

Strategies In 1989, an NCI program was organized to ensure that the oral health

team and dental organizations are routinely involved in tobacco control

activities. Eight strategies were identified to achieve this goal.

Some NCI dental program strategies included efforts to encourage dental

professional organizations to play a more active role in tobacco control.

Other activities were designed to train oral health care providers in tobacco

control interventions.

Efforts to promote tobacco control as an appropriate function of oral

health care providers were directed at the leaders and members of professional

organizations. NCI convened meetings with organization leaders and committees to advise them of the Institute’s interest in cooperating with the

dental profession and to learn about any reciprocal interest. As a result,

leaders from seven major dental organizations wrote to NCI, expressing

support for NCI’s tobacco control initiative and announcing their desire

to work with the Institute to reduce the public’s use of tobacco.

NCI recognized that dental clinicians would most readily adopt new

tobacco intervention methods in their practices if their own professional

organizations urged them to do so. Thus, several dental organization leaders

were encouraged to introduce and seek approval of organizational policies

and position statements that promoted tobacco control efforts by their members. Established policies were assessed and recommendations made for new

policies.

To promote awareness about problems of tobacco use and methods of

control, a series of symposia, panels, and special presentations were introduced into the annual meeting of several organizations, often using distinguished authorities in the field. Articles and news releases were prepared for

dental organization media. Special announcements about the availability of

NCI consultation and assistance were mailed to organization leaders through

lists provided by dental organizations.
Smoking and Tobacco Control Monograph No. 5

364

To promote communication and coordination among the organizations,

NCI convened the National Dental Tobacco-Free Steering Committee, composed of representatives of 14 national organizations. Nearly all oral health

clinicians in the United States are members of one or more of the organizations represented on the committee. The committee advises NCI about the

most feasible and efficient means to advance tobacco control through the

dental profession. The committee is a forum for organizational information

exchange on tobacco control topics and it provides a means for recognizing

previously isolated initiatives and coordinating dental profession activities

with the larger community of tobacco control activities.

As was done for physicians, NCI assembled an ad hoc committee to

propose methods for rapidly strengthening dental clinicians’ knowledge,

skills, and commitment with respect to control of tobacco use. Four basic

differences from the medical development model emerged. First, the more

generic term “tobacco” would be used instead of “smoking,” because both

smoking and smokeless tobacco are addictive, many users switch or use both

types, and the involvement of dentists emerged primarily through their

concern about the oral effects of smokeless tobacco.

Second, the term “oral health team” would be emphasized because

research suggested that the clinical team approach led to more effective

interventions than did individual efforts. Furthermore, the team approach

promotes flexibility in developing clinical intervention systems.

Third, prevention services would be given attention equal to that for

cessation services. About 75 percent of individuals aged 5 to 17 visit a dental

office each year. Because more than 80 percent of tobacco users begin during

their youth, the oral health team could intervene to persuade children and

youth to avoid tobacco use. An intervention reinforced each year as adolescents grow to adults could help prevent psychological and physiological

addiction.

Fourth, dental education institutions would be approached to encourage

continuing education for graduate clinicians and the integration of tobacco

intervention issues into the undergraduate curriculum. Toward this end, a

special program was presented to faculty members of dental education

institutions prior to specific followup with individual institutions. Dental

institutions have been in transition because of changing patterns of disease.

Thus, many schools have been open to concepts and methods that advance

oral medicine and preventive practice services that had not been widely

taught previously.

Training Methods Efforts to train oral health professionals in techniques to stop

tobacco use, although modeled after the program to train medical professionals, were different. First, there are differences between the practices of

medicine and dentistry that must be accommodated in a training program.
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Second, the dental program was developed later and therefore benefited from

experience gained in the medical program.

Two training publications were created for the oral health team. The

first, How To Help Your Patients Stop Using Tobacco: A National Cancer Institute

Manual for the Oral Health Team (Mecklenburg et al., 1990), was based on the

manual for physicians and nurses but differed in several ways. The dental

manual was organized into three parts with a chronology similar to the

behavioral steps of stopping tobacco use:

• The first part, “Get Ready,” addresses activities to create an office

system to treat tobacco users.

• The second, “Help Patients,” discusses the four A’s. This discussion

emphasizes treating patients who use smokeless tobacco. This section

also includes a discussion about preventing the start of tobacco use

among youth. Brief interventions for use with children and adolescents are described.

• The third part, “Follow Through,” which discusses followup care of

patients, includes a conceptual shift that goes beyond the processes

of patient management. Follow Through asks the oral health team to

work for tobacco control outside the office, that is, as citizens of their

communities and in their personal behavior.

The second document developed was How To Help Your Patients Stop

Using Tobacco: Trainer’s Guide (US DHHS, n.d.[b]). As with the dental

manual, case histories and other discussions of patients were modified from

the medical model to reflect dental practice. An introductory section states

the dental program goal, objectives, and strategy, and helps potential trainers

with planning advice.

The trainers’ workshop for the oral health team was also different from

the physician training program. The physician’s manual was organized such

that course content and teaching methods were combined, so the course was

truly a 1-day train-the-trainers program. The dental program equivalent

taught the entire course content for clinicians during the first half-day. The

first session thus served as a demonstration of the course as NCI recommends

trainers teach it. The second session taught training methods, planning for

training, background information about tobacco industry strategies, counterstrategies for clinicians, and NCI’s Smoking and Tobacco Control Program.

Because the two half-days are separate units, many individuals having an

interest in applications in their own office environment attended the first

half-day only. The second half-day included a high proportion of individuals

who work in educational institutions, are affiliated with training programs,

or have a specific interest in sharing tobacco use intervention information

with professional colleagues.
Smoking and Tobacco Control Monograph No. 5

366

Initial Observations Through work with professional organizations and the conduct

of training programs, significant progress has been made in motivating oral

health professionals to intervene in tobacco use. New tobacco control

policies have now been adopted by professional organizations including the

American Dental Association, National Dental Association, American Association of Dental Schools, American Dental Hygienist’s Association, Academy

of General Dentistry, and American Association of Public Health Dentistry.

At one time, a few dental organization policies did little more than prohibit

smoking during meetings. Now many organizations include comprehensive

policies that address tobacco intervention services, intervention research,

dental professional education, public education, organization administration,

collaboration with nondental organizations, and advocacy. Many policies

urge members to become trained in intervention methods and to assist their

patients. Some organizations have joined coalitions of concerned citizens in

the support of stronger public policy for tobacco control at community, state,

and national levels.

Collaborative training programs have been conducted with national

dental organizations. For example, the American Dental Association has a

long record of supporting tobacco control through its professional development and public education programs. The American Dental Association

developed new programs consistent with NCI tobacco intervention research

results and increased the intensity of its promotion of clinician involvement

in tobacco control issues. The Academy of General Dentistry has sponsored

NCI training and has made the control of tobacco use a high-priority national initiative. This is significant because the Academy of General Dentistry is dedicated to professional excellence through continuing education.

Most NCI training has been sponsored by state dental associations, state

dental hygienist organizations, state health departments, state divisions of

the American Cancer Society, and dental schools. California has conducted

an independent training program through a special initiative. The State

coordinates with NCI and uses NCI manuals and concepts in its dental

courses.

As of January 1, 1992, 24 courses had been held in the United States,

training 1,233 clinicians and 668 trainers. Data on the number of clinicians

subsequently taught by the trainers are now being collected.

Dental assistants’ interest in learning tobacco use intervention methods

has accelerated as the program has progressed. Dental hygienists have been

most responsive to the NCI training program and often may be the program

coordinators for tobacco intervention in dentists’ offices. Tobacco intervention methods are compatible with other preventive oral health services by

hygienists. Tobacco use reduces the benefits of dental hygiene services, so

there is a rationale for hygienists’ involvement in intervention.

A few courses have had participants representing both medical and

dental practices. If one profession is dominant, providing appropriate
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Chapter 5

materials for the other has sufficed. If large numbers of both medical and

dental participants attend, it has been necessary to change the order of presentation of dental materials. For improved flexibility, dental courses held

in 1992 were planned to follow the presentation sequence used for medical

training (i.e., “Introduction,” “Help Patients,” “Follow Through,” and “Get

Ready”).

PROJECT The evaluation of the NCI training project will determine how effecEVALUATION tive the training program is in increasing the use of specific smoking

cessation techniques by health care providers. The following questions will

be answered by the evaluation:

• To what extent do the health care providers trained in NCI courses

incorporate these techniques into their practices; and is there an

increase in the use of these techniques that can be attributed to the

training?

• Among trained health care providers, does the extent of technique

adoption, both in total and in specific techniques, vary with professional characteristics, practice characteristics, training class characteristics, or time since training?

• How many health care providers have been trained through this project?

• What characteristics of trainers predict whether they will actively train

their colleagues, and how have they used the NCI materials to conduct

classes?

The first two questions will be answered by surveys of health professionals

who have been trained. A sample of these professionals will be asked to

complete written questionnaires prior to taking the course and 3 to 6 months

after the course. In addition to asking about personal and professional characteristics, the questionnaire will ask about the use of smoking cessation techniques in their practices.

To answer the third and fourth questions, a telephone survey of all trainers

who have participated in the project will be conducted. Trainers will be asked

to provide details of all training they have conducted. Information about their

own professional activities will also be sought.

CONCLUSIONS This project has attempted to take new information on tobacco control

from clinical trials and rapidly disseminate it to practicing clinicians nationwide. To accomplish this, NCI has sought extensive help from professional

organizations. Such organizations have willingly participated in the NCI

health promotion project, recognizing its value to their clinician members

and to patients.

Primary care professionals have expressed interest in the training program

and have been willing to attend courses on this topic. The cost of this project—to both the Federal Government and participating organizations—is low.
Smoking and Tobacco Control Monograph No. 5

368

The potential public health impact of this kind of program is enormous,

especially in the context of other tobacco control efforts channeled through

schools, worksites, mass media, and the community.

Future activities of the program will include formal efforts to incorporate

this class into more training programs, especially medical and dental schools

and residency programs in primary care. An expanded program directed to

clinicians who care for children will also be implemented. Finally, efforts

will be undertaken to make this information and training available to interested clinicians in other nations through collaboration with international

organizations of health care providers.

REFERENCES

Fowler, G., Mant, D., Fuller, A., Jones, L. The “Help

Your Patients Stop” initiative: Evaluation of

smoking prevalence and dissemination of WHO/

UICC guidelines in U.K. general practice. Lancet

1(8649): 1253-1255, 1989.

Glynn, T.J., Manley, M.W. How To Help Your Patients

Stop Smoking: A National Cancer Institute Manual for

Physicians. U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, National Cancer Institute. NIH Publication No. 90-3063, 1990.

Kottke, T.E., Battista, R.N., DeFriese, G.H., Brekke,

M.L. Attributes of successful smoking cessation

interventions in medical practice: A meta-analysis

of 39 controlled trials. Journal of the American

Medical Association 259: 2882-2889, 1988.

Mecklenburg, R.E., Christen, A.G., Gerbert, B., Gift,

H.C., Glynn, T.J., Jones, R.B., Lindsay, E., Manley,

M.W., Severson, H. How To Help Your Patients Stop

Using Tobacco: A National Cancer Institute Manual

for the Oral Health Team. U.S. Department of Health

and Human Services, Public Health Service,

National Institutes of Health, National Cancer

Institute. NIH Publication No. 91-3191, 1990.

Mecklenburg, R.E., Greenspan, D., Kleinman, D.V.,

Manley, M.W., Niessen, L.C., Robertson, P.B.,

Winn, D.E. Tobacco Effects in the Mouth: A National

Cancer Institute and National Institute of Dental

Research Guide for Health Professionals. U.S.

Department of Health and Human Services, Public

Health Service, National Institutes of Health,

National Cancer Institute/National Institute of

Dental Research. NIH Publication No. 92-3330,

1992.

U.S. Department of Health and Human Services. How

To Help Your Patients Stop Smoking: Trainer’s Guide.

U.S. Department of Health and Human Services,

Public Health Service, National Institutes of Health,

no date (a).

U.S. Department of Health and Human Services. How

To Help Your Patients Stop Using Tobacco: Trainer’s

Guide. U.S. Department of Health and Human

Services, Public Health Service, National Institutes

of Health, no date (b).
369

Chapter 5

APPENDIX A

Case Studies

The following case studies demonstrate how three communities have

implemented the COMMIT standardized protocol. The protocol defines

minimum criteria to ensure quality control, and the process objectives help

all sites conform to the standardized quantity of intervention.

SANTA FE, The Health Provider Task Force (HPTF) activities in Santa Fe reflected

NEW MEXICO the unique personality of the city, an internationally recognized

center for the arts and entertainment. Not surprisingly, the HPTF chose

to produce a videotape on smoking cessation as its first major project.

Physicians and dentists from the task force were filmed at their workplaces:

a local health maintenance organization, the cardiac intensive care unit of

the hospital, and a dental office. The chairman of the medical society and

the hospital administrator also appeared. The videotape was distributed to

all primary care physicians and dentists in Santa Fe. Physicians completing

the accompanying evaluation form received 1 hour of CME credit and had

their names listed in local newspaper advertisements encouraging smokers

to “Ask-A-Doc” for help in quitting.

Santa Fe also was the site for the “Emphysema Slims” Tennis Tournament in 1990. This national antismoking event is sponsored by Doctors

Ought to Care. The New Mexico President of DOC, a member of the HPTF,

worked tirelessly to attract television personalities and other celebrities to

help support the project, organize the city’s first hot-air balloon event, and

involve local and national media.

Santa Fe is unique also in supporting a spectrum of “alternative healers.”

The phone directory lists more than 40 acupuncturists, an equal number of

chiropractors, and a number of hypnotists, naturopaths, and massage therapists. The chiropractors are the best organized, and their client population is

from all socioeconomic strata. The opportunity to bring smoking cessation

information to people who might not frequent allopathic physicians and the

literature associating smoking with low back pain (Deyo and Bass, 1989;

Lanier and Stockton, 1988) prompted the COMMIT staff in Santa Fe to

organize a meeting with local chiropractors. The meeting outlined the goals

and structure of COMMIT, the relationship of smoking and low back pain,

options for patient intervention, establishing smoke-free offices, and opportunities for training in cessation counseling skills. As a result of the meeting,

Santa Fe chiropractors have participated in each of the COMMIT task forces,

and the chiropractic association is considering recruitment of a student from

a chiropractic college to come to Santa Fe to prepare a teaching module on

smoking and low back pain. By choosing to participate as individual members of established task forces, rather than organizing their own independent

task force, the chiropractors have averted potential conflicts with physicians

who might not want to be associated with a highly visible chiropractic

initiative in the community.
Smoking and Tobacco Control Monograph No. 5

370

The Santa Fe HPTF activities demonstrate the importance of individuals

in creating opportunities for action. One physician member had a weekly

radio program: Smoking-related issues figured even more prominently on

his show after COMMIT began. After attending the American Medical

Association’s annual media training workshop, he took a lead role in producing the health provider videotape. A local pediatrician joined the HPTF,

appeared in the video, became a speaker on pediatric aspects of smoking, and

participated actively in developing a pediatrics initiative. The latter included

T-shirts with relevant messages for pregnant women and newborns; a videotape on cessation for pregnant, low-income women; and cessation classes for

women attending the WIC (women, infants, and children) nutrition program

in Santa Fe. A family practice physician who had been leading smoking

cessation classes in his own office for many years was able to win support

for a cessation class at the Santa Fe hospital. The attendees were nurses,

respiratory and physical therapists, and other hospital staff. The hospital

administration was very supportive, arranging coverage for those employees

attending the classes. The need for such an in-hospital program was not

apparent until this trusted local physician offered his services.

Despite the enthusiasm of task force members, attracting other physicians and dentists in the community to attend advanced training workshops

in smoking cessation was extraordinarily difficult. Providing continuing

education credits, scheduling the workshops at convenient times and at

attractive locations, and offering door prizes did not prompt sufficient

interest to put on a workshop. It became clear that the health providers

who joined the task force were not representative, with respect to recognizing

the importance of smoking cessation, of the general medical and dental

community. Most doctors and dentists were unwilling to give up 3 hours

of their time for cessation training. Workshops were finally arranged

through a contract with a physician to telephone health providers directly,

inviting them to the workshop, scheduling the workshop in conjunction

with a state medical meeting, and including outside speakers of national

reputation. Another successful approach was to schedule training sessions

over the lunch hour in providers’ offices. When a task force physician or

dentist was included in these extended lunch-hour sessions, the office

physician or dentist would often join his or her staff (nurse, receptionist,

dental hygienist) in learning about counseling skills, office procedures to

promote cessation, and followup strategies. Further participation by physicians was encouraged through a newsletter. The first issue of the newsletter

reviewed diagnostic codes that might be used to bill third-party payers for

smoking cessation services.

The lessons learned from the activities of the Santa Fe HPTF include the

importance of physician-to-physician contacts in providing information and

promoting participation by community providers; the value of office-based

educational approaches that include the entire office team in efforts to

establish smoke-free policies and to identify, counsel, and support smokers’
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Chapter 5

quit attempts; the need to have a broad representation of the health provider

community, not just the “activist” members; and the desirability of designing initiatives around the skills and interests of individual task force

members.

BRANTFORD, Brantford, Ontario, a city of 90,500, is surrounded by farmland and

ONTARIO, located on the edge of the most populated area in Canada. There are

CANADA 72 primary care physicians and 35 dentists practicing in the city and

2 major health care facilities.

Several features of Canadian health care are important to understand, as

they affect the implementation of the COMMIT protocol. Family medicine

is a popular specialty and accounts for 80 percent of the total practicing

physicians in Brantford. Most of the family physicians are in solo practice

(87 percent), and not all physicians employ a nurse as a team member.

Dentists also tend to be in solo practice, and most employ a dental assistant

or hygienist.

Although all Ontario residents are covered by health insurance, smoking

cessation counseling is not always a billable service. The COMMIT task force

has taken action on this issue and through requests to the Ontario government has successfully convinced the health insurance policymakers to

reimburse most tobacco-related visits.

During the early organization of the COMMIT board and task forces, the

planning committee identified two physician leaders who have been central

to the organizing and implementing of the health care provider protocol

activities. The physician leaders have been key individuals in the creation

of smoke-free environments in the city’s hospitals, and one was known for

his ability to give excellent presentations on smoking issues. These two

physicians are from the mainstream of the practitioners in town; they are

viewed as leaders but not extremists.

The HPTF has wide representation from the community, including

physicians, public health nurses, occupational health nurses, pharmacists,

chiropractors, dentists, and respiratory therapists. This group has met

consistently and carried out the activities required. There have been many

training events, and all process objectives regarding the number of professionals attending training have been met.

One of the comprehensive training workshops was attended by both

physicians and chiropractors. This was a first in Brantford and has led

to a clearer understanding of the roles of different professionals in the care

of smoking patients. Referrals between physicians and chiropractors have

become part of normal practice for those individuals who attended this

joint training session.

Oral health team training is an innovation in Ontario. Although there is

strong leadership from the team that was trained to conduct training events,
Smoking and Tobacco Control Monograph No. 5

372

it has been difficult to attract dentists and their staff to workshops. The

COMMIT staff will try a new marketing strategy for the next event that will

first attract the attention of the hygienists.

The Public Health Service in Canada operates differently from that in the

United States. Through the Canadian Public Health Service, nurses access

schools and homes to offer a variety of services that make them potential key

players in the COMMIT interventions. Public Health Service nurses are able

to work in neighborhoods and are working with COMMIT staff to develop

neighborhood cessation programs. Neighborhood physicians will provide

counseling as part of these programs.

In general, the task force has been concerned about the focus on physicians and oral health teams without requiring activities for other health care

professionals. Therefore, from the beginning of the project they have been

creative regarding the inclusion of activities for Public Health Service nurses,

chiropractors (as mentioned above), and pharmacists.

There is strong support in Canada from the profession itself for pharmacies to stop selling tobacco. The task force has facilitated a community-wide

letter-writing campaign in support of banning tobacco products in pharmacies. The pharmacist on the task force represented one of the first stores in

Brantford to stop selling tobacco products.

Ensuring that offices are set up to support effective physician and dental

interventions is a cornerstone of the health care provider interventions. This

activity that motivates and helps receptionists and other staff to implement

chart cueing, monitoring, and provision of self-help materials is one of the

most challenging of the COMMIT activities. It is not enough to convey the

importance of these procedures at the physician and dental training events.

It is apparent that most offices do not get organized until a staff person from

COMMIT visits the office and helps them establish their system of cueing,

monitoring, and ordering resources. It will be important to build this function into the staff requirements in the dissemination stage of COMMIT

activities for health care providers.

As one would expect in a volunteer committee, individuals make different contributions to the project. However, it is important that three or four

key people have continued to be present and give their time and leadership.

It is often difficult to find health care professionals who will give this level

of support to a project, because time spent at meetings often means time lost

from seeing patients and, therefore, a financial loss. Nevertheless, we have

found that there are individuals who will make this contribution, and our

perception is that without them the project would not succeed.

PATERSON, Paterson, New Jersey, is an urban area with a predominantly poor

NEW JERSEY minority population. The largely black and Hispanic citizenry is confronted by high rates of poverty, crime, drug abuse, poor housing, and high

school dropouts. Despite this, the COMMIT protocol has been accepted by
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Chapter 5

the community board, and virtually all of the mandated activities are being

carried out with vigor and imagination. In many respects, the HPTF has led

the way.

Three large hospitals and many health clinics that serve Paterson have

representatives on the board and task forces. By year 2 of the trial, all of

them are smoke-free, and they provide a variety of smoking cessation activities and services for their employees and the public. They have actively

participated in the Great American Smokeout during each year of the trial

to date, and they also participated in two major events (e.g., “Quit Month,”

“Cancer Education Month,” “Blood Pressure Month,” “Non-Dependence

Day”). The hospitals and clinics work closely with COMMIT in sponsoring

health screening, inviting speakers to symposia, and continuing education

activities, all of which include the topic of cigarette smoking on the agenda.

Several Paterson physicians and dentists, as well as other health professionals, have stepped forward as influentials. To date, one Paterson hospital

has sponsored grand rounds on smoking, and the HPTF has carried out three

all-day symposia and workshops on smoking cessation for health professionals (comprehensive training).

Paterson physicians and dentists who attend the comprehensive training,

as well as many others, received an office visit from a COMMIT community

organizer who works under the direction of the HPTF. The organizer then

carries out basic training for the physicians and dentists and their staffs and,

in many cases, “Office Training and Activation of Office Staff.” The content

of these visits may vary, but certain features remain constant and provide

necessary structure for the community organizer as well as the physicians or

dentists and their staffs. Typically, the organizer will select a time when the

office is relatively free. At lunch time, he will bring pizza or sandwiches and

soda. We use the National Heart, Lung, and Blood Institute video, “Making

A Difference,” for training physicians in smoking counseling. The office

staff member, physician, or dentist then is presented with a comprehensive

smoking cessation program in the form of the American Heart Association’s

Heart Rx kit or the American Academy of Family Physicians smoking counseling kit. These kits provide guidelines and material for mobilizing the

office, counseling patients, and followup.

After discussion of the film, the kits, and COMMIT, the organizer

assists with setting up the waiting room area to reduce smoking. He supplies

brochures, buttons, key chains, and posters. Wall racks and a plastic brochure holder are distributed to provide easy access to self-help stop-smoking

and health material. Information on the Great American Smokeout and Quit

and Win, as well as the COMMIT newsletters and other events of interest are

routinely displayed and distributed.
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374

It is not sufficient to visit busy offices on only one occasion and expect

to have a major impact on office behavior. The community organizer serves

as a “drug detail representative,” returning to the office many times per year

with refill material, new brochures, newsletters, and publicity. Events such

as the Great American Smokeout (November), Heart Month (February), High

Blood Pressure Month (May), Non-Dependence Day (July), and Quit and Win

(Fall) provide occasions for the community organizer to return to the offices

to reinforce and support the staff and doctors. A recent “Ask Your Doc”

campaign provided still another occasion to keep in close contact with

the health care community.

In inner-city urban environments, reaching out to the community may

be more important than it is in more affluent, middle-class communities.

This is accomplished in Paterson, under the leadership of the HPTF, by the

COMMIT community organizer traveling with high blood pressure teams

sponsored by the hospitals and the Paterson health department. Typically,

these teams travel to churches, social service agencies, worksites, and community organizations to measure blood pressure and identify hypertensive

individuals. We also measure expired air carbon monoxide of smokers,

distribute self-help and related material, enroll smokers in the network,

and inform them of smoking cessation activities in the community.

In summary, despite real social problems and competing issues, the

COMMIT protocol for health care settings has proved applicable to Paterson.

Health care facilities are smoke-free; physicians, dentists, and other health

professionals are being trained and mobilized; and the health care community participates in many community events and activities. A cessation

resource guide is distributed, and health care facilities are used to recruit

smokers into the network and related smoking cessation activities. Despite

this, there is concern that, in a 4-year intervention, physicians and dentists

will lose their competitive edge and stop counseling smokers, flagging charts,

and selecting quit dates. We try to counter this by returning to their offices

and clinics periodically, by keeping in contact through the mails, and by

providing certificates of appreciation for their involvement. Still, smoking

counseling is a frustrating business with few rewards. It is hoped that the

community-based nature of COMMIT and its comprehensive approach will

yield success.
375

Index

Index

abstinence from smoking 55, 71, 87, 99, 108,

160-161

hospital patients 152

long-term 6-7, 99, 108

TRACC intervention, rates of 148-150

(see also quit rates, smoking)

abstinence from smokeless tobacco 160-161

academic detailing 8, 10, 302, 349, 353

Academy of General Dentistry 366

adolescents, tobacco use

and carbon monoxide testing 163-164

and problem behaviors 164-165

counseling by pediatricians 229-230, 232,

238-244

followup to intervention 163-164

initiation of smoking 4-5

interventions 46, 162-166, 361-362, 364-365

prevalence of smoking 232

prevention of 340, 361, 364-365

quit attempts 164-165

ST cessation programs 157

Adult Use of Tobacco Survey (AUTS) 17-21

advertising

cigarette 27, 29, 31

of clinic smoking intervention 79, 81

tobacco products 7, 232

advice to quit smoking

algorithms for delivery of 262-264, 288-291

alone, physician intervention 144-149, 189, 191,

194, 196, 199-202, 224

booster sessions 262, 264-265, 269-270

brief 92, 94-96, 145, 202, 240

chemical workers 272-280

clinical trial 92-98, 170

confidence in 92, 95-96

demographic factors 18-19, 21

dental practice 157-161, 272, 274

dysfunctional reactions to 279, 284

effects of 21, 273-274

experimental 262-263, 288-291

head and neck cancer patients 262

initial 262, 288-289

institutionalization of 301

negative reactions to 273, 279-280, 284

parents’ attitudes 236-238, 241

patients’ attitudes 24-25

patients report receiving 3, 17-20, 117, 130

pediatricians 230, 233-236, 241

personalized 60, 66, 242, 260

physician and dentist study groups 117, 130

physicians 7-9, 21, 24-25, 50, 88-89, 117, 160,

272-280, 301-303

physicians compared to team approach 145, 149

physicians report giving 3, 20-21

recommendations for giving 280

reminder sheets 95, 175-177

repeated 79, 260

resident training 189, 191, 194, 196, 199

role-play for delivery of 263

samples of 196, 223-225, 288-297

timing of 267

training in 94-96, 278

usual care 262-263, 288

with nicotine gum 92, 95-99

(see also counseling, smoking intervention;

smoking interventions)

African Americans

see black smokers

age

of smokers 12-13, 19, 21

of ST users 159

alcohol 98, 231, 265, 269

American Academy of Family Physicians,

smoking counseling kit 75, 373

American Academy of Pediatrics 361

American Cancer Society 257, 344, 360-361, 366

cancer prevention recommendations 324-325

self-help materials 155-156, 282

American Dental Association 128, 135, 366

American Heart Association 257, 373

American Lung Association 146, 257, 344

self-help materials 156, 282

smoking cessation program 275

American Medical Association 25, 360-361

anticipatory guidance, pediatrician 240,

243-244

antismoking messages 34-35

Asians/Pacific Islanders 12-13, 111, 261

assessment of smoking status 13-14, 116,

130-131, 133-134, 139, 144, 146, 153, 155, 257,

321, 323, 328-329

associations

dental, NCI collaboration 363-364, 366-367

medical, training programs 360-362

attempts to quit smoking

see quit attempts

attitude and practice questionnaire 115, 121,

129, 135

attitudes of parents

about effects of their smoking on children

236-238

about pediatrician counseling 230, 236-238, 241

attitudes of patient to provider intervention

24-25, 247
376

Smoking and Tobacco Control Monograph No. 5

attitudes toward smoking intervention,

physician 48, 52, 82, 87-88, 102, 109-110, 203,

254-255, 260, 263, 330-332, 342, 352

pediatricians 233-236, 239, 241

residents 199, 209-210, 213-215, 239-240, 266

audit-with-feedback interventions 330, 332

barriers

to effectiveness of office-based interventions 10,

254-255

to implementation of training programs 208,

220-221

to pediatrician intervention 233, 235, 238-241,

244

to physician smoking interventions 88-89, 143,

265-266, 303, 321, 329, 341-342, 352

to smoking cessation 7, 104, 151, 195, 211-212,

265-266, 281, 292

bedside counseling in hospital 154-155

behavior

change 24, 344-346, 352-353, 356, 358

counseling, smoking intervention 189, 192, 194,

196, 199-203

shaping 72, 87

skills training 229, 231

therapy and smoking cessation 98, 100

beta-naphthylamine, exposure to 275, 277

biochemical validation of smoking status

57, 102, 105-106, 110, 115-117, 123, 127, 131,

213, 247

carbon monoxide analysis 92, 96, 115-116, 127,

131, 146-148, 150, 163-165, 213, 215

cotinine analysis 57, 164-165, 247

black smokers 12-13, 19, 21, 111, 128, 261, 372

Blue Cross/Blue Shield of Minnesota 75-76

Blue Plus 75-78, 81, 304, 307-308, 319

booster sessions, smoking intervention 262,

264-265, 269-270

sample of 289-291

training sessions 204-205

California Tobacco Survey (1990) 12-14

Canada

COMMIT implementation 337, 371-372

smoking cessation interventions 45, 48, 53-67

cancer

bladder, chemical workers at risk of 229, 231,

272-284

cervix 26

esophagus 156-157

head and neck, interventions for 229, 259-270

larynx 156-157, 259, 261

lung 25-26, 259

oral 156-157, 259, 261

pharynx 259, 261

radiation therapy for 260, 267

squamous cell 259-261, 267

ST-associated 156-157, 259, 261

stomach 156-157

cancer prevention reminder system (CPRS)

321-333

Cancer Prevention Research Consortium 308,

343, 346-347

carbon monoxide testing

see biochemical validation

cardiovascular risk 16, 26

change, behavioral 24

stages of 344-346

techniques 356, 358

transtheoretical model of 344-346, 352-353

charts, patient 46, 54, 56, 62, 146

clinic review of 311-312

computerized CPRS 323, 326-327

flagging 13-14, 241-242, 264

labeling of 72-73, 304-305, 314

marking systems 116, 122, 125-126, 129,

136-138, 140

notes on smoking assessment 256-257

prompt 189, 207, 210

reminder system 207, 210

reminders 46, 116, 125-126, 129, 140, 264

smoking record card 314

chemical workers

bladder cancer risk and smoking 272, 274-275,

284

exposure to carcinogen 272, 274-275

medical/dental advice and counseling 229, 231,

272-276, 278-280

recruitment for intervention 274-278, 283

children

asthmatic 233-234

exposure to environmental tobacco smoke 29,

230, 362

parental smoking, effects of 220, 230, 232-234,

238

parents’ attitudes about pediatrician counseling

of 239

pediatrician smoking intervention 229-230, 232,

239-243

prevalence of smoking 232

prevention of tobacco use 229-230, 232,

239-240, 243, 361-362, 364-365

respiratory illness 232-234, 242

tobacco use intervention 361-362, 364-365

chiropractors 337, 369, 371-372

cigarettes

advertising 27, 29

and ST use 159-161

demarketing 29, 31

first of day 71, 217-218

initiation 4-5

marketing 31

clinic-based smoking interventions 7-9, 69-89,

305-313

Blue Cross/Blue Shield 75-76

Blue Plus 75-78, 81, 304, 307-308, 319
377

Index

components of 72-73

cost-benefit adequacy 79, 81

Doctors Helping Smokers 69-89

Doctors Helping Smokers collaborations 75-89,

304-308, 314-315, 318

environment program 72-73, 79-81, 83, 89

feedback system 79, 81

HMO Midwest 75-76

level of implementation 82

marketing and advertising 79, 81

Nokomis Clinic 14-15, 72-75, 79-80, 304-305

orientation program 79-80

patient experience 84-85

patient surveys 84, 311-313

physician participation 78-80, 82-83, 87-89,

305-307

program evaluation 79, 81

recruitment for 70, 76-79, 81-82, 86-88

research environment 72-73

spirit-building component 79, 81, 83

stress of clinic 306-307

support staff 78-80, 82, 84, 89

supporting elements 74

clinic environment program 72-73, 79-81, 83,

89

clinic quality improvement 301, 303, 319

Clinical Interventions To Prevent Tobacco

Use by Children and Adolescents 239-240

clinical trials, smoking intervention 158, 191,

342-343, 347, 352, 356-358, 362

design 213

phase III 145, 342

physician advice 92-98

Quit for Life 104-109

recruitment for 92-94, 193-194

resident smoking interventions 207, 213-221

CME

see continuing medical education

COMMIT

see Community Intervention Trial for

Smoking Cessation

community

awareness and action 33-36

smoking outcome measures 347, 352

community-based physician interventions

45, 53, 302, 342-344, 346-348

Community Intervention Trial for Smoking

Cessation (COMMIT) 51, 302, 334-341,

369-374

case studies 337, 369-374

community organizer 373-374

design and endpoints 335

goals 334-337

physician and dental training 337-340, 371-373

protocol 334, 336-337, 369, 371, 374

workshops 338-339, 370-371, 373

computerized reminder system 302, 321-333

consent form 93, 97, 115, 123, 128, 170

continuing dental education 338-339, 364, 370

continuing medical education (CME),

smoking intervention

associations 361

methods 51

objectives 49-50

office-based 48-52, 54, 349-351

physician attitudes 52

physician counseling 103, 106, 108, 111

physicians 48-52, 54, 59, 62, 338-339, 349-351,

360

protocol for McMaster/Waterloo Project 53

workshops 59, 62, 94, 370

(see also training programs, smoking

intervention)

continuity of care 10, 265-266

continuous quality improvement (CQI) 10,

309-311

system for smoking cessation 311-319

contract to quit smoking 32, 55, 67, 196-197,

260, 264-265

adolescent/child 243

cost-benefit adequacy of clinic intervention

79, 81

cotinine analysis 57, 164-165, 247

counseling, physician training 189-191, 194,

196-197, 199-200

advice alone 189, 191, 194, 196, 199

amount of time 203

counseling skills 269, 351

frequency of 190

maintenance of skills 199-200

patient-centered behavioral 194-197, 203-204

plus nicotine gum 189, 191, 194, 197, 199

prompts 189-190

research/questions to resolve 203-204

resident training 189-191, 194, 196, 199, 203

samples 196, 198, 223-226

tutorials 189-190

counseling, smoking intervention

attitudes, patients 24-25

behavioral 194, 199-202

clinical trials, residents 207, 213-221

content 213, 215-218, 220

cost-effectiveness 102, 110-111, 149

CPRS 321-333

dental patients 130

dentists 24-26, 143, 157

examples of 224-225

flowchart 210-212, 278

four A’s 13-15, 240, 242-244, 350, 357-359, 365

frequency 213, 215-218, 220

in hospital 154

minimal contact 207-210

nature of 280-283
378

Smoking and Tobacco Control Monograph No. 5

NCI protocol 350

nurse-assisted 46, 52, 109, 144-151, 166

of chemical workers 229, 231, 275-276

of children and adolescents 229, 232, 239,

241-243

of head and neck cancer patients 231, 259-270

of parents 229-230, 232

of pregnant women 229-230, 233, 246-258

of women 246-247

patient reports of 117, 214, 217

physician practices 25, 102-104, 109-111,

143-150, 214-216, 301-302

physician vs. patient reports 217-218

resident training 189, 192, 194, 196, 199, 203,

207-212, 220

self-efficacy 274, 276, 281-284, 295-297

special practice settings 229-244

steps in process 103-104

strategies for 30-33

team approach 143, 145, 149-151, 165-166

techniques 103-104, 213-214

training of nurses 251-254

training of physicians 103, 107-108, 246, 351

tutorial 207, 209-210, 213, 215-218

use of prompt 189-191, 207-210, 213, 215-218

(see also advice to quit smoking; smoking

interventions)

counselors, smoking cessation 275-276, 281

training 276, 283-284

CPRS

see cancer prevention reminder system

CQI

see continuous quality improvement

demarketing of cigarettes 29, 31

demographics of smokers 12-13

and advice to quit 18-19, 21

dental associations 363-364, 366-367

dental education 337-340, 364-365, 370

(see also training programs, smoking

intervention)

dental professionals, tobacco use

intervention

differences from medical model 364

NCI training 362, 366-367

smokeless tobacco intervention 157-162

smoking intervention 14, 135, 340

training, COMMIT 340

training manuals 365

(see also oral health team)

dentists, smoking interventions 9, 13-15, 143,

157

advice to quit smoking, chemical workers 272-280

attitude and practice questionnaire 129, 135

barriers/problems 133-135, 139

compared to medical 113, 141

comparison of approaches 137-138

continuing education 337-340

counseling behavior 138-140

feedback reports 129

followup 159-161

maxillofacial prosthodontists 229, 231, 259-260,

266, 268-270

NCI program 362-367

NCI studies 113, 127-141, 362

of head and neck cancer patients 231, 259-270

office staff 27-28, 132-138, 140-141

patient reports of counseling by 130

patient visits per year 25, 364

provider acceptability/attitude 160

quit rates 131-132

receptivity of patients 157, 160

recruitment 45, 301-302

recruitment for studies 128, 133-135, 139

role in COMMIT 336-337, 340-341

role of 4, 9-10

success of intervention 160

surveys of practices 102, 109

training 45-46, 128-130, 135-137, 268-270,

301-302

training, COMMIT 337-340, 370, 373

dentists, tobacco use intervention 363-367

ST 46, 157-162, 363-365

determination of smoking status 13-14, 116,

130-131, 133-134, 139, 144, 146, 153, 155, 321,

323, 328-329

diffusion theory, smoking intervention

343-344, 346-347, 353

dissemination

of interventions 301-302, 342-353, 356, 367

of training 361

process 343

Division of Cancer Prevention and Control

334

Doctors Helping Smokers (DHS) 12, 45, 69-89,

304-308, 314-315, 318

Doctors Ought to Care (DOC) 27-28, 34-35, 340,

369

education

associations 361

continuing dental 364

level of patient and advice received 13, 19, 21

of physicians, use of nicotine gum 104, 110

(see also continuing medical education;

training programs, smoking

intervention)

educational materials

for dentists 365

for office staff 351

for patients

see self-help materials, smoking cessation

for physicians 75, 239-240, 257, 351, 357-360

on snuff 159

“Enough Snuff” 159
379

Index

environment, clinic 72-73, 79-81, 83, 89

environmental stimuli 6-7

environmental tobacco smoke 29, 36, 230, 362

examples of physician interventions 196, 198,

223-226

exit interview 57, 64, 123, 138, 213-215, 217-218

experimental intervention 262-263, 288-291

face-to-face interaction 86, 260

Fagerstrom tolerance scale 95, 261

family practice physicians, smoking

interventions 92-100, 120

clinical trials 207, 213, 215, 220

computerized reminder 321, 323, 332

counseling 207, 229, 239, 332

Quit for Life project 102-103

recruitment for trial 92-94

training 45-46, 48-50, 53, 193-194, 207, 210,

213, 239

Family Practice Smoking Cessation Project,

McMaster/Waterloo 48, 53-67

fear arousal 279-280, 282, 284

feedback system 79, 81, 97, 330, 332

female smokers

health risks 25-26

lung cancer 25-26

physician visits 12-13

pregnant 26, 229-230, 233, 246-258, 370

report receiving advice to quit 18, 21

flowcharts

CQI system 314-317

smoking counseling 210-212, 278

flowsheets 329, 332

for patient office visit 55-56, 62

FOCUS-PDCA cycle 310-318

followup, dental ST intervention 159-161

followup, resident tutorial 190, 220

followup, smoking intervention

1-week 211

6-month 71-72, 92, 96, 184, 191, 198, 200-201,

214, 218-220

12-month 71-72, 191, 198, 201

18-month 191, 198

24-month 191, 198

adolescents 163-164

by nurses 252

by pediatricians 242-243

difficulty implementing 306

head and neck cancer patients 262, 269-270

hospital patients 154-156

how to deal with 50-51

interviews 70-71

letters 197, 200

long-term 49, 65-67, 191

maximal 191, 197-198, 200

minimal 191, 198, 200

nurse-assisted, TRACC program 144-150

office 33, 134, 357

oral health team 365

patient characteristics 67

patient flowsheet 56

patient reports and perceptions 64-65

postcards 262, 264-265, 270

questionnaires 95-96, 183-185

Quit for Life 103-105, 107

telephone 33, 46, 197-198, 200-201, 203, 269, 305

training 63-64, 359

use of nicotine gum 185

videotape of 359

visits, structuring and timing of 61-62, 66

visits, supportive 54-55, 61

(see also quit rates, smoking)

four A’s of patient counseling 13-15, 350,

357-359, 365

use by pediatricians 240, 242-244

generic reminder sheet 95, 175

grand rounds, smoking intervention 8-9, 115,

348, 373

Great American Smokeout 7, 373-374

gynecological patients 229-230, 246-247,

256-258

head and neck surgeons 229, 231, 259-260, 263,

266-270

Health Care Provider Task Force 337-338, 341

health care providers

barriers to smoking intervention 341

in COMMIT 336-337, 340-341

training, COMMIT 337-340, 371

health effects

of passive smoking 232-234, 237-239, 242

of smoking 25-26, 229, 259, 272-275, 278,

280, 288

of ST use 26, 156-159, 363-364

health maintenance organization (HMO)

304, 306-307

adolescent smoking cessation intervention

162-166

clinical trial recruitment 104, 106

HMO Midwest 75-76

intervention study 120, 122-123, 125

office staff involvement 106-108

pregnant smokers’ intervention 248, 256

smoking intervention training 46

smoking intervention trials 102-111

surveys of internists 109-110

TRACC smoking intervention 143-151

Health Provider Task Force (HPTF) 369-371,

373-374

health risks, screening questionnaire 92-93,

169

health status, self-reported 12-14

Hispanics

COMMIT 335, 372

head and neck cancer patients in intervention

261
380

Smoking and Tobacco Control Monograph No. 5

smokers, physician visits 12-13

smoking behavior 111

Hospital Corporation of America (HCA)

310-311

hospitals

activities, smoking cessation 373-374

patients, smoking intervention 46, 151-156

smoke-free 152-153, 371, 373

hotline, stop smoking 6, 146, 150, 163

How To Help Your Patients Stop Smoking 75,

239, 257, 357, 359-360

How To Help Your Patients Stop Using

Tobacco 365

HPTF

see Health Provider Task Force

hygienist, dental

see dental professionals, tobacco use

intervention

individualizing interventions 29-30

initial advice 262, 288-289

institutionalization of smoking intervention

8, 301

intention to quit 48, 57-58, 92, 95-97, 236, 238

internal medicine, smoking interventions

clinical trials 207, 213, 215, 220

CPRS intervention 321, 323, 332

HMO 102-107

NCI intervention study 113-114, 120

primary care trial 92-98

private practice 102-103, 105-107

recruitment for trials 92, 104-105

surveys of 102, 109-110

training 46, 193-194, 207, 210, 213, 215, 220,

239

intervention strategies for physicians,

summary 351

interventions, smokeless tobacco

see smokeless tobacco interventions

interventions, smoking

see smoking interventions

Johns Hopkins Medical School, smoking

prevalence 15-17

Johns Hopkins Precursors Study 15-16

Kaiser Permanente 46, 103-104, 106-107, 152

adolescent smoking cessation interventional

162-165

Dental Care Program 158

nurse-assisted smoking intervention 144-145,

147-148, 151

Latinos

see Hispanics

leadership, clinic smoking intervention

306-307

legislation, smoking-related 340

linkage system, diffusion of interventions

344, 347, 353

magazines

cigarette advertising 27

in waiting rooms 27-28

sticker for 28

without tobacco advertising 38-39

maintenance of smoking cessation 87, 262,

264-265, 270, 273

male smokers

lung cancer 25

physician visits 12-13

report receiving advice to quit 18, 21

marketing

of cigarettes 27, 29

of clinic smoking intervention 79, 81, 83

of educational events 52

McMaster/Waterloo Project 48, 53-67

media

and legislative advocacy, training in 340

campaigns 6-7

medical associations, training programs

360-362

medical materials development 356-359

medical records

computerized system 323, 326, 329

prompt on 189-190

(see also charts, patient)

medical screening form 93, 174

medical students, smoking prevalence 12,

15-17

meta-analysis of smoking cessation trials

71-72, 87, 240, 303, 358

minimal-contact smoking counseling 207-210

minimal followup to smoking cessation 191,

198, 200

Minnesota Heart Health Program 69-70

morbidity and mortality, smoking 25-26, 28,

35

motivation

and physician reinforcement 102, 104, 260

money 30-32

of health care providers, smoking intervention

8-9, 50, 97, 260, 301

to quit smoking 7, 28, 30-33, 102, 104, 111, 195,

209, 211, 214, 272, 274

National Cancer Institute (NCI)

associations, collaborative training programs

360-364, 366-367

Cancer Prevention Research Consortium 343,

346-347

clinical trials, smoking intervention 106, 334,

342-343, 347, 352, 356-358, 362

COMMIT 51, 302, 334-341, 369-374

counseling protocol 350

dental program strategies 363-364

dental team training programs 127-141

dentist manuals 365

Division of Cancer Prevention and Control 334
381

Index

Doctors Helping Smokers 12, 69-71, 75-89,

304-308, 314-315, 318

elements of medical advice 272

four A’s of patient counseling 13-15, 240,

242-244, 350, 357-359, 365

How To Help Your Patients Stop Smoking 75, 239,

257, 357, 359-360

How To Help Your Patients Stop Using Tobacco 365

medical and dental models compared 364-365

oral health team training 362, 364-366

patient materials 146, 155, 197, 327

phase III trials 342

phase IV studies 343, 347, 352

physician and dentist interventions, studies of

113-141

physician manuals 75, 239-240, 242-243, 257,

353, 357-360

physician smoking cessation trials 260

Physicians Counseling Smokers Project 343, 346,

352

“Quit for Good” pamphlet 115, 121, 129, 136,

197, 327

Smoking and Tobacco Control Program 365

smoking intervention 3, 12

Smoking, Tobacco, and Cancer Program 207,

209

training materials 356-360, 365

training programs 246, 256, 302, 356, 359-362,

366-367

training workshops 339, 359-360

National Health Interview Surveys 17-21

National Heart, Lung, and Blood Institute

counseling protocol for smokers 115, 129

preventive cardiology awards 16

video 373

National Institutes of Health 308

negative reactions to advice 273, 279-280, 284

nicotine addiction 4, 211, 274

nicotine gum 9, 98, 100, 209, 212, 214, 218, 274

and group therapy 98

black smokers 111

dentist training 130, 136-137

effects on smoking cessation 46, 55, 129

followup questionnaire on use 96, 185

instructions on prescribing 122, 137

NCI dentist intervention study groups 127-131,

136-137

NCI physician intervention study groups 113-

114, 116-118, 121-123

patient instructions on use 55, 125, 280, 292

patient use 57-59, 67

physician training in use of 45, 50, 54, 60, 104,

110, 116, 121-122, 195

plus physician advice 92, 95-99

plus physician counseling, training 189, 191,

194, 197

plus reminder 113, 116-118, 127, 130-131

prescription of 110-111, 212, 214, 218, 279-281,

292

quit rates 116-118, 131-132

reminder sheet 176

trial group 92, 95-97

nicotine replacement therapies 7, 92, 94, 98,

100

patch 9, 87

(see also nicotine gum)

nicotine substitutes, patient instructions

125, 140

Nokomis Clinic (Minnesota) 14-15, 72-75,

79-80, 304-305

Nurses Guide 251-253

nurses, smoking interventions 14, 81, 109,

121, 123, 230, 240, 357

adolescents 162-164

burnout 254-255

COMMIT 337, 372

counseling 46, 52

CQI system 314

prenatal clinic 250-255

smoking status of 253, 255

TRACC 144-151, 166

training 145, 151, 240, 250-253, 255, 362

obstacles to smoking cessation

see barriers

obstetrical care practice

see pregnancy

office-based smoking interventions 3, 7-10,

301-319, 349-350, 357-358

barriers to 10, 254-255, 358

clinics 303-309

constraints on 249-250

cueing and monitoring system 62

dental 127-141

dissemination 301-302

examination 28-29

flowcharts 314-317

institutionalization 8, 301

interval between visits 250

medical 113-126

obstetrical 256-258

process of development 7-8

public prenatal care clinics 247-255

recall systems 134

reception area 27-28

recruitment 301-302

steps for 357

office staff, smoking interventions

clinic intervention 78-80, 82, 84, 89

components of successful system 46-47

CQI system 311-319

HMO 106-107

intervention study groups 123, 137-138

involvement in smoking intervention 45-46, 49,

52, 106-108
382

Smoking and Tobacco Control Monograph No. 5

NCI intervention, dental 130, 132-138, 140-141

NCI intervention, physician 115, 119-126

nurse 46, 52

office practice consultants 349-351

private obstetrical 256-258

public prenatal care clinics 249-250

recruitment 45, 301-302, 322-323

role in smoking intervention 221, 357-358

staff coordinator 79-80, 95, 138, 357

support of 79-80, 89

TRACC program 145-146

training 10, 98, 301-302, 304, 326, 331, 349-351,

362

turnover 119, 122-126, 135, 139, 141

oral health

see health effects

oral health team

term defined 364

tobacco cessation 362

tobacco use prevention 362

trainers’ workshop 365

training 135-137, 338-340, 363-365, 371-373

(see also dental entries; dentists entries)

parents

attitudes about pediatrician counseling 230,

238-239, 241, 244

attitudes about smoking 236-238

beliefs 234-235

effects of smoking on children 220, 230, 232-234,

238

pediatrician counseling/intervention 210, 220,

230, 232-238, 241-242

stage of change/readiness to quit 230, 238

passive smoking, effects of 232-234, 237-239,

242

patient-centered counseling 194-197, 202-204

cholesterol lowering 204

four A’s of 350

physical exercise 204

smoking cessation 195-197, 202-203

patient-provider interaction 3, 73, 88, 191-192,

317

patients, smokers

adherence to intervention 266

assessment/determination of smoking status

13-14, 116, 130-131, 133-134, 139, 144, 153,

155, 321, 323, 328-329

attitudes 24-25, 247

cancer prevention reminders 324, 326-327

charts

see charts, patient

compliance 254

confidence in physician advice 92

consent form 115, 123, 128

demographics of 12-13, 18-19, 21

dentist visits per year 3, 25, 301, 364

exit interview 57, 64, 123, 138, 213-215, 217-218

experience in Doctors Helping Smokers 84-85

flowsheet for office visit 55-56, 62

health status, self-reported 12-14

hospitalized 151, 154

initial office visit 54-55

instruction on use of nicotine substitute 125

intake process 10, 210

motivation to quit smoking

see motivation

office visits, structure of 50

perceptions of physician intervention 64-66

physician visits per year 3, 12-14, 17, 25, 98,

102, 301

profile of 12-13

provider interaction flowchart 317

questionnaires 92-93, 95-97, 146, 149-150,

169-174, 179-182

race 12-13, 19, 21, 111, 335

recall of office visit 58

receptivity to interventions 157, 160, 166

recruitment for intervention 192-194, 202,

260-261

recruitment for NCI studies 115, 123, 128,

133-135, 139

report receiving advice to quit 3, 17-21, 25, 214,

217-218, 241

reports on physician and dental counseling 117,

130

screening of 28, 72-73, 115, 128, 304-305

self-efficacy counseling 274, 276, 281-284

self-help materials

see self-help materials, smoking cessation

smoking history 33, 55, 62

surveys 17-21, 84, 158, 160, 311-313

tracking of 10, 264

(see also smokers)

pediatricians, smoking interventions 229,

232-244

anticipatory guidance to prevent smoking 240,

243-244

attitudes and practices of 230, 233-235, 239, 241

attitudes of parents 230, 236-238, 241

barriers 233, 235, 239-241, 244

best opportunities to give advice 235-236

children and adolescents 229-230, 232, 239,

242-243, 361-362

clinical trials 207, 213, 215, 220

COMMIT 370

confidence in delivering advice 230, 233-235, 241

followup 242-243

four A’s for counseling 240, 242-243

incorporating advice into office visits 241-243

NCI manuals for 239-240, 242-243, 361-362

office personnel 240

parents 229-230, 232-236, 238, 240-241

prevention 229-230, 232, 239-240, 243-244

publications for patients 287, 361-362

questionnaire 233-236

residents 207-210, 213, 215, 220, 239
383

Index

surveys of 233-234, 241

training 207-210, 213, 230, 232, 236, 238-240

personalizing risks/benefits 211, 272, 278

pharmacists, COMMIT 337, 372

pharmacological therapies 92, 98-100

(see also nicotine gum; nicotine replacement

therapies)

phase I studies 48, 53-61

phase II studies 48-49, 61-67

phase III clinical trials 145, 342

phase IV studies 343, 347, 352

physician coordinator 79-80

physician counseling

see physicians, smoking interventions

Physician-Delivered Smoking Intervention

Project 194

physician-patient contact 54, 191-192

Physician Smoking Trials 207, 209

physicians

as trainers 208, 210

attitude and practice questionnaire 115, 121

attitudes to intervention 48, 52, 82, 87-88, 102,

109-110, 203, 254-255, 260, 263, 330-332,

342, 352

behavioral influence on 24

community activities 34

community-based 342-344, 346-347

continuing education

see continuing medical education

counseling behavior 24-25, 87-88

counseling practices 204, 213-218

focus groups 349

forgetfulness of 329-330, 332

intervention tasks 89

motivation of 8-9, 50, 97, 260, 301

patient visits per year 3, 12-14, 17, 25, 98, 102

peer influence 24, 322, 343-344, 370

recruitment 70, 76-79, 86, 114-115

reimbursement 8-9, 24-25, 52, 55, 110, 254, 371

reinforcing factors in counseling 24-25

reminders 72-73, 95, 175-177

report advising smokers to quit 3, 20-21, 214-218

smoking counseling rates 323, 328-329

stages of change 346, 350-351

tobacco use 12, 15-17, 25, 230, 255, 260, 307

(see also areas of specialty; e.g., pediatricians)

Physicians Counseling Smokers Project 343,

346, 352

physicians, smoking interventions

adoption and implementation of 343-344,

346-347, 350, 352-353

advantages and disadvantages 143

advice alone 144-149, 189, 191, 194, 196, 199,

200-202, 224

advice plus gum 92, 95-99

advice training 94-96, 278

cancer prevention reminder system 321-333

checklist for implementation 70

clinical trial on advice 92-98, 170

clinics 78-80, 82-83, 86-89, 305-307

communication grid 223

compared to dental 113, 141

compared to team approach 145, 149

comparison of approaches 199-203

compliance 53, 100

computerized reminder system 302, 321-333

confidence 24, 215, 342

content of 213, 215

counseling 57, 117, 143-149, 189, 191, 194,

196-197, 207-221, 224-225

counseling plus gum 189, 191, 194, 197

counseling skills training 351

CQI system 301

criteria 303

dissemination of 301-302, 342-353, 356, 367

educational materials 75, 239-240, 257, 351,

357-360

effectiveness of 342-343

examples of 196, 198, 223-226

for chemical workers 272-276, 278-280

four A’s 13-15, 240, 242-244, 350, 357-359, 365

frequency of 213, 215

implementation of 343-344, 346-347, 350,

352-353

institutionalization 8, 301

McMaster/Waterloo project 48, 53-67

motivating patient

see motivation

NCI manuals for 75, 239-240, 242-243, 257, 353,

357-360

NCI studies 113-126, 260

NCI training 356, 359-362

nurse-assisted 46, 51-52, 144-151, 166

obstacles

see barriers

office practice consultant visits 349-351

office staff

see office staff, smoking interventions

patterns of advice 18

personalized 60, 66, 211, 242, 260, 272, 278

Quit for Life project 45, 102-110

recruitment for 45, 53, 301-302, 321-322,

347-349, 353

reminders 72-73, 302-303, 305

responses to patients’ concerns 226

results of 199-203

role in COMMIT 336-337, 340-341

samples of 196, 198, 211-212, 223-226

summary of strategies 351

time constraints on 143

TRACC intervention 143-149

training

see training programs, smoking

intervention

transtheoretical model of change 344-346,

352-353
384

Smoking and Tobacco Control Monograph No. 5

willingness to intervene 191

(see also advice to quit smoking; smoking

interventions; and areas of specialty)

postcards, smoking cessation maintenance

262, 264-265, 270

pregnancy

physician smoking intervention 229-230,

246-258

prenatal care 29, 247-258

smoking cessation 229, 247-248, 370

smoking during 26, 233

prevalence of smoking

adults 232

children and adolescents 232

medical students 12, 15-17

physicians 12, 15-16, 25

pregnant women 233

women 230, 233

prevention of tobacco use

by adolescents and children 229, 232, 238-240,

243-244, 361

by head and neck cancer patients 229, 231

by pregnant women 229, 233

clinic activities 318-319

computerized reminder system 332-333

dental office 9, 340, 364-365

(see also smoking interventions)

Preventive Cardiology studies 15, 17

primary care physicians, smoking

interventions

brief advice 240

clinic-based 304-319

clinical trials 207, 213-221

COMMIT 336, 340

computerized reminder system 321-322, 332-333

Doctors Helping Smokers 45, 82-83

NCI dissemination studies 342-343, 347, 353

private practice 45-46, 102-103, 106-108

Quit for Life 102-105, 111

recruitment for trials 92-94, 97, 104-105,

321-322

TRACC program 143-151

training 207-208, 213, 220, 359-362

trials 46, 92-100, 113

prompt, smoking intervention 207-210, 213,

215-220

on medical records 189-191

provider attitudes and characteristics

254-255

provider-patient bond 260, 266

psychological treatment, smoking cessation

98, 100

public information 6-7

public prenatal clinics 247-255

quality assurance systems 10, 301, 308-309, 319

quality improvement paradigm 309-310, 319

questionnaires

dental intervention 159-160

for clinical trial 92-93, 95-97, 169-174, 179-185

on smoking 146, 149-150

parents’ attitudes 236-237

pediatricians’ attitudes and practices 233-235

Quit and Win 373-374

quit attempts 4-7, 22, 33, 89, 92, 212, 240,

281-282, 292

adolescents 165

log of 95-96

rates of 15, 71, 96, 148, 220

quit date

contracts 260, 262, 264

NCI study groups 117

physician verification form 95, 178

prescribing 209, 211, 213-214, 218

setting 14, 32, 55-56, 62, 104, 108, 117, 144-148,

150, 159, 209, 211, 213-214, 218, 242-243,

274, 279, 312

training for 50, 54, 67

“Quit for Good” pamphlet 115, 121, 129, 136,

197, 327

Quit for Life 327

Quit for Life project 45, 102-111

quit rates, smoking

1 year 49, 57, 59-61, 65-66, 74, 284

6 months 96, 189, 191, 200, 202, 218-219, 221

and level of physician intervention 200-202

and physician counseling 218-219, 221, 284

and physician training 57, 59-61, 65-66

cancer patients 259

dental intervention 160-161

expectations of 21, 30, 210, 240, 254

hospital patients 151, 155

long-term 49, 108, 191, 273-274

NCI intervention studies 116-118, 131-132

nurse-assisted counseling 149-150

pregnant smokers 247-248

reminder intervention 116-118, 130-131

short-term 59-60, 65

with brief advice 240

with gum use 55, 57, 59-61, 65-66, 96, 218

quit rates, ST 160-161

race, smokers 12-13, 19, 21, 111

radiation oncologists 260, 265-266

randomized factorial trial 210, 213-214

design of 213-214

randomized studies 106, 114, 153, 158

readiness to quit smoking 32, 150, 154-155,

229-230, 238, 251, 278-279

reception area 27-28

receptionist

clinical trial recruitment 93, 97

dental intervention 158, 160

patient screening 93

smoking intervention 14, 52-53, 132-133, 146,

150, 166
385

Index

reimbursement 8-9, 24-25, 52, 55, 110, 254, 371

reinforcement of interventions 143, 145,

162-163, 257, 260, 303

reinforcing factors in physician counseling

24-25

relapse, smoking 22, 33, 50, 63, 71, 212, 251,

273, 279, 282-283, 289-290, 292

abstinence violation effect (AVE) 289-290

postpartum 248

prevention counseling, training 205, 208

prevention, hospitalized smokers 151, 155

risk associated with alcohol 265

stage of change 344-345

reminders

computerized systems 302, 321-333

for physicians 48-49, 72-73, 95, 175-177,

302-303, 305, 321-333

intervention study groups 113, 116-118, 127,

129-131

patient charts 116, 125-126, 129, 140, 207, 210

plus nicotine polacrilex 113, 116-118, 127,

130-131

quit rates with 116-118, 130-131

research assistants

in dental studies 130, 132-134, 137-139

in physician studies 115, 118-119, 122-124

residents, smoking interventions

attitudes about 199, 209-210, 213-215, 239-240,

266

clinical trials 213-221

family practice 194, 207, 210, 213, 215, 220, 239

integration of training 202

internal medicine 46, 193-194, 207, 210, 213,

215, 220, 239

maintenance of counseling skills 199-200

pediatric 207, 210, 213, 215, 220, 232, 239-240

posttraining data 199-201

primary care 207-208, 213, 239

prompt 207-210

receptivity to 204

recruitment for 190, 192-194, 204-205

relapse prevention 205

surgical 266

training programs 8-9, 189-221, 223-226, 239

tutorial 189, 207, 209-210

respiratory therapist 229, 275, 278

Rhode Island Cancer Prevention Research

Consortium 343, 346-347, 352

risks of smoking 25-26, 229, 272-273, 280, 288

and bladder cancer 272-275

communication of 24, 279-280

role-playing in intervention training 95,

103-104, 263, 276, 351, 358

nurses 253

residents 195, 198, 200, 202

scare tactics 279-280, 282, 284

screening

bladder cancer 274-278

cancer prevention 329, 332

clinical trial questionnaires 92-93, 97, 169, 174

patients for NCI study 115, 128

patients for tobacco use 28, 72-73, 304-305

self-efficacy counseling/intervention 272-274,

276, 281-284

recommendations for 282-284

sample 293-294

transcript of 282, 295-297

self-help materials

dental 159

distributed by physician 104, 108, 209, 214, 218,

288-289, 305

for children/adolescents 239-240, 242-243

for head and neck cancer patients 264-265

for nurses’ intervention 251-252

for patients 55, 144-148, 151, 155, 197, 257,

264-265, 270, 280, 282, 327, 373

for smokers in public prenatal clinic 250-253

for spouse/family 262, 265, 270, 288-291

hospital patients 155-156

Minnesota Heart Health Program 69-70

NCI, for patients 146, 155, 197, 327

ST cessation 159

“Tip Sheets” 55

videos 146-148, 150, 156, 373

seminar, training 121, 128, 141, 208

smoke-free health care facilities 337-338, 340,

374

clinic/office 79-80, 83, 256-257, 305, 357

hospitals 152-153, 371, 373

smokeless tobacco (ST)

effects 26, 156-159, 363-364

interventions 29, 46, 141, 156-162, 363-365

users 156-157, 159-161

smokers

African American

see black smokers

assessment of status 13-14, 116, 130-131,

133-134, 139, 144, 146, 153, 155, 321, 323,

328-329

chemical workers 272, 274-278

coping skills 274, 281

demographics of 12-13, 18-19, 21

dental visits per year 25, 301, 364

desire to quit 71, 87, 89

females 12-13, 18, 21, 25-26

identification of 10, 28, 46, 72-73, 89, 133-134,

210, 351

males 12-13, 18, 21, 25

motivation to quit 7, 28, 30-31, 102, 104, 111,

195, 209, 211, 214, 272, 274

physician visits per year 3, 12-14, 17, 25, 98,

102, 301

physicians 12, 15-17, 25, 230, 307
386

Smoking and Tobacco Control Monograph No. 5

pregnant

see pregnancy

profile of 12-13

providers of health care 230, 255

publications for spouse/family 262, 265, 270,

288-291

questionnaires 92-93, 95-97, 169, 171-174,

179-182

race 12-13, 19, 21, 111

readiness to quit 32, 149, 154-155, 229, 251,

278-279

report receiving advice 3, 17-20, 25, 241

resistance to advice 279

self-efficacy/ability to quit smoking 92, 95-97,

272-273, 281-284

self-help materials

see self-help materials

sex of 12-13, 18, 21

stages of change 149-151, 154, 251, 273-274,

277-279, 282

women, nonpregnant 246-247

(see also patients, smokers)

smoking

and anesthesia 267

and ST use 159-161

dependency 4-5, 211, 274

first cigarette in day 71, 217-218

health effects of 25-26, 229, 259, 272-275, 278,

280, 284, 288

initiation of 4-5

mortality from 25-26, 28, 35

oral health effects 26, 363

passive 232-234, 237-239, 242

physician attitudes about 110

prevalence 12, 15-17, 25, 230, 232-233

risks of 25-26, 229, 272-275, 278, 280, 288

social unacceptability 7, 36

Smoking and Tobacco Control Program

(STCP) 365

smoking cessation

algorithms for delivery of advice 288-291

benefits of 25-26, 209, 229, 272, 278, 280, 288

biochemical validation

see biochemical validation of

smoking status

cardiovascular patients 151

contract 32, 55, 67, 196-197, 243, 260, 264-265

hospital patients 151, 155-156

long-term 6-7, 99, 108, 191, 273-274

maintenance of 87, 262, 264-265, 273

motivation 7, 28, 30-31, 102, 104, 111, 195, 209,

211, 214, 272, 274

obstacles to/barriers 7, 104, 151, 195, 211-212,

281, 292

process of 4-7

progress toward 272-273, 279

reasons 7

rewards 30-33

scare tactics/fear arousal 279-280, 282, 284

self-help materials

see self-help materials

short-term 6-7, 59-60, 65, 273

stress of 282, 297

success 5-7, 30, 72

Surgeon General’s report on 25, 233

transtheoretical model of change 344-346

weight gain 50, 63, 95, 211-212, 230, 253, 282,

292, 327

(see also followup, smoking intervention;

quit attempts; quit rates, smoking)

Smoking Cessation and Reduction in Public

Prenatal Clinics project 247, 249-251

training for 251-254

smoking cessation, stages of 22, 344-346

action 5-6, 150, 274, 277, 279-280

contemplation 5-7, 149-151, 154, 230, 251,

273-274, 277, 282

maintenance 87, 262, 264-265, 270, 273

parents 230, 238

precontemplation 5-7, 149-151, 229, 251,

273-274, 277, 284

pregnant women 229-230

readiness to quit 32, 150, 154-155, 229-230, 238,

251, 278-279

relapse

see relapse, smoking

smoking interventions

advice

see advice to quit smoking

approaches 189, 191, 194, 196-203, 248

audit-with-feedback 330, 332

barriers to effectiveness 254-255, 265-266

booster sessions 262, 264-265, 269-270

chemical workers 229, 231, 272-284

clinic-based 7-9, 69-89, 305-313

clinical trials

see clinical trials, smoking intervention

COMMIT 334-341, 369-374

comparisons 48-49, 113, 141, 199-203

computerized CPRS 321-333

cost-effectiveness of 102, 110-111, 149

counseling

see counseling, smoking intervention

criteria for effectiveness 303

dental assistant/hygienist 14, 135, 340, 362, 366,

372

dentists

see dentists, smoking intervention

dissemination of 301-302, 342-353, 356, 367

Doctors Helping Smokers 12, 45, 69-89, 304-308,

314-315, 318

dysfunctional reactions 279, 284 for adolescents

see adolescents, tobacco use
387

Index

for pregnant smokers 246-250

for women 246-258

head and neck cancer patients 229, 259-261

HMO 144-151, 162-165

hospital patients 46, 151-156

individualizing 29-30

institutionalization 8, 301

McMaster/Waterloo Family Practice Smoking

Cessation Project 48, 53-57

medical office 144-151

minimal-contact counseling 207-210

NCI studies 113-141

nicotine polacrilex study groups 113-114,

116-118, 121-122, 127-130

nicotine replacement 7, 92, 94, 98, 100

Nokomis Clinic 14-15, 72-75, 79-80, 304-305

nurse-assisted

see nurses, smoking interventions

office-based 3, 7-10, 301-319, 349-350, 357-358

office coordinator 79-80, 138, 357

office staff

see office staff, smoking interventions

oral health team 338-340, 362-368, 371-372

pharmacological therapies 92, 98-100

physicians

see physicians, smoking interventions

prompt 207-210, 213, 215-219

Quit for Life project 45, 102-111

reinforcement of 143, 145, 162-163, 257, 260,

303

reminder system study group 113, 116-118, 127,

129-131

reminder systems 302, 321-333

resident training 8-9, 189-221, 223-226, 239

samples of 196, 198, 223-226

self-help materials

see self-help materials

self-quit 146-149

software 323, 326, 329

spirit-building component 79, 81, 83

team approach 46, 52, 118, 120-121, 123-126,

135, 143-151, 165-166, 314, 364

TRACC program 46, 143-167

training

see training programs, smoking

intervention

trials 104-109, 207, 213-221

trials, NCI 334, 342-343, 347, 352, 356-358, 362

tutorial 207, 209-210, 213, 215-219

use in smokeless tobacco interventions 157

worksites 275, 277

(see also nicotine gum)

smoking prevalence, U.S. 12, 15-17, 230,

232-233

smoking prevention

see prevention of tobacco use

smoking status

assessment of patient 13-14, 116, 130-131,

133-134, 139, 144, 146, 153, 155, 257, 321,

323, 328-329

of health care providers 230, 253, 255

of nurses 253

of physicians 15-17, 25, 230, 307

Smoking, Tobacco, and Cancer Program

(STCP) 207, 209

Physician Smoking Trials 207, 209

social support materials 262, 265, 270, 288-291

software program, physician reminder system

(CPRS) 323, 326, 329

ST

see smokeless tobacco

stages of behavior change

physicians 204, 346, 350-351

smokers

see smoking cessation, stages of

transtheoretical model of 344-346, 352-353

Stanford Cardiovascular Risk Reduction

project 55

state-level intervention 360-361, 366

STCP

see Smoking and Tobacco Control Program;

Smoking, Tobacco, and Cancer Program

stop-smoking contracts 32, 55, 67, 196-197, 243,

260, 264-265

(see also quit date)

success rates, NCI interventions 116-118,

131-132

Surgeon General’s reports

see U.S. Surgeon General

surgeons, head and neck 229, 259-260, 263,

266-270

surveys

Adult Use of Tobacco Survey (AUTS) 17-21

California Tobacco Survey 12-14

cardiovascular risk of medical school students 16

Johns Hopkins Precursors Study 15-16

National Health Interview Survey 17-21

of health professionals’ practices 102, 109-110,

233-234, 241

of patients 84, 241, 311-313

tobacco use 158, 160, 311-313

teachable moments 28-29, 143-146, 151, 167,

259, 363

dental care 157, 160, 162, 229, 231

teachers, materials for 358

team approach to tobacco interventions 46,

52, 314

compared to physician-centered 145, 149

CQI system 314

dental 135-141, 338-340, 362-365, 371-372

medical staff 118, 120-121, 123-126

TRACC 143, 145, 149-151, 165-166
388

Smoking and Tobacco Control Monograph No. 5

teenagers

see adolescents, tobacco use

telephone

followup

see followup, smoking intervention

hotlines 7, 146, 150, 163

third-party payers 110, 370

tobacco and alcohol use 231, 269

tobacco control strategies 4-7, 33-35

dental 363-364

tobacco industry 31, 33, 36

advertising and promotion 7, 27, 29, 232

company sponsorship 33-34

Tobacco Reduction and Cancer Control

(TRACC) program 46, 143-167

adolescent smoking intervention 162-165

hospital intervention 151-156

nurse-assisted counseling intervention 144-151

ST dental intervention 156-162

tobacco use

and alcohol 231, 269

by children 232

by physicians and office staff 307

cessation flowchart 316

health risks

see risks of smoking

identification of 28

prevention among children and adolescents 362,

365

prevention and cessation services, dental

intervention 364-365

screening of patients 304-305

surveys of 17-21, 84, 158, 160, 311-313

(see also smokeless tobacco; smoking)

TRACC

see Tobacco Reduction and Cancer Control

program

train-the-trainers approach 204, 207-208, 210,

220, 337-339, 361, 365

training materials 340

development of 356-359

for trainers 358-361

training programs, smoking intervention

advice only 189, 191, 194, 196, 199

and prompts 189-191, 208-210, 213, 215-216

approaches 189, 191, 194, 196-203

associations, medical 360-362

at practice site 94, 97

bedside counseling 155

behavioral skills 229, 231

booster sessions 204-205

brief advice 94-95

clinicians 359-360, 362

COMMIT 337-340, 370, 373

counseling 103-104, 145-146, 151, 189-191,

194, 196-197, 199-200, 203-204, 207-209,

223-226, 269, 351

counseling plus gum 189, 191, 194, 197, 199

counselors 275-276

dental staff 301-302, 338-340, 364-367

dentists 45-46, 128-130, 135-137, 268-270,

301-302

development of materials 356-359

educational methods used 194-195

family practice 45-46, 48-50, 53, 193-194, 207,

210, 213, 239

followup visits 63-64, 359

for Smoking Cessation and Reduction project

251-253

grand rounds 8-9, 115

incentives 195, 204

internal medicine 46, 193-194, 207, 210, 213,

215, 220, 239

maintenance of skills 199-200

materials for 199, 340, 358-360

McMaster/Waterloo Project 53-55, 61-63

medical office staff 301-302

methods of teaching 208-209

NCI dental intervention 128-130, 135-137, 141,

364-367

NCI materials 356-360

NCI physician intervention 115-116, 119,

121-122, 124, 256, 302, 356-362, 366-367

nicotine gum use 45, 50, 54, 60, 104, 110, 116,

121-122, 195, 280

nurse-assisted counseling 145-146, 151, 362

objectives 49-50

obstetrical office staff 256-258

office-based 301-302

office staff 10, 45, 119, 122-124, 126, 130,

135-137, 145-146, 351, 358, 362

office staff, CPRS 326, 331

pediatric 207-210, 213, 230, 232, 236, 238-240

physicians 45-46, 54, 62-63, 145, 189, 191-192,

204, 246, 278, 301-302, 304, 342, 351

posttraining data 199-200

practitioner 9-10

prenatal care nurses 250-255

primary care residents 207-208, 213, 220, 239

providers, head and neck cancer patients

263-264, 268-269

Quit for Life 103-104, 108-109

recommendations 49

recruitment to 190, 192-194, 204, 360

relapse prevention counseling 205, 208

residency curricula 8-9

residents 189-205, 207-210, 213, 223-226, 239

role-playing 95, 103-104, 195, 198, 200, 202,

253, 263-264, 276, 351, 358

self-efficacy counseling/intervention 276

self-training materials 204, 258

structure of sessions 205

trainers 358-362, 365

tutorials 189-190, 207, 209-210, 213, 215-216
389

Index

videotapes

see videotapes, smoking intervention for

training programs

workshops 50-51, 59, 62, 94, 305, 338-339,

351-352, 359-361, 365, 373

(see also continuing medical education)

training, tobacco use intervention, oral

health professionals 364-365

differences from medical 364-365

NCI program 364-365

transdermal nicotine replacement 9, 87, 100,

110

transtheoretical model of change 344-346,

352-353

trial design, smoking counseling 213-214

trials, smoking intervention

see clinical trials, smoking intervention

tutorial

counseling group 207, 209-210, 215-220

plus prompt, counseling group 213, 215-219

resident smoking intervention 189-190

UCLA 259-260, 264, 268

University of North Carolina protocol 292

U.S. Surgeon General

report on health benefits of smoking cessation

(1990) 25, 233

report on health consequences of smoking

(1964) 15, 17

role of pediatrician (1985) 233

usual care group 262-263, 288

Veterans Administration patients 260, 266

videotapes, smoking intervention

by Health Provider Task Force 369-370

by National Heart, Lung, and Blood Institute 373

COMMIT 339

for adolescents 163

for hospital patients 154, 156

for physicians 54-55, 121, 136, 263-265, 339,

358-360, 373

for smokers 46

for training programs 195, 210, 276, 278, 358-

360

impact on quit rates 150

interactive 166

physician recruitment for intervention 348

production and cost of 156

self-quit 146-148, 150

TRACC 46, 144-148, 150, 166

videotapes, ST intervention 159-160, 162

waiting room 27-28

weight gain 50, 230, 282

control of 63, 95, 253, 327

fear of 211-212, 292

white smokers 13, 19, 21, 111, 261

withdrawal

from nicotine 292

from smoking 50, 62, 282, 288, 297

women

attitudes to provider intervention 247

counseling by pediatricians 229, 233

in COMMIT 370

pregnant smokers 233, 246-250

risks from smoking 25-26

smoking intervention 246-258, 370

smoking rates 230

worker cohort recruitment 274-277, 283

workshops, intervention training 50-51, 59,

305, 351-352

clinical trial training 94

COMMIT training 338-339, 370-371, 373

Doctors Helping Smokers 78, 82

physician advice 94

trainers 359-362, 365

worksite smoking intervention 275, 277, 374