Effectiveness of nicotine-containing gum in the Physician-Delivered Smoking Intervention Study.

BACKGROUND: We tested the role of nicotine-containing gum (NCG) in conjunction with brief physician counseling in smoking cessation in the Physician-Delivered Smoking Intervention Project (PDSIP). METHOD: Subjects were smokers randomized to the Counseling + NCG arm of the PDSIP. However, receipt and use of NCG were not randomized. Data from base-line, were not randomized. Data from baseline, pharmacy records, and 6-month monitoring calls were used in these post hoc analyses. RESULTS: Of the 299 study subjects, 57% accepted NCG and 36% of acceptors used it for more than 7 days. Predictors of NCG acceptance included high desire to quit (OR = 1.21; 95% CI 1.10, 1.35), social support to quit (OR = 1.62; 95% CI 1.01, 2.59), being a general medicine patient compared with a family practice patient (OR = 3.22; 95% CI 2.01, 5.21), and receiving the intervention from a female physician (female physician-male patient OR = 2.27; 95% CI 0.95, 5.46; female physician-female patient OR = 1.94; 95% CI 1.06, 3.57) relative to the male physician comparisons. Subjects who refilled the NCG prescription had higher cessation rates than those who did not refill or did not accept the prescription (37% vs 19% and 20%, respectively; P = 0.04). Predictors of 6-month cessation among NCG users included a previous period(s) of abstinence > 3 months (OR = 1.23; 95% CI 1.04, 1.47), abstinence during illness (OR = 0.39; 95% CI 0.17, 0.86), and absence of smoking-related physical complaints the month prior to the physician-delivered intervention (OR = 0.40; 95% CI 0.17, 0.94). CONCLUSION: Amount of NCG use in conjunction with physician-delivered smoking cessation counseling might have contributed in helping unselected smokers quit.

The Physician-Delivered Smoking Intervention Project: factors that determine how much the physician intervenes with smokers.

OBJECTIVE: To determine factors that affect how much physicians trained to use a patient-centered smoking intervention intervene with their smoking patients. DESIGN: Forty internal medicine residents and ten internal medicine attending physicians trained in a patient-centered counseling approach were randomized to an algorithm condition (provision of intervention algorithm at each patient visit) or a no-algorithm condition. Smoking intervention steps used by physicians with patients were assessed with Patient Exit Interviews (PEIs). SETTING: Ambulatory clinic; academic medical center. PATIENTS: Five hundred twenty-seven adult smokers seen in clinic between June 1990 and April 1992. MAIN RESULTS: There was no difference in overall PEI scores or in individual PEI steps taken between the algorithm and no-algorithm conditions. Two patient baseline factors (reporting thinking of stopping smoking within six months and higher Fagerstrom Tolerance Score) and one physician factor (older age) were significantly predictive of higher PEI score. CONCLUSION: Provision of an intervention algorithm at each patient visit does not increase the likelihood that trained physicians who are cued to intervene will perform more of the intervention steps taught. Trained physicians are more likely to intervene with smokers who are more nicotine-dependent and who expect and desire to stop smoking.

The physician-delivered smoking intervention project: can short-term interventions produce long-term effects for a general outpatient population?

Patterns of smoking cessation using 6- and 12-month follow-up data are reported for 1,261 primary care patients randomized to 3 physician-delivered smoking interventions: advice only (AO), counseling (CI), and counseling plus availability of nicotine-containing gum (CI + NCG). One-week-point-prevalence cessation rates at 12 months did not differ among the interventions: AO (15.2%), CI (12.9%) and CI + NCG (16.7%). However, maintained cessation rates (abstinent at both 6 and 12 months) increased with intervention intensity: AO (6.0%), CI (7.8%) and CI + NCG (10.0%): Test of trend chi 2 = 5.06, p = .02. CI + NCG was significantly higher than AO (p = .02). The findings support the following conclusions: Brief physician-delivered intervention with availability of nicotine-containing gum can have a beneficial long-term effect on smoking cessation, and cohort data as well as point-prevalence rates are important when assessing the long-term impact of lifestyle interventions.

Factors associated with heavy smoking among men and women: the physician-delivered smoking intervention project.

As part of a randomized trial that compared the effects of three physician-delivered smoking interventions on patients' long-term cessation rates, we examined factors associated with the extent of baseline cigarette smoking separately in 546 men and 715 women who were enrolled in this trial. Several baseline characteristics were significantly related to heavier (> or = 25 cigarettes per day) smoking after controlling for a variety of factors in multivariate analyses, which were performed separately for men and women. Among both men and women, extent of addictiveness to smoking and number of cigarettes smoked during periods of heaviest smoking were significantly related to extent of current cigarette smoking (p < 0.001). In addition, among men shortness of breath, lack of previous attempts to quit and lack of confidence in their ability to stop smoking were significantly related to current heavy cigarette smoking (p < 0.05). The results of this study in ambulatory outpatients suggest a profile of heavy cigarette smokers that may be used for the more effective delivery of targeted smoking intervention efforts.

Comparison of patients' and their resident physicians' responses regarding smoking-cessation interventions.

PURPOSE: To investigate (1) the extent of agreement between what resident physicians and their patients report as having occurred in physician-delivered smoking interventions and (2) the ability of residents to effectively transmit information concerning smoking interventions to their patients. METHODS: A total of 263 patients and 91 residents in internal medicine or family practice completed paper-and-pencil exit interviews after a regularly scheduled clinic appointment between 1986 and 1988 at the University of Massachusetts Medical School; the residents had been trained to deliver counseling interventions. The kappa statistic was used as an index of chance-corrected agreement between the patients' and residents' responses. RESULTS: Agreement was substantial regarding whether a specific plan for the patient to stop or reduce smoking was agreed upon, whether written materials on how to quit smoking were provided, and whether nicotine-containing chewing gum was prescribed. CONCLUSIONS: There was positive agreement between the patients and their resident physicians concerning the residents' delivery of quit-smoking messages and the provision of written materials to assist in stopping. Programs must continue to be designed, for residents and for more senior physicians, so that physicians can be encouraged to incorporate smoking interventions into their practice activities.

Patient characteristics and the effect of three physician-delivered smoking interventions.

BACKGROUND: This paper investigates individual patient characteristics predicting differential response to each of three physician-delivered smoking interventions after 6 months. METHODS: Participants were 1,286 currently smoking patients seen by 196 medical and family practice residents in five primary care clinics affiliated with the University of Massachusetts Medical School. Of the participants, 57% were female, 92% were white, their average age was 35 years, and they smoked an average of 23 cigarettes per day. Physicians were trained to provide the following interventions: advice only (AO), a brief (< 10 min) patient-centered counseling intervention (CI), and counseling plus prescription of the nicotine-containing gum Nicorette (CI+NCG). The CI+NCG condition included NCG only when appropriate and if acceptable to the patient. Patients were randomized to one of these three physician-delivered intervention conditions. RESULTS: Overall, stratified univariate analyses revealed that AO produced consistently lower cessation rates across most subgroups (generally 9-13%) but was somewhat more effective for certain groups of lighter smokers. Relative to AO, CI was somewhat more effective (about 20-24%) for less addicted smokers, for those with more previous quit attempts, and for those with fewer close associates who smoke, but generally failed to produce higher quit rates for harder core smokers or for women. CI+NCG had an overall pattern of greater effectiveness for both more addicted and less addicted smokers, with the highest absolute levels of cessation (about 27-30%) among less dependent smokers. Women in this group had cessation rates (20.6%) comparable to those of men (23.6%). Condition-stratified logistic regression analyses, controlling for a wide range of covariates, revealed associations similar to those observed in the univariate analyses: An overall logistic model in which intervention conditions were fitted as dummy variables produced the following significant main effects: sex, years smoked, contact with other smokers, symptoms, and CI+NCG condition. Significant interactions were observed for both CI and CI+NCG and smoking when feeling too ill to continue normal activities and CI+NCG and amount smoked. CONCLUSIONS: We observed significant main effects on cessation of variables related to addiction, sex, social factors, and physician counseling interventions. Specific interactions were observed between reported smoking when feeling ill and each of the counseling interventions as well as by amount smoked in the CI+NCG condition.

Training family practice and internal medicine residents to counsel patients who smoke: improvement and retention of counseling skills.

This investigation builds on an earlier study by describing the final results of a training program that teaches internal medicine and family practice residents to counsel patients to stop smoking. In this study, 198 residents participated in a three-hour training program which included small group discussion and role-playing exercises. Videotaped observations of role-playing performances were used to assess behavioral outcomes related to counseling skills for 104 residents who completed pre-, immediate post-, and long-term follow-up testing. The present findings support previous results that show the training program has a significant positive effect on physician smoking cessation counseling skills. A subsample of residents continued to exhibit improved counseling skills one year after the initial educational interventions, suggesting that these skills can be retained over time.

Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial.

OBJECTIVE: To assess the relative impacts of three physician-delivered smoking interventions in combination with follow-up contact from behavioral counselors. DESIGN: Randomized controlled trial with pre- post measures of smoking rates. This paper reports six-month outcome data. SETTING: Participants were recruited from among patients seen by 196 medical and family practice residents in five primary care clinics. PARTICIPANTS: Participants were 1,286 patients out of 1,946 eligible smokers approached. The patient group was 57% female and 91% white, had an average age of 35 years, and smoked, on average, slightly over one pack per day. INTERVENTION: Physicians were trained to provide each of three interventions: advice only, brief patient-centered counseling, and counseling plus prescription of nicotine-containing gum (Nicorette). Half the patients received follow-up in the form of telephone counseling at three-monthly intervals from behavioral counselors. MEASUREMENTS AND MAIN RESULTS: Changes in smoking behaviors were assessed by telephone interview six months after physician intervention. The differences in one-week point prevalence cessation rates among the physician interventions were significant (p less than 0.01): advice only, 9.1%; counseling, 11.9%; counseling plus gum, 17.4%; with no effect for telephone counseling. The time elapsed from physician encounter to initial quitting and the length of that period of abstinence also showed significant benefit of the counseling interventions. Patients receiving physician counseling were much more likely than those not receiving counseling to rate their physician as very helpful (p less than 0.001). Multiple regression analyses are also reported. CONCLUSION: Smoking intervention counseling provided by physicians is well received by patients and significantly increases the likelihood of cessation at six months, an effect that is augmented by the prescription of nicotine-containing gum, when compared with physician-delivered advice. Follow-up telephone counseling does not contribute significantly to smoking behavior changes.

A residents' training program for the development of smoking intervention skills.

This article describes the results of a three-hour training program that teaches residents a patient-centered counseling approach to smoking cessation, emphasizing questioning and exploring feelings, rather than providing information. Fifty internal medicine and family practice residents affiliated with a university medical center were assessed before and after training using questionnaires and videotape documenting changes in their knowledge about smoking, attitudes concerning intervention, and intervention skills. The residents showed a significant increase in knowledge and perceived themselves as having significantly more influence on their patients who smoke after completion of the training program. Counseling skills improved significantly in the use of questions and exploring feelings as judged by blind evaluation of videotapes. The results of this three-hour training program suggest that physicians in training are responsive to the teaching of specialized skills deemed important for promoting health behavior changes in their patients.