Mobilizing physicians to conduct
clinical intervention in tobacco use
through a medical-association program:
5 years' experience in British Columbia
Frederic Bass, MD, DSc
Dr. Bass is director of BC Doctors' Stop-Smoking Program, Vancouver, BC.
Canadian Medical Association Journal 1996; 154: 159-164
Paper reprints of the full text may be obtained from: Dr. Frederic Bass, BC Doctors' Stop-Smoking Program, British Columbia Medical Association, 1665 W Broadway, Vancouver BC V6J 5A4; fax 604 736-4566
Contents
Abstract
Introduction
Role of physicians and components
of intervention
BC Doctors' Stop-Smoking Program
Discussion
Conclusion
References
See also:
Abstract
During the last 5 years, a program run by the medical association in British Columbia has recruited 23% of the province's general practitioners (GPs) to take an active, systematic approach to clinical intervention in tobacco use. Another 9% of GPs (considered "semi-active") regularly use the program's educational materials for patients, and another 25% have been trained in intervention or have been given intervention materials or both. If the cessation rate (rate of patients who quit smoking who would not otherwise have done so) was 4% among physicians actively involved in intervention and 2% among physicians considered semi-active, in 1995 an estimated 4700 smokers quit and were followed by their GPs as a result of the program. Another 135 000 smokers received brief counselling from their GPs and were also followed. This article reviews the strategies and methods used in this program to mobilize physicians.
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Introduction
Systematic, brief clinical intervention in tobacco use by physicians is a proven approach to lowering the prevalence of smoking.(1) The Canadian Guide to Clinical Preventive Health Care(2,3) and the US Guide to Clinical Preventive Services(4) both assign clinical intervention in tobacco use an A rating, meaning that the intervention is supported by first-class or the highest level of evidence. Randomized controlled trials have shown that, among smokers who are subject to brief intervention by their physician, the smoking cessation rate doubles, from 6% to 12% each year.(5) However, systematic clinical intervention in tobacco use does not appear to be widely conducted by physicians.(6) Since 1990 the BC Doctors' Stop-Smoking Program has addressed this gap by helping physicians to implement such intervention.
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Role of physicians and components
of intervention
Most smokers are not ready to stop smoking. Surveys find that, at any time, only 12% to 20% of smokers are actively preparing to stop smoking (Omnibus Survey of British Columbia, Campbell and Goodell Associates, Vancouver: unpublished data, 1994 and 1995).(7) Achieving long-term abstinence from smoking takes most smokers 5 to 10 years from the date of their initial attempt.(8) Physicians, especially general practitioners (GPs), are in a unique position to influence the many smokers who are not ready to quit as well as to aid the ones who are ready. GPs see patients who smoke at many opportune moments when they are concerned about their health. A GP may see the same patient who smokes over decades.
In a recent population survey conducted in British Columbia, smokers were asked which kinds of assistance to stop smoking they would choose (they could choose as many as they wished) (Omnibus Survey of British Columbia, Campbell and Goodell Associates, Vancouver: unpublished data, 1995). The largest proportion of respondents (44%) chose the nicotine patch or nicotine gum, 33% chose a program offered by their physician, 23% wanted none of the listed options and 20% chose a program offered by another health care professional. Other methods, ranging from booklets and videotapes to stop-smoking groups, were chosen by 6% to 15% of respondents. This is consistent with the findings of another survey.(9)
The components of physicians' clinical intervention in tobacco use, in broad terms, are:
- asking patients about smoking,
- advising smokers to stop smoking and young people not to start,
- assisting those who are ready, and motivating those who are not ready, to stop smoking and
- following up all smokers and those who have recently stopped smoking.(10,11)
To these four basic components, the Guide Your Patients program of the Canadian Council on Smoking and Health adds:(10)
- assessing the practice's effectiveness in intervening in tobacco use and
- advocating effective tobacco-control policies in the community.
The specific components of clinical intervention in tobacco use are
- asking each smoker and recent ex-smoker about smoking as well as updating the patient record,(12)
- putting a label (Fig. 1) or computer-generated reminder in the record to prompt regular attention to smoking,(6,12,13)
- offering strong advice and personalized risk information to patients repeatedly,(6,14)
- listening empathically and reflectively to patients who smoke in order to motivate them to stop smoking,(15-19)
- giving patients printed information about the risks of smoking and how to stop smoking,(10-12)
- stressing behavioural self-management,(20,21)
- helping those ready to stop smoking to set a target date,(10-11)
- offering nicotine-replacement therapy to those who are ready to stop and who are addicted to nicotine,(10,11,22)
- using a stepped-care algorithm to match treatment to patients' needs,(23,24)
- referring patients to community programs and to addiction specialists as required,(10,11,24)
- maintaining long-term follow-up of all patients who smoke or who have quit smoking(6,10-12) and
- involving office staff in clinical intervention in tobacco use.(10,11,25)
A stepped-care approach to smoking cessation involves three steps: self-managed smoking cessation, smoking cessation guided by a physician (with or without nicotine-replacement therapy) and supervision by a clinician trained in treating nicotine addiction.(23,24)
Most smokers stop on their own, without any formal assistance.(1,23) A small proportion of smokers require the specialized care of physicians who are familiar with the treatment of nicotine addiction.(24) Some patients (for example, those with schizophrenia or depression, addicted to other drugs or under great stress) require special care.
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BC doctors' stop-smoking program
Goals and objectives
The goal of the BC Doctors' Stop-Smoking Program, launched by the British Columbia Medical Association (BCMA) in May 1990, is to recruit GPs to deliver systematically a clinical smoking-cessation strategy. The program's specific objectives are to:(26)
- recruit target numbers of physicians each year,
- follow up the physicians' clinical intervention in tobacco use,
- use the BCMA's physician database to track physicians' involvement,
- encourage physicians to involve their office personnel in the program,
- improve the program materials and procedures on the basis of physicians' feedback and
- count the number of patients who consequently stop smoking.
Recruiting physicians
Physicians have been recruited through hospital rounds, medical conferences (including the BCMA annual meeting), training conducted as part of the Guide Your Patients program, the British Columbia Medical Journal, brochures included in mailings from physicians' organizations (the Society of General Practitioners of British Columbia and the British Columbia College of Family Physicians), the Medical Office Assistant Association of British Columbia and direct physician enquiries to the program. The program is located in the same building as the BCMA, which provides the program with mail, telephone, fax and communication services.
The program's goal for the first year (up to May 1991) was to train 500 physicians through hospital rounds and to have 10% of them adopt a systematic approach. Each year the program has set, and subsequently met, targets for the number of GPs to be recruited. The numbers of GPs recruited since 1990 are shown in Tables l and 2.
Table 1
Table 2
Defining involvement in clinical intervention in tobacco use
Despite the absence of recognized operational criteria, program organizers had to classify the level of intervention in a practice. We chose to consider the ordering of clinical-intervention materials from the program as the principal indicator of a commitment to intervention in the practice. An "active" practice was one in which one or more of the following items were ordered:
- adhesive labels for patient records (to indicate the patient's smoking-cessation status, see Fig. 1),
- a rubber date stamp (to track patients' smoking behaviour),
- target-date forms (to help patients set quit dates and to structure follow-up) and
- a target-date roster (to track all patients who set target dates).
The labels and date stamp entail a small cost, signifying a financial commitment by the physician; the target-date forms and roster involve a modest time commitment. We selected these criteria because research has shown that regular prompting, together with long-term follow-up, lead to significantly increased rates of smoking cessation.(5,6,12)
GPs who do not meet the definition of "active" but who regularly use the materials for patients are considered "semi-active."
Follow-up of practices
Each year all physicians considered active are mailed a follow-up questionnaire in which they are asked whether the components of clinical intervention in tobacco use are being conducted in the practice. Telephone follow-up of one third of respondents has been necessary to obtain an adequate response rate. In 1994, 77% of 391 physicians completed the follow-up questionnaire (Table 3).
Table 3
Progress
The BC Doctors' Stop-Smoking Program today provides smoking-cessation tools and support to one third of GPs in the province. The program now follows up all active and semi-active physicians every year to evaluate how program tools and procedures have been used and to obtain physicians' comments and suggestions for improvements. As a result of this feedback, and of developments in the literature on smoking cessation, the materials and procedures have been revised several times.
We have completed a small pilot project to assist practices to evaluate their clinical intervention. However, attempts to encourage physicians to count how many patients try to stop smoking have met with limited success. Inadequate staff support has been a major factor hindering practice self-evaluation.
The program's tools and procedures have been presented to health care workers in other sectors, such as hospital-based physicians, dentists, pharmacists and respiratory therapists. We tried on several occasions to offer education in tobacco-use intervention in the physician's office and to involve the office staff in this "in-office" training. However, this approach requires much more staff time than is now available from this program and from the physician's staff.
Estimation of the program's effectiveness
Kottke and associates,5 in a review of 39 randomized controlled trials of smoking-cessation programs, showed a median difference of 5.8% in smoking-cessation rates between patients attending practices without a systematic tobacco-use intervention program and those attending practices with such a program. The typical GP in British Columbia comes face to face with 150 smokers each year. If British Columbia's 655 GPs active in this program induced 4% of their patients who would not otherwise have stopped smoking to quit, and if the 258 GPs semi-active in the program induced 2% of their patients to quit, in 1995 the program would have resulted in an estimated 4700 smokers quitting and receiving follow-up by their GP as well as 135 000 smokers receiving improved counselling and follow-up from their GP.
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Discussion
Good treatment of nicotine addiction requires good dissemination of the intervention and good quality assurance. Research has shown, in no uncertain terms, that clinical intervention in tobacco use is effective. Yet we have very little information on how physicians deliver this type of intervention.(27) We need better information, from physicians, patients, office staff and patient records, on how this intervention is delivered in actual practice.
Medical associations can be very effective in mobilizing physicians to intervene. Provincial, state or regional medical associations represent the physician community. Just as public health units help local communities to mobilize to intervene in tobacco use, so can medical communities mobilize to take action in regard to clinical preventive medicine.
A medical association's database represents a unique resource for tobacco-use reduction. It is rare to have a database that contains the entire target population for a program; but, in the case of physician-based intervention programs, that is precisely what we have. We have found that physicians appreciate the support, materials and follow-up that we offer them because we use the database. The physician database provides the means to:
- track the intervention conducted by individual physicians, through the annual follow-up questionnaires,
- evaluate the progress of the dissemination of the intervention,
- direct mailings to subgroups of physicians, by specialty and by the physicians' present level of clinical intervention,
- estimate physicians' needs for materials and
- sample the population for evaluative research.
We have learned much about gaining cooperation from physicians through our efforts in this program. Physicians will cooperate if their time and their judgement are respected. We suggest these rules of thumb.
- Keep whatever you offer practical, simple and brief.
- Ensure that intervention takes less than 1 to 2 minutes for most patients, since clinical intervention in tobacco use involves the many smokers who are not ready to quit.
- Offer physicians a menu of intervention options from which to choose those appropriate to their practice.
- After presenting the menu of intervention options, suggest a simple way of getting started, such as affixing stickers about patients' smoking-cessation status to their records.
- Send potential participants letters from their colleagues in leadership positions (e.g., the president of the college of family physicians).
We have recruited more GPs through mailings from GP organizations than through traditional continuing medical education. As a result of four mailings of flyers to all GPs from the British Columbia College of Family Physicians and from the Society of General Practitioners of British Columbia, we recruited 337 new active physicians during the past 2 years.
Barriers
Three barriers are worth noting: lack of funding, need for reimbursement through the fee-for-service system and physicians' underestimation of their effectiveness.
The funding of programs such as the one described in this article is not part of conventional health care expenditure, neither at the program nor at the clinical level. The government of British Columbia estimates that it will receive $505 million from tobacco taxes in 1995,(28) yet it has allocated only $350 000 to all of its tobacco-control programs. In contrast, the provincial government will receive $579 million from alcohol sales, and it has allocated more than $50 million to address alcohol problems.
If clinical intervention in tobacco use is to be reimbursed through the fee-for-service system, a new type of fee is needed, one for a practice-level service that consists of brief interventions, most of which are too brief to be considered billable.
Finally, physicians tend to underestimate their effectiveness in helping people to stop smoking. Much of the clinical intervention in tobacco use does not produce observable, short-term results. In fact, patients may attribute quitting smoking entirely to their own efforts. This may enhance patients' sense of personal effectiveness but may also reduce physicians' sense of efficacy in clinical interventions.
Future plans
We intend to recruit 200 more physicians each year to deliver clinical intervention in tobacco use. With the GP base well established, we are now working with the Society of Specialist Physicians and Surgeons of British Columbia to focus on the contribution of specialists -- particularly obstetricians, anesthesiologists, psychiatrists, cardiologists, respirologists and surgeons doing elective surgery -- to clinical intervention in tobacco use.
With the CMA, the Ontario Medical Association and the Medical Society of Prince Edward Island, we have begun a program called Mobilizing Physicians -- Clinical Tobacco Intervention, in order to translate what has been learned in British Columbia to other provincial medical associations and to collaborate with the Guide Your Patients program, through which physicians across Canada are trained in clinical intervention in tobacco use.
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Conclusion
A medical association's communication system and database constitute a potent means of recruiting physicians to conduct systematic, clinical intervention. This type of program requires support from the leaders of the medical association, expertise in such intervention, a committed staff and adequate financial resources to sustain the long-term effort required to get results. If these are in place, a medical association can play a useful role in mobilizing physicians to adopt and sustain clinical intervention in tobacco use.
The BC Doctors' Stop-Smoking Program is funded by Health Canada and the BC Ministry of Health and sponsored by the BCMA. It has also been funded by Hoechst Marion Roussel, the BC Lung Association, Ciba-Geigy and Physicians for a Smoke-Free Canada. Key support is provided by the British Columbia College of Family Physicians, the Society of General Practitioners of British Columbia and the Society of Specialist Physicians of British Columbia.
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References
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| CMAJ January 15, 1996 (vol 154, no 2) |