For the AHRQ Smoking Cessation Guideline Study Group
Affiliations of authors: Departments of Medicine (DAK, DRM, MCF), Population Health Sciences (DAK), Nursing (RLB), Psychology (TBB), and the Center for Tobacco Research and Intervention (MCF, TBB), University of Wisconsin, Madison
Correspondence to: David A. Katz, MD, MSc, University of Iowa Hospital and Clinics, SE618-GH, 200 Hawkins Dr., Iowa City, IA 52242 (e-mail: david-katz{at}uiowa.edu)
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ABSTRACT |
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INTRODUCTION |
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Although the AHRQ Smoking Cessation Clinical Practice Guideline was based on a comprehensive literature review and meta-analysis of controlled trials (1), the recommendation that clinicians should advise smokers to quit at every visit has relatively little empiric support (12) and is not widely accepted by physicians (9). Because there was no experimental evidence on the effectiveness of the Guideline or its feasibility in primary care practices, we conducted a pilot study to evaluate a guideline-based intervention in which intake clinicians (nurses or medical assistants who document the reasons for the office visit and check patients vital signs) assessed smoking status in all patients and provided brief cessation counseling for smokers (13). This study demonstrated a statistically nonsignificant increase in self-reported abstinence among smokers at the 6-month follow-up among participants from a clinic that administered the intervention (11% of patients treated during the baseline period versus 21% of patients treated during the intervention period).
To validate the results of the pilot investigation, we conducted a randomized, controlled trial of the same intervention among eight clinics within different primary care settings. We hypothesized that performance of Guideline recommendations by clinic staff and smoking cessation rates would be higher at study sites that received the intervention than at those that did not.
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METHODS |
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We conducted a randomized, controlled trial of a multi-modality intervention to implement the AHRQ Smoking Cessation Guideline among eight community-based clinics (six family practice clinics and two internal medicine clinics) in southern Wisconsin. We worked with local and regional clinic organizations and the Wisconsin Research Network (WReN) (14) to identify potentially eligible community-based clinics for this study. Eligible clinics were staffed by at least five full-time physicians or mid-level clinicians (physicians assistants or nurse practitioners), assigned intake clinicians to specific physicians or mid-level clinicians (with minimal crossover), did not have an on-site, nurse-based smoking cessation program during the study period, had not recently participated in a smoking cessation trial or prevention trial that addressed smoking cessation (within 2 years prior to the start date of the trial), did not have a residency training program, and were located within a 60-mile radius of Madison, WI (13). Of the 12 eligible clinics that agreed to an initial meeting and presentation that explained the purpose of our study, nine clinics agreed to participate; one clinic participated in only the pilot test of the intervention (13) and was not included in the current analysis (because it was not randomly assigned to the intervention). The primary reasons for nonparticipation were lack of time by clinic staff to undertake additional projects, lack of support from clinic leadership and management, absence of an identifiable facilitator or leader, major ongoing changes in clinic organization related to a merger or integration with another institution, and/or changes in clinic infrastructure during the study period (e.g., recent loss of staff, new computer system, new building).
We matched clinic sites by primary care discipline and health plan affiliation (if any); for each pair of clinics, the project statistician (R. L. Brown) used a random number generator to randomly assign each clinic to receive either the intervention (test sites, n = 4) or usual care (control sites, n = 4). It was impractical to randomly assign individual clinicians within each clinic to receive the intervention because of the high likelihood that control clinicians and their patients would be exposed to the study intervention.
At all clinic sites, we enrolled 2163 consecutive adult patients (i.e., at least 18 years old) who smoked an average of one or more cigarettes per day into the study across two study periods: the baseline period (from June 16, 1999, to June 20, 2000) and the intervention period (from June 21, 2000, to May 3, 2001). During the baseline period, patients were enrolled at test and control sites before implementation of the study intervention. This approach permitted us to verify that the test and control sites were similar with regard to patient characteristics and baseline performance of Guideline-recommended actions. During the intervention period, patients were enrolled at both test and control sites, but the intervention was implemented at test sites only. Eligible patients had an appointment with a primary care clinician (physician, physicians assistant, or nurse practitioner) for routine, nonemergency care and were willing to complete a brief exit interview immediately after the clinic appointment. At the exit interview, a research interviewer asked each departing patient about his or her smoking status; current smokers were asked whether the staff had performed Guideline-recommended actions. During each study period, we enrolled a new cohort of patients at each site until we reached the enrollment target for that site. All patients were followed prospectively for 6 months.
Smoking Cessation Intervention
The intervention was based on an adaptation of a previously proposed disease management model (15,16) that provides a framework for improving the quality of care for chronic conditions such as nicotine dependence. With support from the administrative leadership at each test site, we worked with a designated physician and nurse (or medical assistant) facilitator to implement the AHRQ Guideline intervention and then verified that implementation of the intervention was compatible with organizational goals and did not conflict with other quality improvement initiatives.
The intervention, which has been described previously (13), included five components. The first component was a tutorial for intake clinicians that instructed them on how to assess the patients smoking status and how to provide a brief smoking cessation message to each smoker at every visit; intake clinicians were also trained to offer additional assistance to patients according to their expressed readiness to make an attempt to quit smoking (Fig. 1) (1719). Attendance at the tutorial sessions was 84% among all intake clinicians (full- and part-time) and 90% among full-time intake clinicians.
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The third and fourth components of the intervention were an offer of transdermal nicotine patches and/or proactive telephone counseling. At the conclusion of each clinic visit, all patients who expressed a willingness to quit smoking and were able to set a quit date (within 30 days of the visit) were offered proactive telephone counseling; in addition, those patients who smoked at least 10 cigarettes per day were also offered an 8-week supply of nicotine patches (Nicoderm CQ; GlaxoSmithKline, Research Triangle Park, NC). Contact information and quit dates for all patients who were eligible for telephone counseling were recorded by intake clinicians and faxed daily to the study coordinating center. The cessation counselor, a registered nurse who was hired and trained by the principal investigator (D. Katz) specifically for this project, telephoned the patient just before and approximately 1 week after the scheduled quit date (2123). The telephone counseling protocol focused on the patients preparations for quitting, ways of coping with nicotine withdrawal, and problem-solving skills. During the initial telephone session (which typically lasted 2530 minutes), the counselor probed into the patients past experiences with quitting, discussed strategies for dealing with urges to smoke, and helped the patient prepare for challenges to quitting or triggers to continue smoking during the upcoming quit attempt (e.g., alcohol, other smoker in household) (1). During the follow-up session (which typically lasted 1015 minutes), the counselor reviewed events over the preceding week pertinent to cessation, including any "slips" that may have occurred, any adverse effects possibly related to transdermal nicotine, and any specific concerns raised by the patient (e.g., weight gain, mood disturbance). Additional counseling sessions were scheduled as needed at the counselors discretion (e.g., if the patient requested additional help because of a relapse or problems experienced with nicotine replacement therapy).
The fifth component of the intervention consisted of group and confidential individual feedback on whether intake clinicians had assessed smoking status and whether they had provided cessation counseling. These performance data were based on exit interviews with patients and were presented to intake clinicians at test sites during the training session (baseline period data) and midway during the intervention (intervention period data) (24). Individual feedback highlighted the proportion of patients who were advised to stop smoking by a given intake clinician compared with the proportion of patients who were advised to stop smoking by their unidentified peers at the same site.
Usual Care
Intake clinicians and physicians at control sites were provided with general information about the AHRQ Guideline evaluation trial during the process of recruiting eligible clinics into the trial. These clinic staff were aware that they were participating in a randomized, controlled trial but were not told specifically when they would receive training about use of the intervention (all control sites received training at the end of the trial). Smokers were identified and counseled at the discretion of the clinic staff; neither intake clinicians nor primary care clinicians were instructed to provide (or to not provide) smoking cessation counseling.
Data Collection
Study personnel performed face-to-face exit interviews of all eligible patients immediately after their office visit to assess how well the clinic staff had performed Guideline-recommended activities. Study personnel who were blinded to treatment group assignment (i.e., test site versus control site) and were not involved in telephone counseling interviewed patients by telephone about their smoking habits at 2 and 6 months following the exit interview (i.e., date of enrollment in the study). Patients who were not successfully contacted by telephone after 13 attempts were sent a follow-up survey that included a stamped self-addressed return envelope. If these measures failed, the patient was considered lost to follow-up and was considered not to have quit smoking in the analysis.
During the intervention period, patients who reported that they had not smoked any cigarettes over the prior 7 days at the 6-month follow-up interview were mailed kits for saliva collection and reminders to return the kits. Patients received $20 for returning a sample of their saliva. Cotinine assays were performed on the saliva samples by the American Health Foundation (Valhalla, NY); a cutoff of less than 20 ng/mL cotinine was used to determine abstinence because this threshold is associated with high sensitivity and specificity (>90%) (25). Because of the poor return rate of saliva specimens for cotinine analysis and the possibility of nonresponse bias for reasons unrelated to smoking status (e.g., inertia, privacy concerns, insufficient sample, loss of sample in mail) (26), we used self-reported abstinence as the primary outcome at both the 2- and 6-month assessments. In addition, we received fewer saliva specimens than we expected, partly because 33 of 148 self-reported quitters during the intervention period had inadvertently not been sent a saliva collection kit.
Intake clinicians were surveyed immediately before and after the intervention period. We collected data on type of medical training (registered nurse, license practical nurse, or medical assistant), date of training completion, and smoking status (never, former, or current). These clinicians were also asked to rate their self-efficacy (on a 4-point scale) and role satisfaction with smoking cessation counseling (on a 5-point scale). Descriptive and/or survey data were unavailable for those intake clinicians who were not working at the start of the intervention period, who were employed as "floating" (or locum tenens) staff and did not attend project meetings, or who refused to complete the staff survey.
To calculate the costs related to the intervention, we first tracked the time required to train intake clinicians and estimated the time required for identification and brief counseling of smokers by intake clinicians. Salaries for intake clinicians were based on recent U.S. national data (27); intake clinician costs were estimated by multiplying average hourly salaries by the number of hours expended during the intervention. We also tracked the time spent on telephone counseling and estimated these costs by multiplying the hourly salary of the registered nurse cessation counselor by the number of hours spent on telephone counseling. Costs also included the salary for a full-time research assistant who served as an on-site coordinator, study materials, pharmacotherapy, and technical support for nursing care staff at all test sites. The costs of pharmacotherapy were based on the average wholesale price for transdermal nicotine replacement therapy: $200 for a full 8-week course (28). We also included the costs of reminders, training materials, and patient education brochures.
This project was approved by the Institutional Research Board of the University of Wisconsin. Patients were provided with information about the study, and verbal consent to participate was obtained at the time of the initial interview.
Statistical Analysis
Differences in the distributions of patient and intake clinician characteristics between the test and control sites were determined using the Pearson chi-square test for categorical variables and Students t test for continuous variables; Wilcoxons rank sum test was used to assess differences in variables with highly skewed distributions.
The primary outcomes of this study were the performance of recommended smoking cessation activities by clinic staff (intake clinicians or primary care clinicians), abstinence at 2 and 6 months after the initial clinic visit [7-day point prevalence defined as the proportion of patients who reported abstinence over the previous 7 days (29)], and continuous abstinence (defined as self-reported abstinence at both the 2- and 6-month interviews). We analyzed these outcomes according to treatment group assignment among all patients who agreed during the exit interview to participate in the follow-up (1022 patients enrolled during the baseline period and 1141 patients enrolled during the intervention period). We also computed biochemically confirmed abstinence at 6-month follow-up to determine whether the actual magnitude of the intervention effect was comparable to that based on self-report. For this analysis, we assumed that subjects who reported abstinence but did not provide a saliva sample were still smoking. Patients at test sites who were initially interviewed during the baseline period and were later re-interviewed at the time of a subsequent clinic visit during the intervention period (n = 117) were considered to be intervention-period patients in our analysis, and data obtained for these 117 patients during the baseline period were dropped from the analysis. For those patients who were interviewed more than once during the same study period, we included data from the initial interview only in the analysis.
Because individual patients were grouped by individual intake clinicians (who were grouped by clinic), we also constructed three-level hierarchical logistic regression models of performance and cessation outcomes across the test and control sites combined (30). For example, in a model of advice to quit, yijk denotes the dependent variable for patient i under the care of intake clinician j in clinic k and had a value of 1 for patients who received advice to quit smoking and a value of 0 for patients who did not receive advice to quit smoking. The fixed part of the model was denoted by fijk, and random error variables were denoted by rj (intake clinician-level) and rk (clinic-level). If ijk is the probability of patients having been advised to quit smoking, our three-level logistic model was defined as
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Equation 1 was rewritten and incorporated into a full model that included residual random error terms at the patient level (eijk) as follows:
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The result of the functional relationship in equation 2 is the probability that the patient received advice to quit smoking conditional on the fixed and random variables from all levels of information. On the basis of this model, we estimated the odds ratio (OR) and 95% confidence interval (CI) associated with treatment group assignment after adjusting for patient characteristics that have previously been associated with smoking cessation counseling and/or abstinence (age, sex, educational level, alcohol use, cigarettes smoked per day, self-reported health status, and presence of another smoker in the household) (3133). To account for differences in characteristics of intake clinicians between test and control sites, we also constructed models that included these covariates for the subset of clinicians who provided complete survey data. Planned subgroup analyses were performed for two categories of cigarette use across all cessation outcomes: light smokers (patients who smoked fewer than 10 cigarettes per day) and moderate-to-heavy smokers (patients who smoked 10 or more cigarettes per day).
The projected sample size was 1200 smokers per comparison period (i.e., eight clinics x 10 intake clinicians/clinic x 15 smokers/intake clinician) or 2400 smokers for the entire study. The trial was designed to have 80% power, with an alpha error of .05, to detect an intervention effect size of 0.40 for the 6-month quit rate (34). We aimed to recruit approximately 15 patients per intake clinician because variance estimates are relatively stable at this cluster size (35). The optimal sample sizes we projected were based on prior work on statistical power with group means (36). This approach required that we use only two unknown parameters: the population intra-class correlation coefficient and the predicted magnitude of the intervention effect. We assumed a small intra-class correlation within clinics (i.e., = .05), based on an assessment of the smoking status of patients seen at primary care clinics in five upper midwestern states (Brown RL, Baumann LJ, Helberg CP, Han Y, Fontana SA, Love RR: unpublished data). The observed intra-class correlation coefficients within clinics for the 2-month and 6-month quit rates in this study were .082 and .015, respectively.
Statistical analyses were performed using Stata, version 7.0 (Stata Corp., College Station, TX) and MLwiN (37) software. All tests were two-sided, and a P value less than or equal to .05 was considered to indicate statistical significance.
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RESULTS |
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In addition to increasing adherence to Guideline recommendations, the smoking cessation intervention led to improved cessation outcomes. As shown in Table 4, more patients from test sites than from control sites made an attempt to quit smoking during the 6 months of follow-up, although the difference was not statistically significant (adjusted OR = 1.4, 95% CI = 0.98 to 1.9; P = .06). Patients at test sites were more likely than patients at control sites to report being abstinent for the prior 7 days at both the 2-month follow-up (adjusted OR = 3.3, 95% CI = 1.9 to 5.6; P<.001) and the 6-month follow-up (adjusted OR = 1.7, 95% CI = 1.2 to 2.6; P = .009). Patients from test sites were also more likely than patients from control sites to have been continuously abstinent (i.e., abstinent at both the 2-month and 6-month follow-up assessments) (adjusted OR = 3.4, 95% CI = 1.8 to 6.3; P<.001). Crude and adjusted odds ratios were similar, suggesting that adjustment for patient covariates had a minimal effect on the odds ratios for the intervention (data not shown). Crude odds ratios were also similar to odds ratios adjusted for intake clinician covariates (data not shown). With biochemically confirmed abstinence at 6 months as the dependent variable, patients at test sites were more likely than patients at control sites to have quit smoking, although the difference was not statistically significant (adjusted OR = 1.4, 95% CI = 0.8 to 2.5; P = .30). This analysis incorporated biochemical data from 60 of the 115 self-reported quitters who returned saliva samples for cotinine measurement. Among intervention-period patients who were sent a saliva collection kit, the response rates for patients from control and test sites were similar (53% and 52%, respectively; P = .96). Of the 60 self-reported quitters who provided a saliva specimen for biochemical analysis, 14% and 15% tested positive for cotinine at test and control sites, respectively (P = .91).
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The effects of the intervention on quit attempts, quit rates, and continuous abstinence were statistically significant for moderate-to-heavy smokers but not for light smokers (Table 4). Analysis of the interaction between number of cigarettes smoked and intervention showed a greater increase in the proportion who had made a quit attempt (P = .08) and a greater increase in the proportion of moderate-to-heavy smokers who were abstinent at the 2-month follow-up (P = .06) compared with light smokers; however, none of the interaction terms in our models attained statistical significance. Among moderate-to-heavy smokers (n = 918), patients from test sites were twice as likely to be abstinent upon biochemical testing at the 6-month follow-up as those from control sites (adjusted OR = 2.0, 95% CI = 0.98 to 4.2; P = .06).
Because most patients continued to smoke cigarettes at follow-up, we also assessed whether the intervention affected smoking behaviors in this subgroup of patients (Table 5). During the intervention period, more current smokers from test sites than from control sites reported at the 2-month follow-up that they had made a quit attempt of at least 7 days in duration at some point during the follow-up period, but the difference was not statistically significant (21% versus 11%; adjusted OR = 2.3, 95% CI = 0.9 to 5.7; P = .07). There was no difference between the percentage of current smokers from test and control sites who reported a quit attempt of at least 7 days at some point during the 6-month follow-up period (23% in both groups). However, more patients from test sites than from control sites reported having a plan to quit smoking at the 6-month follow-up (50% versus 39%; adjusted OR = 1.7, 95% CI = 1.1 to 2.5; P = .009). There were no statistically significant differences between patients from test and control sites during either study period in the number of cigarettes smoked (Table 5) or in the number of attempts made to quit smoking (data not shown).
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By designing the brief counseling protocol (Fig. 1) to be performed within 23 minutes, on average, the intervention was well accepted by intake clinicians. A majority indicated that they intended to continue using elements of the intervention (e.g., modified vital signs stamp) after the end of the trial. Moreover, the intervention was generally associated with improved self-efficacy and role satisfaction in cessation counseling among intake clinicians (data not shown).
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DISCUSSION |
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In the current trial, implementation of the AHRQ Guideline by intake clinicians was associated with a 5.6% absolute increase in the 6-month quit rate, an increase that is consistent with the effectiveness of transdermal nicotine therapy plus counseling observed in meta-analyses of controlled clinical trials (1,43). For comparison, the estimated abstinence rates for participants receiving transdermal nicotine therapy or placebo in a meta-analysis of 27 trials were 17.7% and 10.0%, respectively (1). Quit rates among patients from control sites changed minimally over the course of this trial, suggesting that it is unlikely that the increase in quit rates among patients from test sites was attributable to secular trends in smoking cessation.
A unique aspect of the study intervention was that drug therapy and telephone counseling were integrated into clinic-based cessation services and were provided free of charge to smokers. In particular, the study cessation counselor maintained regular communication with the intake clinicians at the test sites and functioned in much the same capacity as a health educator in a managed care organization. The design of the study intervention was consistent with the AHRQ Guideline and with recent national recommendations for creating effective delivery systems (1,44). In addition, studies of guideline implementation support the use of multiple modalities in changing clinicians practice behavior (45,46).
A potential drawback of the study intervention was the need for additional staff time and resources. However, managed care organizations have demonstrated the feasibility of providing pharmacotherapy and counseling as part of a comprehensive strategy for smoking cessation (47). Moreover, the incremental cost per quitter associated with the study intervention compared favorably with that computed in a formal cost-effectiveness analysis, which demonstrated that implementation of the AHRQ Guideline was highly cost-effective relative to other preventive care interventions ($1822 versus $3779) (48).
The limitations of this study warrant discussion. First, biochemical confirmation was not performed for all self-reported quitters. However, biochemical testing has been shown to have limited value in low-intensity interventions such as the one used in this study (29,49,50). In addition, among the patients who provided a saliva specimen for biochemical analysis, a similar proportion of self-reported quitters from test and control sites tested positive for cotinine. Thus, differential overreporting of abstinence is unlikely to account for the higher quit rates observed at test sites. Even if patients at test sites were 5% more likely to overreport abstinence than patients at control sites (51), the difference in 6-month quit rates between patients from test and control sites would still be statistically significant (12.3% versus 8.3%; P = .03; starting with the self-reported abstinence rates of 15.4% and 9.8% for test and control sites, respectively, and multiplying by the proportion of participants who were biochemically confirmed in each group [0.80 and 0.85, respectively, under the assumption of differential overreporting of abstinence in the test group]).
Second, the intervention did not offer patients alternative forms of counseling or drug therapy (e.g., sustained-release bupropion or other forms of nicotine replacement therapy). Although patients were allowed to use pharmacotherapy other than transdermal nicotine patches during the study, a priority of the intervention was to ensure that all eligible smokers had access to effective drug therapy that did not require a physicians prescription (and with no cost to the patient).
Third, the study intervention did not target physicians. The intervention was purposely designed to minimize demands on physicians by reassigning primary responsibility for the identification and brief counseling of smokers to intake clinicians. We presume that the effectiveness of this intervention would have been enhanced if we had actively involved primary care clinicians in implementing the Guideline.
Fourth, we did not achieve our original enrollment target and thus had a slightly lower power than originally planned to detect differences in cessation outcomes between test and control sites. Our recruitment strategy primarily focused on enrolling a sufficient number of patients per intake clinician (to obtain stable estimates of performance for each clinician), and we terminated recruitment at smaller clinics (i.e., those with fewer than 10 intake clinicians) before we attained the original target of 150 smokers per clinic (per study period). Finally, it is unclear if the intervention would be as effective in unselected primary care clinics that might have less interest in smoking cessation or less organizational readiness for change. Patients who participated in the current study were similar to those in a recent preventive care survey of U.S. primary care clinics (52).
Our results suggest that intake clinicians can effectively implement the AHRQ Guideline-based strategy to improve the delivery of smoking cessation advice and pharmacotherapy in a time- and cost-efficient manner. For the 70% of U.S. smokers who visit their physicians at least once a year, exposure to this opportunistic intervention could potentially lead to smoking cessation for approximately 2 million patients annually. To realize these benefits, health care organizations should aim to enhance the impact of brief counseling in primary care settings by providing effective drug and behavioral therapies for properly selected smokers who are committed to quitting. Future research should determine whether strategies based on the AHRQ Guideline can be effectively implemented and sustained in different practice settings over the long term and should evaluate strategies that integrate AHRQ smoking cessation guidelines into the management of other chronic conditions, including diabetes and hypercholesterolemia (53).
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APPENDIX |
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NOTES |
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Editors note: M. C. Fiore has served as a consultant for, has given lectures sponsored by, or has conducted research sponsored by GlaxoSmithKline (Research Triangle Park, NC) and was appointed by the University of Wisconsin to a named Chair made possible by an unrestricted gift to the university from GlaxoSmithKline.
Funded by a Preventive Oncology Academic Award (K07-CA78540) from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services, with supplemental support from the University of Wisconsin Comprehensive Cancer Center and the University of Wisconsin Medical School. GlaxoSmithKline donated transdermal nicotine patches for use in this trial.
We thank those who provided research assistance and technical support throughout the study: Nicole Zillmer, Christine Calmes, Jennifer Martin-McKay, Kylee Carolfi, Meredith Lins, and Betty Granda. We also thank John Beasley, MD, of the Wisconsin Research Network for his insightful comments and Gina Bjudstad for assistance with database design.
Presented at the American Society of Preventive Oncology Annual Meeting, Bethesda, MD, March 11, 2002.
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REFERENCES |
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1 Fiore M, Bailey W, Cohen S, Dorfman S, Goldstein M, Gritz E, et al. Treating tobacco use and dependence. Clinical Practice Guideline. Rockville (MD): U.S. Department of Health and Human Services, U.S. Public Health Service; 2000. Available at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf. [Last accessed: March 6, 2004.]
2 Physician and other health-care professional counseling of smokers to quit--United States, 1991. MMWR Morb Mortal Wkly Rep 1993;42:8547. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00022151.htm. [Last accessed: March 9, 2004.][Medline]
3 Jaen CR, Stange KC, Tumiel LM, Nutting P. Missed opportunities for prevention: smoking cessation counseling and the competing demands of practice. J Fam Pract 1997;45:34854.[ISI][Medline]
4 Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998;279:6048.
5 McPhee SJ, Bird JA. Implementation of cancer prevention guidelines in clinical practice. J Gen Intern Med 1990;(5 Suppl):S11622.
6 Carter WB, Belcher DW, Inui TS. Implementing preventive care in clinical practice. II. Problems for managers, clinicians and patients. Med Care Rev 1981;38:195216.[Medline]
7 Rosen MA, Logsdon DN, Demak MM. Prevention and health promotion in primary care: baseline results on physicians from the INSURE Project on Lifecycle Preventive Health Services. Prev Med 1984;13:53548.[ISI][Medline]
8 Orleans C, George L, Houpt J, Brodie K. Health promotion in primary care: a survey of U.S. family practitioners. Prev Med 1985;14:63647.[ISI][Medline]
9 Coleman T, Wilson A. Anti-smoking advice in general practice consultations: general practitioners attitudes, reported practice and perceived problems. Br J Gen Pract 1996;46:8791.[ISI][Medline]
10 Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998;317:85861.
11 Chernof B, Sherman S, Lanto A, Lee M, Yano E, Rubenstein L. Health habit counseling amidst competing demands: effects of patient health habits and visit characteristics. Med Care 1999;37:73847.[CrossRef][ISI][Medline]
12 Jaen CR, McIlvain H, Pol L, Phillips RL Jr, Flocke S, Crabtree BF. Tailoring tobacco counseling to the competing demands in the clinical encounter. J Fam Pract 2001;50:85963.[ISI][Medline]
13 Katz D, Muehlenbruch D, Brown R, Fiore M, Baker T. Effectiveness of a nurse-based strategy for implementing the AHRQ Smoking Cessation Guideline in primary care. Prev Med 2002;35:293302.[CrossRef][ISI][Medline]
14 Beasley JW, Cox NS, Livingston BT, Davis JE, McBride P, Hankey TL, et al. Development and operation of the Wisconsin Research Network. Wis Med J 1991;90:5312, 5347.[Medline]
15 Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:51144.[ISI][Medline]
16 Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q 2001;79:579612.[CrossRef][ISI][Medline]
17 Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol 1992;47:110214.[CrossRef][ISI][Medline]
18 Jorenby DE, Fiore MC. The Agency for Health Care Policy and Research smoking cessation clinical practice guideline: basics and beyond. Prim Care Clin Off Pract 1999;26:51328.
19 DiClemente CC. Motivational interviewing and the stages of change. In: Miller W, Rollnick S, editors. Motivational interviewing. New York (NY): Guilford Press; 1991. p. 191202.
20 Fiore M, Jorenby D, Schensky A, Smith S, Bauer R, Baker T. Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clin Proc 1995;70:20913.[ISI][Medline]
21 Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation. Who will quit with and without the nicotine patch. JAMA 1994;271:58994.[Abstract]
22 Zhu SH, Stretch V, Balabanis M, Rosbrook B, Sadler G, Pierce JP. Telephone counseling for smoking cesation: effects of single-session and multiple-session interventions. J Consult Clin Psychol 1996;64:20211.[CrossRef][ISI][Medline]
23 Smith SS, Jorenby DE, Fiore MC, Anderson JE, Mielke MM, Beach KE, et al. Strike while the iron is hot: can stepped-care treatments resurrect relapsing smokers? J Consult Clin Psychol 2001;69:42939.[CrossRef][ISI][Medline]
24 Andrews JO, Tingen MS, Waller JL, Harper RJ. Provider feedback improves adherence with AHCPR Smoking Cessation Guideline. Prev Med 2001;33:41521.[CrossRef][ISI][Medline]
25 Etter JF, Vu Duc T, Perneger TV. Saliva cotinine levels in smokers and nonsmokers. Am J Epidemiol 2000;151:2518.[Abstract]
26 Etter J, Perneger T, Ronchi A. Collecting saliva samples by mail. Am J Epidemiol 1998;147:1416.[Abstract]
27 Weiss GG. How to find and keep topnotch clinical staff. Med Econ 2002;79:368, 41, 45.
28 2002 Drug topics redbook. Montvale (NJ): Thomsen Medical Economics; 2002. p.749.
29 Velicer WF, Prochaska JO, Rossi JS, Snow MG. Assessing outcome in smoking cessation studies. Psych Bull 1992;111:2341.[CrossRef][ISI][Medline]
30 Bryk A, Raudenbush S. Hierarchical linear models: applications and data analysis methods. Vol 1. Newbury Park (CA): Sage Publications; 1992.
31 Kabat G, Wynder E. Determinants of quitting smoking. Am J Public Health 1987;77:13015.[Abstract]
32 Hymowitz N, Sexton M, Ockene J, Grandits G. Baseline factors associated with smoking cessation and relapse. Prev Med 1991;20:590601.[ISI][Medline]
33 Sherman S, Wang M, Nguyen B. Predictor of success in a smoking cessation clinic. J Gen Intern Med 1996;11:7024.[ISI][Medline]
34 Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale (NJ): Lawrence Erlbaum; 1988.
35 Brown R. A method of obtaining stable physician/clinic performance estimates. Proceedings of the Fourteenth Annual Primary Care Research Methods and Statistics Conference; 1999 Dec 36; San Antonio. San Antonio (TX): University of Texas Health Sciences Center; 1999.
36 Barcikowski R. Statistical power with group mean as the unit of analysis. J Educ Stat 1981;6:26786.
37 Goldstein H. Multilevel statistical models. London (UK): Edward Arnold; 1995.
38 Jaen CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:16671.[ISI][Medline]
39 Stange K, Flocke S, Goodwin M. Opportunistic preventive services delivery: are time limitations and patient satisfaction barriers? J Fam Pract 1998;46:41924.[ISI][Medline]
40 Curry SJ. Building effective strategies to decrease tobacco use in a health maintenance organisation: Group Health Cooperative of Puget Sound. Tob Control 1998;7 Suppl:S213.
41 Roski J. Changing practice patterns as a result of implementing the Agency for Health Care Policy and Research guideline in 20 primary care clinics. Tob Control 1998;7 Suppl:S1920.
42 Bentz CJ, Davis N, Bayley B. The feasibility of paper-based Tracking Codes and electronic medical record systems to monitor tobacco-use assessment and intervention in an Individual Practice Association (IPA) Model health maintenance organization (HMO). Nicotine Tob Res 2002;4 Suppl 1:S9S17.[CrossRef][Medline]
43 Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation (Systematic Review). Cochrane Database of Systematic Reviews. 2002:(4);CD000146.
44 Curry SJ, Byers T, Hewitt M, editors. Executive summary: fulfilling the potential of cancer prevention and early detection. National Cancer Policy Board, Institute of Medicine, National Research Council. Washington (DC): National Academies Press; 2003. p. 114. Available at: http://books.nap.edu/execsum_pdf/10263.pdf. [Last accessed: March 8, 2004.]
45 Wensing M, van der Weijden T, Grol R. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 1998;48:9917.[ISI][Medline]
46 Grimshaw J. Effective health care: getting evidence into practice. Vol 5. No. 1. NHS Centre for Reviews and Dissemination; February 1999. p. 116. Available at: http://www.york.ac.uk/inst/crd/ehc51.pdf. [Last accessed: March 8, 2004.]
47 Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. N Engl J Med 1998;339:6739.
48 Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. Agency for Health Care Policy and Research. JAMA 1997;278:175966.[Abstract]
49 SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine Tob Res 2002;4:14959.[CrossRef][Medline]
50 Zhu SH, Anderson C, Tedeschi G, Rosbrook B, Johnson C, Byrd M, et al. Evidence of real-world effectiveness of a telephone quitline for smokers. N Engl J Med 2002;347:108793.
51 Murray RP, Connett JE, Lauger GG, Voelker HT. Error in smoking measures: effects of intervention on relations of cotinine and carbon monoxide to self-reported smoking. The Lung Health Study Research Group. Am J Public Health 1993;83:12517.[Abstract]
52 McBride P, Plane M, Underbakke G, Brown R, Solberg L. Smoking screening and management in primary care practices. Arch Fam Med 1997;6:16572.[Abstract]
53 McBride P, Underbakke G, Plane MB, Massoth K, Brown RL, Solberg LI, et al. Improving prevention systems in primary care practices: the Health Education and Research Trial (HEART). J Fam Pract 2000;49:11525.[ISI][Medline]
Manuscript received August 18, 2003; revised February 10, 2004; accepted February 27, 2004.
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