EDITORIALS

Tobacco Control in the Physician’s Office: A Matter of Adequate Training and Resources

Robert A. Schnoll, Paul F. Engstrom

Affiliation of authors: Fox Chase Cancer Center, Cheltenham, PA

Correspondence to: Robert A. Schnoll, PhD, Division of Population Science, Fox Chase Cancer Center, 510 Township Line Rd., Cheltenham, PA 19012 (e-mail: ra_schnoll{at}fccc.edu)

The results reported by Katz et al. (1) in this issue of the Journal are noteworthy because they demonstrate that training physician-based medical practices in smoking cessation treatment guidelines can reduce the rate of patient tobacco use. This study also serves as a catalyst for a broader discussion on the role of physicians’ practices in the treatment of nicotine addiction, a discussion that should consider the degree to which medical practices possess the requisite skills and resources for guideline implementation.

Despite the modest effects of physician-based smoking cessation interventions compared with those of pharmacotherapies (24), the "reach" of physician-based treatments (i.e., the proportion of smokers affected by the treatment) makes the impact value of this treatment approach substantial. Given that approximately 70% of smokers visit a physician each year (5), physician-based smoking interventions are a cost-effective way to disseminate cessation treatment to most smokers (6). By contrast, it has been estimated that only 25% of smokers use an over-the-counter transdermal nicotine patch and only 6% of smokers use formal behavioral counseling treatments to quit smoking (7). Furthermore, a physician-based approach to treating nicotine addiction may be especially effective because smokers perceive medical personnel as a valuable, credible, and reliable source of health information and typically show a high level of adherence to advice they receive from health care workers (8).

Unfortunately, most physician-based medical practices do not capitalize on this opportunity to provide smoking cessation treatment (9). In 1995, only 21% of U.S. smokers indicated that they had received smoking cessation counseling during a visit to a physician—a rate that decreased from 29% in 1993 (10). More recent assessments suggest some improvement in the rate of treatment of smokers by physicians (11). For example, the California Department of Health Services found that, in 1998, 49% of smokers were advised to quit smoking by their physician (12), and the National Committee for Quality Assurance (13) found that, in 2000, 66% of smokers were advised to quit smoking during visits to a physician. Nevertheless, these estimates underscore the fact that many patients who smoke do not receive adequate treatment for tobacco use. Although certain barriers to implementation of smoking cessation guidelines may be overcome by providing adequate training to physicians, other barriers to guideline implementation, such as time constraints and the availability of personnel, may be surmounted only through the use of creative methodology. The study by Katz et al. (1) addressed lack of skill by providing training seminars and addressed resource issues by training nurses, intake clinicians, and medical assistants in implementing the Agency for Healthcare Research and Quality Smoking Cessation Clinical Practice Guideline. In short, their study demonstrates that, not only is it feasible to increase adherence to the Guideline among physician-based medical practices but also that such efforts are cost-effective, improve clinical practices by enhancing clinician self-efficacy and role satisfaction and, importantly, reduce patient tobacco use. The authors’ use of a randomized study design, a large sample, and statistical methods to isolate the treatment effects from sources of error or confounding instill confidence in the overall findings.

Nonetheless, certain study limitations are worth noting. First, the study tracked patients for only 6 months; thus, the effect of training physician-based medical practices in using the Guideline on long-term abstinence is unclear. However, one potential advantage of physician-based treatments versus, for example, nicotine replacement therapy is that the physician-based intervention can be reinforced at every visit. Although physician-based interventions may outperform other types of smoking cessation treatments in terms of their long-term abstinence rates, the benefits cannot be determined from the Katz et al. study. In addition, because continuous abstinence was defined as abstinence for the preceding 7 days at the 2- and 6-month assessments, patients who were abstinent for the 7 days prior to these time points but relapsed between assessments would incorrectly be classified as continuous abstainers. A timeline follow-back, whereby the patients record the number of cigarettes smoked on each day preceding the interview date back to the preceding data point, would have offered a method for avoiding this possible misclassification.

Second, the Katz et al. study did not use biochemical verification of self-reported cessation. This limitation is of some concern because the rate of false reporting (i.e., the percentage of self-reported quitters who tested positive for saliva cotinine) was 14%–15% and because there was no statistically significant difference across study conditions when biochemically confirmed abstinence was used as the outcome measure.

Third, it is unclear whether the results reported by Katz et al. are generalizable to clinics that do not resemble those that participated in the study. The implementation of the clinical services described in this study requires that the clinic maintain adequate support personnel. Because many clinics lack such resources, the study results may lack widespread generalizability.

Fourth, the study intervention did not offer patients access to bupropion, the smoking cessation treatment that yields the highest sustained quit rates (14). This decision, although understandable given that bupropion requires a prescription, may have limited the potential impact of the intervention.

In light of these issues and because adherence to the Guideline by clinics assigned to receive the smoking cessation intervention was suboptimal at follow-up (e.g., only 38% of patients at those clinics received cessation literature and only 39% received nicotine replacement therapy), several priorities for future research remain. First, novel and creative approaches to training physicians in using the Guideline should be assessed. To date, all studies (including the study by Katz et al.) have used classroom instruction, lectures, and literature to train clinicians in smoking cessation counseling. Alternative methods of training worthy of investigation include the use of the Internet or CD-ROM (e.g., training tutorials available on the Internet or on CD-ROM) and the use of physician incentives to adhere to the Guideline. Innovative training methods may be critical to reach rural medical practices, to ensure that most practices receive training, and to enhance Guideline implementation among clinics that lack resources. Second, future studies should examine methods to address the barriers to Guideline implementation because medical practices are not fully capitalizing on their opportunity to promote patient smoking cessation. Time constraints among clinicians hinder integration of adjunctive clinical services such as smoking cessation counseling into routine care (15), and third-party reimbursement for providing such clinical services is rare (11). Furthermore, a lack of training in smoking cessation counseling can foster perceptions among clinic personnel, such as lack of confidence in their ability to provide cessation counseling and belief that counseling patients to quit smoking is not part of their job or would be ineffective (16), which may serve as barriers to providing smoking cessation interventions. Future studies, therefore, may need to address training issues, clinician perceptions, and system-wide problems that impede broad implementation of the Guideline.

Future research should also explore whether the approach used by Katz et al. can be applied to other types of medical practices such as oncology, gynecology/obstetrics, and pediatrics. For instance, a recent survey of oncologists found that 1) one-third to one-half of oncologists have not received training in how to follow the Guideline; 2) although most oncologists assess the smoking status of their patients (i.e., they ask about status), only one-third to one-half of oncologists adhere to the "Advise," "Assess," "Assist," or "Arrange" components of the Guideline; and 3) most oncologists lack the time and expertise to counsel patients about smoking cessation or believe that patients lack interest in receiving such counseling (17). Given the prevalence of continued tobacco use among cancer patients (18), the link between tobacco use and adverse health outcomes (18), and our failure to demonstrate reductions in patient smoking following oncologist training in use of the Guideline (19), the assessment of novel approaches to Guideline implementation in oncology is a priority.

Lastly, studies that assess Guideline implementation within small clinical practices with limited resources are needed. Results of the Katz et al. study (1) suggest that adequate training and personnel are sufficient to change Guideline implementation in clinical practice and reduce patient smoking. However, many physicians lack the time to treat nicotine addiction, especially in the current managed-care environment, and many clinics in the United States lack the personnel to dedicate to Guideline implementation.

Overall, the Katz et al. study demonstrates that implementing the Guideline in physician-based medical practices is feasible and can reduce patient tobacco use. However, broad dissemination of their approach depends on medical clinics possessing adequate skill and resources. Future research is needed, therefore, to assess innovative and generalizable methods for enhancing adherence to the Guideline across the spectrum of U.S. physicians’ practices.

NOTES

Supported by Public Health Service grant CA95678 (to R. A. Schnoll) from the National Cancer Institute, National Institutes of Health, Department of Health and Human Services.

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