Smoking-cessation strategies observed in videotaped general practice consultations

Is identification of smoking, risky alcohol consumption and overweight and obesity by General Practitioners improving? A comparison over time

BACKGROUND

Detection of lifestyle risk factors by GPs is the first step required for intervention. Despite significant investment in preventive health care in general practice, little is known about whether GP detection of lifestyle risk factors have improved over time.

OBJECTIVES

To examine whether sensitivity and specificity of GP detection of smoking, risky alcohol consumption and overweight and obesity has increased in patients presenting to see their GP, by comparing results from four Australian studies conducted between 1982 and 2011.

METHODS

Demographic characteristics of patient and GP samples and the prevalence, sensitivity and specificity of detection of each risk factor were extracted from published studies. Differences between GP and patient sample characteristics were examined. To identify trends over time in prevalence of risk factors, sensitivity and specificity of detection across studies and the Cochran-Armitage test for trend were calculated for each risk factor for the overall sample and by male and female subgroups.

RESULTS

There were no statistically significant changes in the sensitivity of GP detection of smoking or overweight or obesity over time. Specificity of detection of smoking increased from 64.7% to 98% (P < 0.0001) and decreased for overweight or obesity from 92% to 89% (P = 0.01). There was a small decrease in the sensitivity of detection of alcohol consumption (P = 0.02) and an increase in specificity (P = 0.01).

CONCLUSIONS

Despite significant investment to increase GP detection and intervention for lifestyle risk factors, accurate detection of smoking, risky alcohol consumption and overweight and obesity occurs for less than two-thirds of all patients.

Sequence-analysis of video-recorded practitioner-patient communication about smoking in general practice: do smokers express negative statements about quitting?

OBJECTIVE

To examine the extent to which smokers express negative statements about quitting and the extent to which these statements influence general practitioners' (GPs') and practice nurses' (PNs') (dis)continuation of guideline-recommended smoking cessation care.

METHODS

Fifty-two video-consultations were observed (GP-consultations: 2007-2008; PN-consultations: 2010-2011). Dialogues were transcribed verbatim and professionals' and patients' speech units were coded and analysed using sequential analyses (n=1424 speech units).

RESULTS

GPs focused on asking about smoking (GPs: 42.4% versus PNs: 26.2%, p=0.011) and advising them to quit (GPs: 15.3% versus PNs: 3.5%, p<0.001), whereas PNs focused on assisting them with quitting (GPs: 25.4% versus PNs: 55.2%, p<0.001). Overall, patients expressed more negative statements about quitting than positive statements (negative: 25.3% versus positive: 11.9%, p<0.001), especially when PNs assessed their willingness to quit (OR 3.61, 95% CI 1.44-9.01) or assisted them with quitting (OR 2.23, 95% CI 1.43-3.48).

PRACTICE IMPLICATIONS

An alternative approach to smoking cessation care is proposed in which GPs' tasks are limited to asking, advising, and arranging follow-up. This approach seems the least likely to evoke negative statements of patients about quitting during dialogues with GPs and is compatible with the tasks and skills of PNs who could, subsequently, assist smokers with quitting.

Teaching Brief Interventions for Smoking Cessation via an Interactive Computer-based Tutorial

Many current smokers do not plan on quitting any time soon. For these smokers, the immediate treatment goal is not a quit attempt, but an increase in readiness to stop smoking. In the present study we developed an interactive multimedia simulation and tutoring environment that teaches healthcare professionals to provide brief motivational interviewing-based smoking cessation interventions tailored to the patient's current readiness to change. This tutorial utilizes a cognitive science-derived learning approach that provides tailored feedback and lessons based on learners' pre-existing knowledge, is highly interactive and allows learners to practice skills in simulated clinical situations. Results from two pilot studies indicate that healthcare professionals and students found the software easy and enjoyable to use and successfully learned MI-based strategies for smoking cessation.

Smoking prevalence, cigarette consumption and advice received from physicians: Change between 1996 and 2006 in Geneva, Switzerland

OBJECTIVE

To assess change between 1996 and 2006 in smoking prevalence, cigarette consumption, quit attempts, motivation to quit and advice received from physicians in Geneva, Switzerland.

METHODS

Postal surveys in cross-sectional, representative samples of the general population of Geneva in 1996 and 2006.

RESULTS

There were 742 participants in 1996 (response rate 75%) and 1487 in 2006 (response rate 76%). Smoking prevalence remained stable between 1996 (28.0%, 95% confidence interval: 24.7 to 31.3%) and 2006 (26.5%, 24.3 to 28.7%, p=0.46). Among smokers, cigarette consumption fell from 15 to 13 cig./day between 1996 and 2006 (p=0.003). However, tobacco dependence, as measured by the Heaviness of Smoking Index, remained stable (mean=1.9 vs. 1.7, p=0.18). The proportion of smokers who made a 24-hour quit attempt in the previous year remained stable (29.2% in 1996, 32.1% in 2006, p=0.52), but more smokers reported that they intended to quit in the next 6 months in 2006 (39.6%) than in 1996 (29.1%, p=0.045). The association between smoking prevalence and income was stronger in 2006 (chi(2)=53.7, p<0.001) than in 1996 (chi(2)=10.9, p=0.012). In 2006 (no change since 1996), few smokers reported that, during their last medical visit, their physician told them to quit smoking (27.3%) or offered them help to quit (13.3%).

CONCLUSIONS

Over these 10 years, smoking prevalence, nicotine dependence levels and the frequency of quit attempts remained stable, but smokers' motivation to quit increased. We observed a growing social gap in smoking prevalence and cigarette consumption. Smoking cessation advice was seldom received during medical visits.

Enabling and sustaining the activities of lay health influencers: lessons from a community-based tobacco cessation intervention study

The authors present findings from a community-based tobacco cessation project that trained lay health influencers to conduct brief interventions. They outline four major lessons regarding sustainability. First, participants were concerned about the impact that promoting cessation might have on social relationships. "Social risk" must be addressed during training to ensure long-term sustainability. Second, formal training provided participants with an increased sense of self-efficacy, allowed them to embrace a health influencer identity, and aided in further reducing social risk. Third, material resources functioned to mediate social tensions during health intervention conversations. A variety of resources should be made available to health influencers to accommodate type of relationship, timing, and location of the interaction. Finally, project design must be attentive to the creation of a "community of practice" among health influencers as an integral part of project sustainability. These lessons have broad implications for successful health promotion beyond tobacco cessation.

Audio-visual recording of patient-GP consultations for research purposes: a literature review on recruiting rates and strategies

OBJECTIVE

To identify ethical processes and recruitment strategies, participation rates of studies using audio or video recording of primary health care consultations for research purposes, and the effect of recording on the behaviour, attitudes and feelings of participants.

METHODS

A structured literature review using Medline, Embase, Cochrane Library, and Psychinfo. This was followed by extensive hand search.

RESULTS

Recording consultations were regarded as ethically acceptable with some additional safeguards recommended. A range of sampling and recruitment strategies were identified although specific detail was often lacking. Non-participation rates in audio-recording studies ranged from 3 to 83% for patients and 7 to 84% for GPs; in video-recording studies they ranged from 0 to 83% for patients and 0 to 93% for GPs. There was little evidence to suggest that recording significantly affects patient or practitioner behaviour.

CONCLUSIONS

Research involving audio or video recording of consultations is both feasible and acceptable. More detailed reporting of the methodical characteristics of recruitment in the published literature is needed.

PRACTICE IMPLICATIONS

Researchers should consider the impact of diverse sampling and recruitment strategies on participation levels. Participants should be informed that there is little evidence that recording consultations negatively affects their content or the decisions made. Researchers should increase reporting of ethical and recruitment processes in order to facilitate future reviews and meta-analyses.

Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: a randomised trial in Australian general practice

BACKGROUND

GPs often lack time to provide intensive cessation advice for patients who smoke. This study aimed to determine the effectiveness of opportunistic referral of smokers by their GP for telephone cessation counselling by a trained nurse.

METHODS

Adult smokers (n = 318) attending 30 GPs in South Western Sydney, Australia were randomly allocated to usual care or referral to a telephone-based program comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse. Self-reported point prevalence abstinence at six and 12 months was compared between groups. Characteristics of patients who accepted and completed the intervention were investigated.

RESULTS

Of 169 smokers randomised to the intervention, 76 (45%) consented to referral. Compared with smokers in 'pre-contemplation', those further along the stage-of-change continuum were significantly more likely to consent (p = 0.003). Those further along the continuum also were significantly more likely to complete all four calls of the intervention (OR 2.6, 95% CI: 0.8-8.1 and OR 8.6, 95% CI: 1.7-44.4 for 'contemplation' and 'preparation' respectively). At six months, there was no significant difference between groups in point prevalence abstinence (intention to treat) (9% versus 8%, p = 0.7). There was no evidence of differential intervention effectiveness by baseline stage-of-change (p = 0.6) or patient sex (p = 0.5). At 12 months, point prevalence abstinence in the intervention and control groups was 8% and 6% respectively (p = 0.6).

CONCLUSION

Acceptance of opportunistic referral for nurse delivered telephone cessation advice was low. This trial did not demonstrate improved quit rates following the intervention. Future research efforts might better focus support for those patients who are motivated to quit. AUSTRALIAN CLINICAL TRIALS REGISTRY NUMBER: ACTRN012607000091404.

Healthcare providers' sun-protection promotion and at-risk clients' skin-cancer-prevention outcomes

BACKGROUND

This study aims to determine whether healthcare providers' (HCPs') communication dealing with sun-protection (i.e., counseling) is associated with clients' skin-cancer-related prevention practices, detection self-efficacy, and knowledge.

METHODS

Secondary analysis of two surveys of 1,469 randomly sampled farmers and soccer participants from southeast and coastal Georgia.

RESULTS

Farmers and soccer participants who report ever having been counseled by a HCP about how to protect their skin from the sun report being more likely to wear sunscreen (P < 0.05), get clinical exams of their skin (P < 0.001), be certain that they can recognize unhealthy changes in their skin (P < 0.001), be certain that they know how to perform a skin exam (P < 0.001), and be knowledgeable about skin cancer prevention (P < 0.05 and P < 0.001, respectively); soccer participants are additionally more likely to wear protective headgear (P < 0.05) and perform monthly self-exams of their skin (P < 0.001). All analyses incorporated three control variables: participants' prior history of skin cancer, age, and non-HCP-derived skin-cancer awareness.

CONCLUSIONS

Findings suggest that HCPs' counseling can positively shape skin-cancer-related prevention practices, detection self-efficacy, and knowledge. Additional research is needed on HCPs' actual communication about skin cancer and sun protection and its influence on client outcomes.

A new curriculum using active learning methods and standardized patients to train residents in smoking cessation

Physicians can play a key role in smoking cessation but often fail to advise smokers effectively, mainly because they lack counseling skills. We need effective training programs starting during residency to improve physicians' smoking cessation interventions and smokers' quit rates. To achieve this goal, we developed a curriculum using active learning methods and the stages-of-change model. A randomized trial demonstrated that this program increased the quality of physician's counseling and smokers' quit rates at 1 year. This paper describes the educational content and methods of this program. Participants learn to assess smokers' stage of change, to use counseling strategies matching the smoker's stage, and to prescribe pharmacological therapy. This 2 half-day training program includes observation of video-clips, interactive workshops, role plays, practice with standardized patients, and written material for physicians and patients. Participants reached learning objectives and appreciated the content and active methods of the program.

Preventive dentistry: what do Australian patients endorse and recall of smoking cessation advice by their dentists?

OBJECTIVE

To investigate patients' views regarding dentists' smoking cessation advice.

DESIGN

Survey questionnaire.

SETTING

One hundred and thirty five dental practices in Sydney Australia. Subjects Two thousand, four hundred and fifty one dental patients.

RESULTS

One thousand, one hundred and sixty pre-consultation questionnaires were obtained (RR=80%), 302 (26%) were self-reported smokers. From these, 623 post-consultation questionnaires were returned (RR = 54%). Most patients expected dentists to be interested in their smoking status (n = 847/1160, 73%, 95% CI: 70% to 76%) and to discuss smoking with them (n = 713/1160, 61%, 95% CI: 59% to 64%), however, smokers were significantly less likely to respond as such compared with non-smokers (P < 0.001). Smokers and non-smokers equally would not change dentist even if asked about their smoking status opportunistically (59% versus 62%) (OR = 0.91, 95% CI: 0.67 to 1.22). Less than one third of all smokers would try to quit if their dentist suggested they do so (n = 90/302, 30%, 95% CI: 25% to 35%). Smokers' recall of quit advice from their recent consultation was low (n = 22/124, 18%).

CONCLUSIONS

Smoking cessation advice by dentists is not self-evidently effective. These findings behove interventional research to ascertain efficacy of smoking cessation advice delivered by dentists before admonishing changes in routine clinical practice.

Correspondence among patients' self-reports, chart records, and audio/videotapes of medical visits

This pilot study examined the covariation of patients' self-reports of instrumental and affective aspects of communication during physician-patient visits with 2 other sources of data: medical chart records and audio/videotapes. Participants were 17 community-based (nonuniversity) primary-care physicians and 77 of their patients, ages 50 to 80. Patients were interviewed by telephone within 1 week after their medical visits. Thirty-five of these visits were audio- and videotaped. Patients were asked to report on their receipt of specific cancer screening in the previous 2 years, the occurrence of instrumental communication events during the visit (e.g., recommendations), their affect, and their visit experiences and communication with their physicians. Results showed (a) noteworthy disagreements between patients' self-reports and medical charts regarding cancer screening; (b) better agreement of patients' self-reports with videotape records than with chart records regarding physicians' recommendations; (c) accurate recognition of patients' self-reported affect, communication, and visit experiences by third-party raters of both audiotapes and videotapes; and (d) similar correlations of audio- and videotape ratings with patients' self-reports as well as substantial correlations between audio and video ratings. The implications of these findings are discussed, and recommendations are made for future research.

Screening and counseling for adolescent alcohol use among primary care physicians in the United States

OBJECTIVE

To examine the prevalence and quality of alcohol prevention services delivered to adolescents in the United States.

METHODS

A national, stratified random sample of pediatricians and family practitioners was drawn from the American Medical Association Masterfile. The response rate was 63%, and the final sample size was 1842 physicians. Quality of services delivered was assessed by 2 scales: quality of screening (percentage of patients screened and depth of screening questions used) and quality of education (level of effectiveness of educational methods used and frequency of use).

RESULTS

Although most physicians reported providing some degree of alcohol prevention services, their efforts were typically inconsistent, not in enough depth, and they failed to incorporate the most effective educational methods. Reported rates of universal screening and counseling were low, and younger adolescents were less likely to receive services. Physicians' beliefs about their alcohol management skills and perceptions of resource availability were the most consistent correlates of higher quality service.

CONCLUSIONS

Prospective studies that elucidate the conditions under which individual physicians do and do not screen, as well as future efforts to educate physicians about the most effective brief intervention approaches, seem warranted.

Physician smoking-cessation actions: are they dependent on insurance coverage or on patients?

BACKGROUND

Despite good evidence that their smoking-cessation actions can be very effective, physicians have not consistently used the 5A actions (being asked, advised, assessed, assisted, and arranged) recommended in the U.S. Public Health Service tobacco guidelines. We tested the hypothesis that the introduction of coverage for smoking-cessation pharmacotherapy by the health plans covering most of the population in one region would increase physician use of 5A's.

METHODS

A cohort of smoking members of two health plans was surveyed before and after the introduction of coverage for smoking cessation. A total of 1560 current smokers with a physician visit in the last year responded to both surveys. The key outcome measures were smoker reports of the guideline 5As for smoking-cessation support during the last physician visit.

RESULTS

There were small significant absolute percentage increases only for reports of being assessed (+4.9%, p=0.01) and assisted (set quit date +6.5%, p=0.0004); encouraged to use medications (+8.8%, p=0.03); and given a prescription (+8.6%, p=0.0005). However, these increases were limited to smokers reporting awareness of the coverage, asking for quitting help, or both.

CONCLUSION

Coverage for pharmacotherapy alone appears to have had no effect on physician behavior beyond that stimulated by smokers who were aware of the coverage, perhaps because they raised the issue. More research is needed on this suggestion that patients create physician behavior change.

Can distance learning improve smoking cessation advice in family practice? A randomized trial

INTRODUCTION

Family physicians (FPs) underuse opportunities to provide smoking cessation advice during routine consultations with patients who smoke. Distance learning is a promising approach to continuing medical education, particularly for FPs practicing in rural and remote areas. We developed a distance learning module, conducting a randomized trial to assess its educational impact on knowledge, attitudes and skills ("competence"), self-rated competence, confidence, and readiness to change.

METHODS

Volunteer FPs were randomly allocated to receive either a distance learning module or a preventive care guideline. Self-administered questionnaires were completed at baseline and post-test.

RESULTS

Fifty-three FPs enrolled in the study. There were no changes in knowledge or attitudes. Change in skills was limited to a reduction in use of one ineffective technique, namely "nicotine fading." Change in self-rated competence between baseline and post-test was significantly greater for the intervention than for the control group, however (p = .03). Although self-ratings of confidence increased significantly between baseline and post-test in both groups, the magnitude of change was no greater in the intervention than the control group (p = .3). Both groups demonstrated only nonsignificant shifts in readiness to change.

DISCUSSION

These modest changes are of uncertain educational value, inviting caution before recommending distance learning approaches to promote smoking cessation advice in family practice.

Evidence-based medicine in general practice: beliefs and barriers among Australian GPs

If implemented, evidence-based medicine (EBM) in general practice will improve health outcomes for patients. This paper examines the views of 60 Australian general practitioners about EBM. While 57% of respondents had a computer in their surgery, 15% had Internet access and only 3% had access to the Cochrane Library at work. The most commonly cited barrier to EBM was 'patient demand for treatment despite lack of evidence for effectiveness' (45%). The next three most highly rated barriers related to lack of time. For each of three tasks of EBM, namely searching for evidence, appraising evidence and discussing the implications of evidence with patients, lack of time was rated as a 'very important barrier' by significantly more participants than lack of skills (McNemar's tests: chi2(1) = 7.1, P = 0.008, chi2(1) = 14.0, P = 0.001 and chi2(1) = 9.0, P = 0.003, respectively). Preferred resources for EBM included clinical practice guidelines (rated as 'very useful' by 55%) and journals that summarize research evidence, for example Evidence-based Medicine (52%). Systematic reviews were considered 'very useful' by only 15% of respondents, consistent with our finding that 30% did not understand the term 'systematic review'. Furthermore, 43% did not understand 'meta-analysis'. A minority indicated they understood the terms 'relative risk' (23%), 'absolute risk' (28%) and 'number needed to treat' (15%) sufficiently to explain to others. Skills development is crucial to achieve EBM in general practice.

Smoking cessation in the hospitalized patient using the transtheoretical model of behavior change

Tobacco use continues to be the most prevalent cause of preventable morbidity and mortality in the United States, causing more than 430,000 deaths each year, or 1 in every 5 deaths. In addition, many health care providers employed in critical care settings deal with patients who have experienced a near-death event that has led them to consider smoking cessation. The smoking cessation rate 1 year after a myocardial infarction is approximately 70% in those patients who receive a smoking cessation intervention. Theory-based smoking cessation interventions have been found to be effective. The purpose of this article is to present the transtheoretical model as basis for developing a hospital-based smoking cessation intervention. In addition, symptom management options will be discussed.

Implementing guidelines for smoking cessation advice in Australian general practice: opinions, current practices, readiness to change and perceived barriers

OBJECTIVE

The aim of this study was to ascertain opinions, current practices, likely readiness to change and perceived barriers to change among Australian GPs in order to develop a plan to implement national guidelines for smoking cessation advice.

METHOD

A postal survey of randomly selected GPs in New South Wales, Australia was carried out.

RESULTS

We received 311 returned questionnaires (73% response rate). Only 34% of respondents reported providing cessation advice during every routine consultation with a smoker, in accordance with national guidelines. Specific evidence-based approaches recommended in guidelines were under-utilized, with only 54% 'always' or 'frequently' arranging follow-up, 32% providing written materials and 28% setting a 'quit date'. Respondents were no more likely to advise quitting completely than the less effective method of nicotine fading. More than one in four respondents (28%) indicated readiness to change their behaviour. Respondents rated their patients' lack of motivation and uninterest as the most important barriers to smoking cessation advice in general practice. Neither uncertainty about effective smoking cessation strategies nor lack of reimbursement for smoking cessation advice were identified as barriers.

CONCLUSIONS

A multicomponent intervention to address suboptimal behaviour and barriers as revealed by this survey holds considerable potential to plan effective implementation of smoking cessation guidelines in general practice. The use of readiness to change as a tool to 'individualize' strategies for guideline implementation should be explored.

Patient satisfaction and discussion of smoking cessation during clinical visits

OBJECTIVE

To learn whether patients who smoke and who receive smoking cessation information during medical office visits were less likely to be satisfied with the smoking cessation help they received than patients who smoke but who did not receive such information.

PATIENTS AND METHODS

A total of 3703 current cigarette smokers were identified by a mailing in November 1998 to 163,596 members of 2 Minnesota health plans, and 2714 (77.3%) responses to a 44-item questionnaire were available for analysis. Using hierarchical analysis to control confounding variables, we assessed the relationship between patient-reported smoking cessation support actions at the last physician visit and satisfaction "with the help received from your doctor about quitting smoking."

RESULTS

Smokers were very satisfied (12.0%), satisfied (25.3%), neutral (48.6%), and dissatisfied or very dissatisfied (13.5%) with physician help. After controlling for other characteristics, the 1898 patients who reported that they had been asked about tobacco use or advised to quit during the latest visit had 10 percentage point greater satisfaction ratings and 5 percentage point less dissatisfaction than those not reporting such discussions (P<.001). Smokers reporting no interest in quitting at the time of the latest visit also demonstrated greater satisfaction in association with these actions.

CONCLUSION

Smoking cessation interventions during physician visits were associated with increased patient satisfaction with their care among those who smoke. This information should reduce concerns of physicians or nurses about providing tobacco cessation assistance to patients during office visits.

Tobacco cessation skills certification in Arizona: application of a state wide, community based model for diffusion of evidence based practice guidelines

OBJECTIVE

To describe the development and preliminary results from a community based certification model for training in tobacco cessation skills in Arizona.

DESIGN

A programme evaluation using both quantitative pre-post measures and qualitative methods.

SETTING

Arizona's comprehensive tobacco control programme of state funded, community based local projects and their community partners providing tobacco treatment services for geographically, socioeconomically, and ethnically diverse communities.

INTERVENTION

A three tiered model of skills based training emphasising Agency for Health Care Policy and Research guidelines, and utilising a training of trainers approach to build community capacity. Certification roles addressed basic tobacco cessation skills, tobacco cessation specialist, and tobacco treatment services manager.

PARTICIPANTS

Initial target audience was community based local project personnel and their community partners, with later adoption by community organisations unaffiliated with local projects, and the general public. MAIN EVALUATION MEASURES: Process measures: participant satisfaction, knowledge, skills, and self-efficacy.

OUTCOME

participant demographics, community organisations represented, post-training, cessation related activities.

RESULTS

During the model's implementation year, 1075 participants attended certification training, 947 participants received basic skills certificates and 82 received specialist certificates. Pre, post, and three month measures of self efficacy showed significant and durable increases. Analysis of participant characteristics demonstrated broad community representation. At post-training follow up, 80.9% of basic skills trainees had performed at least one brief intervention and 74.8% had made a referral to intensive services. Among cessation specialists, 48.8% were delivering intensive services and 69.5% were teaching basic skills classes.

CONCLUSIONS

Initial experience with Arizona's state wide, community based model for certification of tobacco cessation skills training suggests this model may be a promising method for broad, population based diffusion of evidence based tobacco cessation guidelines.

Telephone counseling as adjuvant treatment for nicotine replacement therapy in a "real-world" setting

BACKGROUND

Physicians prescribing nicotine replacement therapy (NRT), or health plans covering NRT, often want their patients to receive adjuvant behavioral treatment. However, how to do that in a "real world" is unclear. This paper reports results from a public health program that uses proactive telephone counseling as support for physician advice and provides adjuvant treatment for NRT users.

METHODS

Participants were NRT users (N = 8,832) who called the California Smokers' Helpline, a statewide cessation service that provides proactive counseling, one session before NRT use and multisessions after the smokers received NRT. After receiving NRT, some participants discontinued the counseling while others continued with follow-up sessions. A subset of the 8,832 participants (n = 664) was interviewed 13 months later for quitting status.

RESULTS

After receiving NRT, 79% of the participants continued with counseling and received 4.2 sessions on average, while 21% of them received only one session. Overall, 82.8% of all participants made a quit attempt. Nicotine patch users were more likely to make an attempt than nicotine gum users (85.2% vs 66.3%), but the relapse probability was the same for these attempts. Those who received multiple counseling were more likely to make an attempt than those receiving single counseling (84.4% vs 77.1%) and were more likely to stay quit for 1 year (25.6% vs 16.1%).

CONCLUSIONS

Proactive telephone counseling is a promising adjuvant treatment for NRT users in a "real-world" setting: a convenient referral service for supporting health plans or physicians who advise their patients to quit smoking.

Using content analysis of video-recorded consultations to identify smokers' "readiness" and "resistance" towards stopping smoking

Although physicians' brief advice against smoking is effective in helping smokers to stop, very little is known about the process of counseling smokers. We describe the development of a coding system for describing smokers' motivation to stop smoking as judged by their behaviour when discussing smoking with their family physician. We analysed video-recordings of consultations between 47 self-reported smokers and 29 family physicians where smoking was discussed. By a process of observing recordings, reading transcripts and discussion, we developed a coding system for describing smokers' levels of motivation to stop smoking. This consists of four behaviours thought to indicate "readiness" (higher motivation to stop) and four "resistance" (lower motivation to stop). Interobserver reliability between two observers was good (Kappa = 0.71 for readiness, 0.73 for resistance behaviours). We discuss the relevance of our descriptions for clinicians and the possibility of developing this work further to enable systematic research into doctor-patient interactions where smokers are counseled to stop.

Labeling smokers' charts with a "smoker" sticker: results of a randomized controlled trial among private practitioners

We randomly assigned private practitioners (n = 393) to receiving, by mail, a box of "Smoker" stickers and a recommendation to label smokers' charts with these stickers, or to no intervention. Twenty percent of the physicians reported using the stickers and applying them on 43% of their smoking patients' charts. The intervention had no impact on physician reports of the proportion of smokers advised to quit smoking, but physicians who reported using the stickers stated that they advised more smokers to quit after the intervention (89%) than before (80%, P =.02). Thus, self-reports by physicians indicated that use of the stickers was associated with an increased proportion of smokers advised to quit. However, overall, the intervention did not modify physicians' behavior.

A strategy for involving general practitioners in smoking control

OBJECTIVE

In 1991, the Victorian Smoking and Health Program introduced a simple intervention strategy for general practitioners that could be integrated conveniently and inexpensively into the routine care of patients who smoke. The aim of this study was to determine whether there had been a change over time in whether or not GPs advised their patients not to smoke.

METHOD

The extent to which smokers remembered GPs talking to them about smoking was assessed in population-based surveys of adults in Victoria in 1990 (prior to the implementation of the intervention) and in 1992, 1994 and 1996.

RESULTS

Over time there was a significant increase in the proportion of smokers who reported that their GP had provided them with help or information to stop smoking (chi 2 = 17.58, p < 0.001). In 1996, 9% of smokers said their doctor had advised them to contact Quit.

CONCLUSION

Levels of recalled advice and provision of information regarding smoking cessation have increased by 10% over the past six years. However, nearly half the smokers in this study reported that they had been given inappropriate advice or no advice at all.

IMPLICATIONS

A brief intervention by GPs, supplemented by appropriate referrals, has the potential to assist significant numbers of smokers to quit and may be more practical for GPs who are unable to personally provide all of the support smokers may need to quit.

Australian doctors' beliefs and practice regarding Helicobacter pylori

OBJECTIVE

To determine beliefs and behaviours of Australian doctors regarding Helicobacter pylori.

DESIGN

Anonymous reply-paid postal survey mailed in December 1995 and again in March 1996.

SUBJECTS

All members on the mailing lists of the Gastroenterological Society of Australia Endoscopy Section (n = 397) and the Australian Society of Infectious Diseases (n = 264; those without medical qualifications were asked not to reply), and 400 general practitioners (GPs) randomly selected from the Royal Australian College of General Practitioners.

MAIN OUTCOME MEASURES

Differences between specialist groups in belief in a causative association between H. pylori and peptic disease and in use of eradication therapy and pre- and post-treatment testing for H. pylori.

RESULTS

92.6% of doctors believed H. pylori causes duodenal ulcer, with GPs significantly less likely to believe than gastroenterologists (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.00-0.81). In duodenal ulcer, 93.4% of doctors believed H. pylori eradication therapy should be given, but fewer (83.4%) claimed to give it "always or mostly", with GPs less likely to report giving it than gastroenterologists (OR, 0.06; 95% CI, 0.02-0.19). For non-ulcer dyspepsia, gastrointestinal surgeons were more likely than gastroenterologists to believe in a causative link with H. pylori (OR, 5.6; 95% CI, 3.0-10.7) and in a need for eradication therapy (OR, 3.6; 95% CI, 1.7-7.7). Most doctors (79.3%) believed in confirming the presence of H. pylori before eradication therapy in duodenal ulcer. Only 51.6% believed post-eradication testing necessary (45.5%), yet 79.1% reported performing it.

CONCLUSIONS

Significant differences exist between specialist groups in beliefs and self-reported behaviours regarding H. pylori.

Influence of physician and patient gender on provision of smoking cessation advice in general practice

OBJECTIVE

To examine the association between physician and patient gender and physicians' self-reported likelihood of providing smoking cessation advice to smokers using hypothetical case scenarios in primary care.

DESIGN

Cross-sectional analysis of a self-administered questionnaire.

SUBJECTS

National random sample of Australian general practitioners (GPs).

MAIN OUTCOME MEASURES

Self-reported likelihood of advising hypothetical male and female smokers to stop smoking during a consultation for ear-syringing ("opportunistic" approach) or a dedicated preventive health "check up".

RESULTS

855 GPs returned questionnaires (67% response rate). Significantly more respondents indicated they would be "highly likely" to initiate an opportunistic discussion about smoking with a male smoker (47.8% (95% confidence intervals (CI) = 44.5 to 51.2)) than a female smoker (36.3% (95% CI = 33.1 to 39.5]). Older, male GPs were less likely to adopt an opportunistic approach to smoking cessation for patients of either sex. Respondents were more likely to recommend that a male patient return for a specific preventive health check up. Furthermore, in the context of a health check up, a greater proportion in total of respondents indicated they would be "highly likely" to discuss smoking with a man (86.9%, 95% CI = 84.5 to 89.0) than a female smoker (82.5%, 95% CI = 79.8 to 84.9).

CONCLUSIONS

As measured by physician self-report, the likelihood of advising smokers to quit during primary care consultations in Australia appears to be influenced by gender bias. Gender-sensitive strategies to support cessation activities are recommended.

Improving smoking cessation advice in Australian general practice: what do GPs suggest is needed?

Smoking cessation advice from a general practitioner (GP) significantly increases quit rates among patients who smoke. However, smoking is not discussed during most routine consultations with smokers. This study describes GPs' own views about strategies to support their cessation advice. In 1997, a random sample of 311 GPs in NSW (73% response rate) completed a self-administered questionnaire about smoking cessation. Most respondents were 'very confident' about discussing the health effects of smoking (81.7%). Fewer were as confident about negotiating a quit date (21.5%) or using evidence-based smoking cessation techniques (19.3%). The top three preferred strategies to support smoking cessation advice were all resources for patients: subsidised nicotine replacement therapy (rated as 'quite useful' by 60.5%), pamphlets (55.0%) and free access to smoking cessation clinics (50.8%). Skills training (39.7%) was the preferred resource to improve practitioner effectiveness. Interventions combining skills training with patient resources are likely to be well received by GPs.