Practice-Based or Community-Based Smoking Cessation Counseling?

CLINICAL QUESTION: How effective is self-referred phone counseling for smoking cessation compared with physician advice, face-to-face nurse counseling, and phone counseling?

BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) guideline on smoking cessation recommends that primary care physicians provide both brief advice and follow-up care for all smokers. Although physician advice alone achieves quit rates of less than 10%, telephone support counseling services have achieved success rates of 20% to 34%. The authors emphasize that implementing smoking cessation programs in clinical settings is difficult and not usually reimbursed. Therefore, this study addressed the question of whether smoker self-referral for phone counseling alone (community-based group) was as effective as physician advice with follow-up care consisting of both face-to-face counseling and phone counseling (practice-based group).

POPULATION STUDIED: The 319 subjects in the community-based group were recruited from mid-Michigan communities using local advertisements. The 168 subjects in the practice-based group were recruited during regular office visits to 4 university-affiliated practices in the same geographic area. All subjects were aged 18 years or older and were willing to quit smoking within 30 days. Practice-based subjects were significantly more likely to have incomes below $10,000, be covered by Medicaid, be enrolled in managed care, be less educated, and use nicotine replacement.

STUDY DESIGN AND VALIDITY: This was a nonrandomized controlled trial that compared 2 smoking cessation strategies. Nurses and phone counselors were trained in computer-assisted relapse prevention counseling and evaluated for intervention skills to improve reliability and decrease potential bias from differing counseling proficiency. Practice-based subjects received brief advice from their physicians and had 3 face-to-face sessions and 3 telephone sessions, while community-based subjects participated in 6 telephone sessions. All subjects were offered free nicotine replacement. All 6 treatment sessions were completed by 63% of practice-based subjects and 64% of community-based subjects. Confirmatory carbon monoxide monitoring was offered to every subject; however, funding limitations allowed confirmation of only 51% of self-reported smoke-free subjects. The authors attempted to control for potential self-selection bias by demonstrating that there were no significant differences between the 2 groups regarding their self-assessed confidence to quit smoking. Logistic regression analysis was also used to control for demographic differences between the 2 populations.

OUTCOMES MEASURED: The primary outcome was self-reported 7-day smoke-free status at 6 months. Secondary outcomes included: smoke-free days per participant; nurse compliance with treatment protocols; physician, nurse, and counselor satisfaction; smoker-participant satisfaction; and nicotine replacement use.

RESULTS: Using intention-to-treat analysis, 1-week abstinence rates were not statistically significant (26% and 22% for practice-based and community-based groups, respectively). One-week abstinence rates were 35% and 36%, respectively, when patients were excluded because of lack of follow-up. No significant differences were found in the logistic regression analysis. Adjusting for lack of follow-up showed no differences between the 2 groups. All participants evaluated the program positively. However, physicians and nurses felt that financial incentives and dedicated scheduling would be required to sustain a practice-based program.