Primary care intervention can boost smoking cessation rate

Intervention from primary care physicians can increase patients' chances of quitting.
Intervention from primary care physicians can increase patients' chances of quitting.

Primary care providers who offer counseling and arrange follow-up sessions for patients can help increase the chances of smoking cessation after lung screenings, according to research from the National Lung Screening Trial (NLSN).

In February 2015, Medicare announced the decision to cover annual lung screenings for individuals with a smoking history of at least 30 years after the U.S. Preventive Services Task Force recommended annual screenings for high-risk individuals. As a result, lung screenings have become widespread among smokers, and this puts clinicians in a position to help their patients quit smoking through active post-screening counseling.

The National Comprehensive Cancer Network recommends smoking cessation counseling for all individuals who receive a lung screening. The post-screening intervention methods used by primary care clinicians are grouped into the 5As (ask, advise, assess, assist, and arrange a follow-up).

“Despite evidence that one in five smokers at a primary care appointment are willing to make a serious quit attempt with the help of treatment that incorporates evidence-based counseling and some form of pharmacologic aid,” the authors note, “most studies report that clinician-delivered rates of assist (recommending and/or providing counseling or prescriptions) are low.”

The researchers examined the rate of delivery of the 5As to 3,336 of the NLSN participants and the effect of each 5A method on the participants' smoking behavior. The study pool consisted of high-risk current or former smokers, 55 to 74 years of age, with a smoking history of at least 30 years. 

The participants were randomly assigned to either a low-dose computed tomography (LDCT) or chest radiography, with an initial lung screen at baseline and two additional annual follow-up screenings. 

Follow-up questionnaires were scheduled every 6 months, where participants were asked if they attended any follow-up visits at primary care facilities and which of the 5A methods their clinicians used.  Participants also recorded their smoking behavior outcomes on the same form.

The researchers compared the rates of the 5A deliveries for 5 years after the participants' initial lung screenings. After the first year of initial screenings, the data showed that the least-frequently used methods were offering assistance and arranging a follow-up (ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange a follow-up, 10.4%). For the 4 years that followed, the ask and advise methods remained stable, while the assess, assist, and arrange methods increased only slightly.

The assist method increased an individual's chances of quitting by 40%, and an arranged follow-up increased the chances by 46%, after demographic adjustments. The researchers found that age, race, positive medical history, or screening result did not affect the impact of the 5As. They found that higher education levels and lower nicotine dependence led to an increased chance of smoking cessation.

The data showed that the ask, advise, and assess methods did not significantly affect smoking cessation rates after lung screenings. “A practitioner who does not extend beyond ask, advise, and assess may be perceived as simply evaluative or may even evoke feelings of discomfort or helplessness from a patient,” the researchers wrote. “Assist and arrange may have a more positive connotation with patients because the clinicians are aligning themselves with patients and helping them to take action by providing support and links that will help them quit.”

Only about half of the participants reported being assisted during primary care visits. Clinicians need to actively engage in intervention with patients after screenings by recommending counseling and prescribing medications to help them quit smoking.

To increase rates of smoking cessation, the authors conclude: “Providers should engage with patients with lower levels of education who are more highly addicted to smoking and are most vulnerable to continued smoking after screening.”

Reference

  1. Park ER, Gareen IF, Japuntich S et al.  Primary Care Provider-Delivered Smoking Cessation Interventions and Smoking Cessation Among Participants in the National Lung Screening Trial. JAMA Intern Med. September 2015; doi: 10.1001/jamainternmed.2015.2391.
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