Smoking cessation in patients with COPD in daily general practice (SMOCC): Six months' results
Introduction
Chronic Obstructive Pulmonary Disease (COPD), a life threatening and disabling disease, has become an increasing health problem (World Health Organisation, 2000, National Heart, Lung and Blood Institute, 2003). Smoking is the dominant risk factor, smoking cessation remains the major aspect of treatment (National Heart, Lung and Blood Institute, 2003). Quitting smoking reduces ongoing deterioration of the disease and improves the prognosis of COPD related complaints (Scanlon et al., 2000, Anthonisen et al., 1994, Willemse et al., 2004). A number of smoking cessation interventions can be incorporated in general practice: a simple physician's advice to quit (Silagy and Stead, 2003) (in combination with spirometry (Gorecka et al., 2003)), pharmacological therapies (i.e., nicotine replacement therapy (NRT) and antidepressants) (Silagy et al., 2003, Hughes et al., 2003), minimal intervention (counseling) (Pieterse et al., 2001) and pro-active telephone counseling (Stead et al., 2003). In case of stop-smoking support for COPD patients, combinations of pharmacological and behavioral strategies are likely to be effective (van der Meer et al., 2003).
The stages of change (Prochaska and DiClemente, 1983, Prochaska and DiClemente, 1982), a central concept in smoking cessation interventions, divides the process of behavioral change into five steps. Precontemplators do not consider any change (quitting smoking within the next six months). The next stage, contemplation, is the intention to quit smoking within the next six months. In the preparation stage, one is willing to quit within 1 month; the person is preparing to take action. The two other stages, action and maintenance, respectively, relate to the actual change of the behavior and the maintenance of this change.
The Minimal Intervention Strategy (MIS) is a so-called stage-based smoking cessation intervention for general practitioners (Pieterse et al., 2001). It can be applied during normal practice visits and is effective in decreasing smoking prevalence. Applications of the protocol for risk populations (cardiac patients and pregnant women) also showed effects (Bolman et al., 2002, Bakker, 2001).
Approximately one third of patients with COPD still smokes of which 54% considers to quit smoking within six months or sooner (Hilberink et al., in press). Despite the emphasis in treatment guidelines on smoking cessation, patients with COPD have been found to be a particularly difficult group regarding smoking cessation treatment (Postma and Sluiter, 1989, Crowley et al., 1995, Pederson et al., 1991, Daughton et al., 1980). Since the COPD patient should visit the general practitioner (GP) once in 6 months for a regular control consultation (National Heart, Lung and Blood Institute, 2003), the GP can contribute to the smoking cessation process. Therefore, we changed the MIS into an intensified strategy (SMOking Cessation in COPD in general practice (SMOCC)). The SMOCC program was embedded in normal daily practice as recommended in the COPD treatment guidelines (National Heart, Lung and Blood Institute, 2003).
Implementation of guidelines should be tuned to barriers and stimuli already known and should make use of the knowledge base of effective implementation strategies. Training of health professionals improves their performance of smoking cessation activities, however, organizational factors need also to be addressed (Grol and Grimshaw, 2003). Implementation research shows that interactive education of professionals is mostly effective and suggests that multifaceted interventions and especially outreach visits may be useful to implement guidelines (Grol and Grimshaw, 2003, Thomson O'Brien et al., 2004). Therefore, we designed a multifaceted intervention including professional training and outreach visits to implement a smoking cessation counseling protocol. In the present study, the SMOCC strategy is evaluated on its effectiveness on self-reported quit rates after six months.
Section snippets
Study design
The study is a two-armed randomized controlled trial. General practices in the intervention group received support to implement the SMOCC program, whereas the control group practices delivered usual care. Randomization took place on practice level. Practices were classified in four classes: with high or low task delegation from GP to practice nurses and either or not having experience with smoking cessation counseling. The practices in the classes were then randomly allocated to the groups.
Inclusion of general practices
Twenty-five practices were allocated to the control group and 23 practices to the intervention group, 5 of these practices dropped out (see Fig. 1). Table 1 shows the baseline characteristics of the practices and the GPs, no differences between the arms were observed.
Inclusion of the patients
Of the 406 COPD patients included, two patients died during the study and two patients felt too ill for ongoing participation. After inclusion, 14 patients were excluded from the sample. The total sample consisted of 392 patients
Discussion
The protocol was successfully implemented and doubled the quit rate compared to usual care. Other studies on COPD found continuous abstinence rates at 6 months between 33.3% and 15.7% versus 21.4% and 9.0%, respectively, favoring an intervention (Pederson et al., 1991, Tashkin et al., 2001). However, these more intensive interventions compared to the SMOCC strategy took place in a more controlled environment (Pederson et al., 1991, Tashkin et al., 2001), either with patients with severe lung
Acknowledgments
The present study was financed by the Dutch Asthma Foundation, Netherlands Organization for Health Research and Development (ZonMW), and Pharmacia.
The study was initiated by the Centre for Quality of Care Research (WOK) in Maastricht and Nijmegen. Data analyses were performed by the researcher.
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