Validity of urges to smoke measures in predicting smoking relapse during treatment in primary care.

In the context of smoking cessation treatment in primary care, identifying patients at the highest risk of relapse is relevant. We explored data from a primary care trial to assess the validity of two simple urges to smoke questions in predicting long-term relapse and their diagnostic value. Of 295 patients who received behavioural support and varenicline, 180 were abstinent at week 9. In this subgroup, we measured time spent with urges to smoke (TSU) and strength of urges to smoke (SUT; both scales 1 to 6 = highest). We used separate regression models with TSU or SUT as predictor and relapse from week 9-26 or week 9-52 as an outcome. We also calculated the sensitivity (SP), specificity and positive predictive values (PPV) of TSU and SUT in correctly identifying patients who relapsed at follow-up. The adjusted odds ratios (aOR) for predicting relapse from week 9-26 were 1.74 per point increase (95% CI = 1.05-2.89) for TSU and 1.59 (95% CI = 1.11-2.28) for SUT. The aORs for predicting relapse from week 9-52 were 2.41 (95% CI = 1.33-4.37) and 1.71 (95% CI = 1.14-2.56), respectively. Applying a cut-point of ≥3 on TSU resulted in SP = 97.1 and PPV = 70.0 in week 9-26, and SP = 98.8 and PPV = 90.0 in week 9-52. Applying a cut-point of ≥4 on SUT resulted in SP = 99.0 and PPV = 85.7 in week 9-26, and SP = 98.8 and PPV = 85.7 in week 9-52. Both TSU and SUT were valid predictors of long-term relapse in patients under smoking cessation treatment in primary care. These simple questions may be useful to implement in primary care.Trial registration: Dutch Trial Register (NTR3067).

Effectiveness of intensive practice nurse counselling versus brief general practitioner advice, both combined with varenicline, for smoking cessation: a randomized pragmatic trial in primary care.

AIMS: To study the effectiveness of intensive counselling by a practice nurse (PN) versus brief advice by a general practitioner (GP), each combined with pharmacotherapy, for 6 months' tobacco abstinence (primary outcome). Secondary outcomes included 12-month abstinence, medication adherence and incremental costs per life-year gained. DESIGN: A multi-site (n = 10), two-group, parallel, pragmatic randomized controlled trial. SETTING: A network of primary health-care centres in the Netherlands. PARTICIPANTS: A total of 295 adult daily smokers (mean age = 48 years; mean cigarettes/day = 19). INTERVENTION AND COMPARATOR: Patients were randomized to receive individual counselling by a practice nurse (PN) (n = 149) or brief advice by a general practitioner (GP) (146). All patients received 12 weeks of open-label varenicline. MEASUREMENTS: The primary outcome was prolonged biochemically validated abstinence from weeks 9 to 26 after treatment initiation. Secondary outcomes included abstinence from weeks 9 to 52, good dosing adherence (> 80% days taken) and incremental costs per life-year gained. FINDINGS: Abstinence rates in the PN versus GP groups were 32.2% (n = 48) versus 39.0% [n = 57; odds ratio (OR) = 0.71; 95% confidence interval (CI) = 0.44-1.16] from weeks 9 to 26 and 25.5% (n = 38) versus 28.8% (n = 42; OR = 0.84, 95% CI = 0.50-1.43) from weeks 9 to 52, respectively. Values of the Bayes factor indicated that the PN and GP were equally effective. Good dosing adherence was significantly lower in the PN (45.5%, n = 56/123) than in the GP group (62.0%, n = 75/121; OR = 0.45, 95% CI = 0.26-0.77), and the incremental costs per life-year gained were -€416.10. CONCLUSIONS: Among people seeking help to stop smoking from their general practice, one-off brief advice from a general practitioner appears to be as effective as several sessions of behavioural support from a practice nurse when smoking cessation medication is provided.

Experiences of tobacco smoking and quitting in smokers with and without chronic obstructive pulmonary disease-a qualitative analysis.

BACKGROUND: Smokers with chronic obstructive pulmonary disease (COPD) seem to be a special subgroup of smokers that have a more urgent need to quit smoking but might find it more difficult to do so. This study aimed to explore which justifications for tobacco smoking and experiences of quitting were commonly shared in smokers with and without COPD, and which, if any, were specific to smokers with COPD. METHODS: In ten primary healthcare centres in the Netherlands, we conducted semi-structured, in-depth interviews in 10 smokers with and 10 smokers without COPD. RESULTS: Three themes were generated: 'balancing the impact on health of smoking', 'challenging of autonomy by social interference', 'prerequisites for quitting'. All participants trivialized health consequences of smoking; those with COPD seemed to be less knowledgeable about smoking and health. Both groups of smokers found autonomy very important. Smokers with COPD were indignant about a perceived lack of empathy in their communication with doctors. Furthermore, smokers with COPD in particular had little faith in the efficacy of smoking cessation aids. Lastly, motivation for quitting was dominated by fluctuation and smokers with COPD specifically maintained that their vision of life was linked with quitting. CONCLUSIONS: The participants showed many similarities in their reasoning about smoking and quitting. The corresponding themes argue for a less paternalistic regime in the communication with smokers with attention required for the motivational stage and room made for smokers' own views, and with clear information and education. Furthermore, addressing social interactions, health perceptions and moral agendas in the communication with smokers with COPD may help to make smoking cessation interventions more suitable for them.

Do we need tailored smoking cessation interventions for smokers with COPD? A comparative study of smokers with and without COPD regarding factors associated with tobacco smoking.

BACKGROUND: The prevalence of tobacco smoking in patients with chronic obstructive pulmonary disease (COPD) is high. It is assumed that this group of smokers has more difficulties quitting than smokers without COPD. In order to increase the effectiveness of smoking cessation treatments in smokers with COPD it is important to identify any smoking-related factors which are specific to this group of smokers. OBJECTIVE: To compare smokers with COPD with smokers without COPD regarding factors associated with tobacco smoking and quitting. METHODS: We conducted a questionnaire survey in all smoking patients with a recorded diagnosis of COPD from a large Dutch primary health care network. We compared this group with twice as many age-, sex- and health care centre-matched smokers without COPD. RESULTS: Respondents were 107 smokers with COPD and 86 smokers without COPD. The number of attempts to quit was similar in both groups but more smokers with COPD had ever used pharmacological, behavioural and alternative smoking cessation treatments. Furthermore, smokers with COPD more often received triggers to quit from their environment and from their general practitioner, and they were more concerned about, and aware of, the health risks of smoking. Importantly, smokers with COPD reported higher levels of depression and cigarette dependence and a lower self-efficacy to refrain from smoking than smokers without COPD. CONCLUSION: Smokers with COPD differ from smokers without COPD on several factors which are associated with tobacco smoking and quitting. Taking into account these differences may help to increase the effectiveness of smoking cessation treatments for the specific group of smokers with COPD.

Smoking cessation in primary care: Exploration of barriers and solutions in current daily practice from the perspective of smokers and healthcare professionals.

BACKGROUND: Evidence based recommendations for smoking cessation are not followed in routine primary care. A better understanding is needed why smoking cessation treatment is still underutilized. OBJECTIVES: To explore barriers and solutions of smoking cessation treatment, from the perspective of smokers and healthcare professionals in Dutch primary care. METHODS: Focus groups were conducted with 14 smokers (smokers and ex-smokers) and semi-structured individual interviews with nine healthcare professionals (general practitioners and practice nurses). Data was analysed using the Constant Comparative Method. RESULTS: Barriers that prevented successful smoking cessation treatment were the lack of awareness regarding the available smoking cessation treatments at the healthcare centre among smokers and the resistance against preventive tasks among healthcare professionals. Nonetheless, general practitioners (GPs) did not fear jeopardizing the doctor-patient relationship by discussing smoking. Quitting was regarded as the smokers' own responsibility and GPs felt that merely using medication was no guarantee for successful quitting. Even so, practice nurses and smokers preferred medication use. Proposed solutions were that GPs should advise smokers to quit, whereas someone else should deliver intensive behavioural support, preferably the practice nurse. CONCLUSION: Smokers and healthcare professionals seem to wait for each other to start smoking cessation. GPs should know that they could discuss smoking cessation with every patient without jeopardizing the doctor-patient relationship, preferably followed by referral to a practice nurse for intensive behavioural support. Furthermore, more patients should know that they could receive pharmacological treatment as well as behavioural support for smoking cessation in their healthcare centre.