Smoking cessation: health system challenges and opportunities.

The systematic integration of evidence-based tobacco treatment has yet to be broadly viewed as a standard-of-care. The Framework Convention on Tobacco Control recommends the provision of support for tobacco cessation. We argue that the provision of smoking cessation services in clinical settings is a fundamental clinical responsibility and permits the opportunity to more effectively assist with cessation. The role of clinicians in prioritising smoking cessation is essential in all settings. Clinical benefits of implementing cessation services in hospital settings have been recognised for three decades-but have not been consistently provided. The Ottawa Model for Smoking Cessation has used an 'organisational change' approach to its introduction and has served as the basis for the introduction of cessation programmes in hospital and primary care settings in Canada and elsewhere. The significance of smoking cessation dwarfs that of many preventive interventions in primary care. Compelling evidence attests to the importance of providing cessation services as part of cancer treatment, but implementation of such programmes has been slow. We recognise that the provision of such services must reflect the realities and resources of a particular health system. In low-income and middle-income countries, access to treatment facilities pose unique challenges. The integration of cessation programmes with tuberculosis control services may offer opportunities; and standardisation of peri-operative care to include smoking cessation may not require additional resources. Mobile phones afford unique opportunities for interactive cessation programming. Health system change is fundamental to improving the provision of cessation services; clinicians can be powerful advocates for such change.

Factors associated with changes in inpatients' smoking pattern during hospitalization and one month after discharge: A cohort study.

INTRODUCTION: Smokers are frequent users of healthcare services. Admissions to hospital can serve as a "teachable moment" for quitting smoking. Clinical guidelines recommend initiating smoking cessation services during hospitalization; however, in Southern European countries less than 5% of inpatients receive a brief intervention for smoking cessation. OBJECTIVES: The aims of this study were (i) to examine rates of smoking abstinence during and after hospitalization; (ii) to measure changes in smoking patterns among persons who continued smoking after discharge; and (iii) to identify predictors of abstinence during hospitalization and after discharge. METHODS: A cohort study of a representative sample of current adult smokers hospitalized in two Spanish and two Portuguese hospitals. We surveyed smokers during hospitalization and recontacted them one month after discharge. We used a 25-item ad hoc questionnaire regarding their smoking pattern, the smoking cessation intervention they have received during hospitalization, and hospital and sociodemographic characteristics. We performed a descriptive analysis using the chi-square test and a multivariate logistic regression to characterize the participant, hospital, and smoking cessation intervention (5As model) characteristics associated with smoking abstinence. RESULTS: Smoking patients from both countries presented high abstinence rates during hospitalization (Spain: 76.4%; Portugal: 70.2%); however, after discharge, their abstinence rates decreased to 55.3% and 46.8%, respectively. In Spain, smokers who tried to quit before hospital admission showed higher abstinence rates, and those who continued smoking reduced a mean of five cigarettes the number of cigarettes per day (p ≤ 0.001). In Portugal, abstinence rates were higher among women (p = 0.030), those not living with a smoker (p = 0.008), those admitted to medical-surgical wards (p = 0.035), who consumed their first cigarette within 60 min after waking (p = 0.006), and those who were trying to quit before hospitalization (p = 0.043). CONCLUSIONS: Half of the smokers admitted into the Spanish hospitals are abstinent one month after discharge or have reduced their cigarettes per day. Nevertheless, success rates could be increased by implementing evidence-based tobacco cessation programs at the organizational-level, including post-discharge active quitting smoking support. CLINICAL RELEVANCE: Three-quarters of the inpatients who smoke remain abstinent during hospitalization and over half achieve to maintain their abstinence or at least reduce their consumption one month after discharge, proving that admission to hospitals is an excellent teachable moment to quit smoking.

Strategies to improve smoking cessation rates in primary care.

BACKGROUND: Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials). OBJECTIVES: To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). MAIN RESULTS: We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation. AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.

Quitting behaviours and cessation methods used in eight European Countries in 2018: findings from the EUREST-PLUS ITC Europe Surveys.

BACKGROUND: We examined quit attempts, use of cessation assistance, quitting beliefs and intentions among smokers who participated in the 2018 International Tobacco Control (ITC) Europe Surveys in eight European Union Member States (England, Germany, Greece, Hungary, the Netherlands, Poland, Romania and Spain). METHODS: Cross-sectional data from 11 543 smokers were collected from Wave 2 of the ITC Six European Country (6E) Survey (Germany, Greece, Hungary, Poland, Romania and Spain-2018), the ITC Netherlands Survey (the Netherlands-late 2017) and the Four Countries Smoking and Vaping (4CV1) Survey (England-2018). Logistic regression was used to examine associations between smokers' characteristics and recent quit attempts. RESULTS: Quit attempts in the past 12 months were more frequently reported by respondents in the Netherlands (33.0%) and England (29.3%) and least frequently in Hungary (11.5%), Greece (14.7%), Poland (16.7%) and Germany (16.7%). With the exception of England (35.9%), the majority (56-84%) of recent quit attempts was unaided. Making a quit attempt was associated with younger age, higher education and income, having a smoking-related illness and living in England. In all countries, the majority of continuing smokers did not intend to quit in the next 6 months, had moderate to high levels of nicotine dependence and perceived quitting to be difficult. CONCLUSIONS: Apart from England and the Netherlands, smokers made few quit attempts in the past year and had low intentions to quit in the near future. The use of cessation assistance was sub-optimal. There is a need to examine approaches to supporting quitting among the significant proportion of tobacco users in Europe and increase the use of cessation support as part of quit attempts.

'Very brief advice' (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user's perspective.

BACKGROUND: Very Brief Advice on smoking (VBA) is an evidence-based intervention designed to increase quit attempts among patients who smoke. VBA has been widely disseminated in general practice settings in the United Kingdom, however its transferability to Southern European settings is not well established. This study sought to document the perspectives of Greek general practice patients in terms of the acceptability and satisfaction with receiving VBA from their general practitioner (GP) and its influence on patients' motivation to make a quit attempt. We also examine patient identified barriers and facilitators to acting on VBA. METHODS: Semi-structured interviews were conducted with 50 patients who reported current tobacco use recruited from five general practices in Crete, Greece. All patients received VBA from their GP and interviews were conducted immediately after the GP appointment. Thematic analysis was used to analyze data. RESULTS: The majority of patients were satisfied with the VBA intervention. Approximately one quarter of patients reported they were motivated to make an attempt to quit smoking after receiving VBA from their GP. Patients identified a clear preference for VBA to be delivered in a supportive manner, which communicated genuine concern versus fear-based approaches. Patients with an existing smoking-related illness were more likely to report plans to act on their GP's VBA. Patients not ready to quit smoking indicated they would be likely to seek the support of their GP for future quit attempts as a result of VBA. Many patients reported low self-efficacy with quitting and apprehension about available quit smoking supports. CONCLUSIONS: VBA was positively received by the majority of smokers interviewed. Participating patients confirmed the motivational role of advice when delivered in a supportive and caring manner. Personal health status, beliefs about quit smoking supports, and low self-efficacy appear to influence patient's motivation to make an aided quit attempt.

From Good to Great: The Role of Performance Coaching in Enhancing Tobacco-Dependence Treatment Rates.

PURPOSE: The purpose of this study was to examine the incremental effect of performance coaching, delivered as part of a multicomponent intervention (Ottawa Model for Smoking Cessation [OMSC]), in increasing rates of tobacco-dependence treatment by primary care clinicians. METHODS: In a cluster-randomized controlled trial, 15 primary care practices were randomly assigned to 1 of the following active-treatment conditions: OMSC or OMSC plus performance coaching (OMSC+). All practices received support to implement the OMSC. In addition, clinicians in the OMSC+ group participated in a 1.5-hour skills-based coaching session and received an individualized performance report. All clinicians and a cross-sectional sample of their patients were surveyed before and 4 months after introduction of the interventions. The primary outcome measure was rates of tobacco-dependence treatment strategy (Ask, Advise, Assist, Arrange) delivery. Secondary outcomes were patient quit attempts and smoking abstinence measured at 6 months' follow-up. RESULTS: Primary care clinicians (166) and patients (1,990) were enrolled in the trial. Clinicians in the OMSC+ group had statistically greater rates of delivery for Ask (adjusted odds ratio [AOR] = 1.69; 95% CI, 1.05-2.72), Assist (AOR = 1.64; 95% CI, 1.08-2.49), and Arrange (AOR = 2.01; 95% CI, 1.22-3.31). Sensitivity analysis found that the rate of delivery for Advise was greater only among those clinicians who attended the coaching session (AOR = 1.65; 95% CI, 1.10-2.49; P = .02). No differences were documented between groups for cessation outcomes. CONCLUSIONS: Performance coaching significantly increased rates of tobacco-dependence treatment by primary care clinicians when delivered as part of a multicomponent intervention.

Smoking cessation delivery by general practitioners in Crete, Greece.

Background: Tobacco dependence treatment in clinical settings is of prime public health importance, especially in Greece, a country experiencing one of the highest rates of tobacco use in Europe. Methods: Our study aimed to examine the characteristics of tobacco users and document rates of tobacco treatment delivery in general practice settings in Crete, Greece. A cross-sectional sample of patients (n = 2, 261) was screened for current tobacco use in 25 general practices in Crete, Greece in 2015/16. Current tobacco users completed a survey following their clinic appointment that collected information on patient characteristics and rates at which the primary care physician delivered tobacco treatment using the evidence-based 4 A's (Ask, Advise, Assist, Arrange) model during their medical appointment and over the previous 12-month period. Multi-level modeling was used to analyze data and examine predictors of 4 A's delivery. Results: Tobacco use prevalence was 38% among all patients screened. A total of 840 tobacco users completed the study survey [mean age 48.0 (SD 14.5) years, 57.6% male]. Approximately, half of the tobacco users reported their general practitioner 'asked' about their tobacco use and 'advised' them to quit smoking. Receiving 'assistance' with quitting (15.7%) and 'arranging' follow-up support (<3%) was infrequent. Patient education, presence of smoking-related illness, a positive screen for anxiety or depression and the type of medical appointment were associated with 4 A's delivery. Conclusion: Given the fundamental importance of addressing tobacco treatment, increasing the rates of 4 A's treatment in primary care settings in Greece is an important target for improving patient care.

Informing primary care reform in Greece: patient expectations and experiences (the QUALICOPC study).

BACKGROUND: Primary health care is the cornerstone of a high quality health care system. Greece has been actively attempting to reform health care services in order to improve heath outcomes and reduce health care spending. Patient-centered approaches to health care delivery have been increasingly acknowledged for their value informing quality improvement activities. This paper reports the quality of primary health care services in Greece as perceived by patients and aspects of health care delivery that are valued by patients. METHODS: This study was conducted as part of the Quality and Costs of Primary Care in Europe (QUALICOPC) study. A cross-sectional sample of patients were recruited from general practitioner's offices in Greece and surveyed. Patients rated five features of person-focused primary care: accessibility; continuity and coordination; comprehensiveness; patient activation; and doctor-patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. Comparisons were made between patients with and without chronic disease. RESULTS: The sample included 220 general practitioners from both public and private sector. A total of 1964 patients that completed the experience questionnaire and 219 patients that completed the patient values questionnaire were analyzed. Patients overall report a positive experiences with the general practice they visited. Several gaps were identified in particular in terms of wait times for appointments, general practitioner access to patient medical history, delivery of preventative services, patient involvement in decision-making. Patients with chronic disease report better experience than respondents without a chronic condition, however these patient groups report the same values in terms of qualities of the primary care system that are important to them. CONCLUSIONS: Data gathered may be used to improve the quality of primary health care services in Greece through an increased focus on patient-centered approaches. Our study has identified several gaps as well as factors within the primary care health system that patient's perceive as most important which can be used to prioritize quality improvement activities, especially within the austerity period. Study findings may also have application to other countries with similar context and infrastructure.

Increasing Rates of Tobacco Treatment Delivery in Primary Care Practice: Evaluation of the Ottawa Model for Smoking Cessation.

PURPOSE: We report on the effectiveness of the Ottawa Model for Smoking Cessation (OMSC), a multicomponent knowledge translation intervention, in increasing the rate at which primary care providers delivered smoking cessation interventions using the 3 A's model-Ask, Advise, and Act, and examine clinic-, provider-and patient-level determinants of 3 A's delivery. METHODS: We examined the effect of the knowledge translation intervention in 32 primary care practices in Ontario, Canada, by assessing a cross-sectional sample of patients before the implementation of the OMSC and a second cross-sectional sample following implementation. We used 3-level modeling (clinic, clinician, patient) to examine the main effects and predictors of 3 A's delivery. RESULTS: Four hundred eighty-one primary care clinicians and more than 3,500 tobacco users contributed data to the evaluation. Rates of delivery of the 3 A's increased significantly following program implementation (Ask: 55.3% vs 71.3%, P <.001; Advise: 45.5% vs 63.6%, P <.001; Act: 35.4% vs 54.4%, P <.001). The adjusted odds ratios (AOR) for the delivery of 3 A's between the pre- and post-assessments were AOR = 1.94; (95% CI, 1.61-2.34) for Ask, AOR = 1.92; (95% CI, 1.60-2.29) for Advise, and AOR = 2.03; (95% CI, 1.71-2.42) for Act. The quality of program implementation and the reason for clinic visit were associated with increased rates of 3 A's delivery. CONCLUSIONS: Implementation of the OMSC was associated with increased rates of smoking cessation treatment delivery. High quality implementation of the OMSC program was associated with increased rates of 3 A's delivery.

Effect of an intervention to improve the cardiovascular health of family members of patients with coronary artery disease: a randomized trial.

BACKGROUND: Family members of patients with coronary artery disease (CAD) have higher risk of vascular events. We conducted a trial to determine if a family heart-health intervention could reduce their risk of CAD. METHODS: We assessed coronary risk factors and randomized 426 family members of patients with CAD to a family heart-health intervention (n = 211) or control (n = 215). The intervention included feedback about risk factors, assistance with goal setting and counselling from health educators for 12 months. Reports were sent to the primary care physicians of patients whose lipid levels and blood pressure exceeded threshold values. All participants received printed materials about smoking cessation, healthy eating, weight management and physical activity; the control group received only these materials. The main outcomes (ratio of total cholesterol to high-density lipoprotein [HDL] cholesterol; physical activity; fruit and vegetable consumption) were assessed at 3 and 12 months. We examined group and time effects using mixed models analyses with the baseline values as covariates. The secondary outcomes were plasma lipid levels (total cholesterol, low-density lipoprotein cholesterol, HDL cholesterol and triglycerides); glucose level; blood pressure; smoking status; waist circumference; body mass index; and the use of blood pressure, lipid-lowering and smoking cessation medications. RESULTS: We found no effect of the intervention on the ratio of total cholesterol to HDL cholesterol. However, participants in the intervention group reported consuming more fruit and vegetables (1.2 servings per day more after 3 mo and 0.8 servings at 12 mo; p < 0.001). There was a significant group by time interaction for physical activity (p = 0.03). At 3 months, those in the intervention group reported 65.8 more minutes of physical activity per week (95% confidence interval [CI] 47.0-84.7 min). At 12 months, participants in the intervention group reported 23.9 more minutes each week (95% CI 3.9-44.0 min). INTERPRETATION: A health educator-led heart-health intervention did not improve the ratio of total cholesterol to HDL cholesterol but did increase reported physical activity and fruit and vegetable consumption among family members of patients with CAD. Hospitalization of a spouse, sibling or parent is an opportunity to improve cardiovascular health among other family members. TRIAL REGISTRATION: clinicaltrials.gov, no NCT00552591.

Tobacco use disorder treatment in primary care: implementing a clinical system pathway in Alberta.

OBJECTIVE: To test a team-based, site-specific, multicomponent clinical system pathway designed for enhancing tobacco use disorder treatment by primary care physicians. DESIGN: A prospective cohort study. SETTING: Sixty primary care sites in Alberta. PARTICIPANTS: A convenience sample of 198 primary care physicians from the population of 2857. MAIN OUTCOME MEASURES: Data collection occurred between September 2010 and February 2012 on 3 distinct measures. Twenty-four weeks after the intervention, audits of the primary care practices assessed the adoption and sustainability of 10 tobacco clinical system pathway components, a survey measured changes in physicians' treatment intentions, and patient chart reviews examined changes in physicians' consistency with the treatment algorithm. RESULTS: The completion rate by physicians was 89.4%. An intention-to-treat approach was undertaken for statistical analysis. Intervention uptake was demonstrated by positive changes at 4 weeks in how many of the 10 clinical system measures were performed (mean [SD] = 4.22 [1.60] vs 8.57 [1.46]; P < .001). Physicians demonstrated significant favourable changes in 9 of the 12 measures of treatment intention (P < .05). The 18 282 chart reviews documented significant increases in 6 of the 8 algorithm components. CONCLUSION: Our findings suggest that the provision of a tobacco clinical system pathway that incorporates other members of the health care team and builds on existing office infrastructures will support positive and sustainable changes in tobacco use disorder treatment by physicians in primary care. This study reaffirms the substantive and important role of supporting how treatment is delivered in physicians' practices.

Delivering evidence-based smoking cessation treatment in primary care practice: experience of Ontario family health teams.

OBJECTIVE: To report on the delivery of evidence-based smoking cessation treatments (EBSCTs) within a sample of 40 Ontario family health teams (FHTs). DESIGN: In each FHT, consecutive patients were screened for smoking status and eligible patients completed a questionnaire immediately following their clinic visits (index visits). Multilevel analysis was used to examine FHT-level, provider-level, and patient-level predictors of EBSCT delivery. SETTING: Forty FHTs in Ontario. PARTICIPANTS: Across the 40 participating FHTs, 24,033 patients were screened and 2501 eligible patients contributed data. MAIN OUTCOME MEASURES: Provider performance in the delivery of EBSCTs during the preceding 12 months and during the index visits was assessed. RESULTS: The rate of provider delivery of EBSCT for the previous 12 months was 74.0% for the advise strategy. At the index visit, rates of EBSCT strategy delivery were 56.8% for ask; 46.9% for advise; 38.7% for assist; 11.6% for prescribing pharmacotherapy; and 11.3% for arrange follow-up. Significant intra-FHT and intraprovider variability in the rates of EBSCT delivery was identified. Family health teams with a physician champion (odds ratio [OR] 2.0; 95% CI 1.1 to 3.6; P < .01) and providers who highly ranked the importance of smoking cessation (OR 1.7; 95% CI 1.1 to 2.7; P < .01) were more likely to deliver EBSCTs. Patient readiness to quit (OR 1.6; 95% CI 1.3 to 1.9; P < .001), presence of smoking-related illness (OR 1.6; 95% CI 1.2 to 2.1; P < .01), and presenting for an annual health examination (OR 2.0; 95% CI 1.6 to 2.5; P < .001) were associated with the delivery of EBSCTs. CONCLUSION: Rates of smoking cessation advice were higher than previously reported for Canadian physicians; however, rates of assistance with quitting were lower. Future quality improvement initiatives should specifically target increasing the rates of screening and advising among low-performing FHTs and providers within FHTs, with a particular emphasis on doing so at all clinic appointments; and improving the rate at which assistance with quitting is delivered.

Improving tobacco cessation interventions in hospitals: Pre-post evaluation of an innovative health systems intervention in Catalonia (Spain).

This study measured changes in healthcare professionals' (HCPs) performance in tobacco cessation intervention before and 6 months after a health system intervention. The intervention involved exposure to online training for staff and the implementation of a structured organizational change-level practice model that included some strategies, comprising establishing tobacco cessation steering groups with champions in each hospital, developing tailored protocols and guidelines within each organization, conducting on-site workshops for clinicians, and creating posters and pocket materials summarizing the intervention. Pre-post evaluation in four hospitals in Barcelona province (Catalonia, Spain). We assessed the knowledge, attitudes, behaviors, and organizational factors (KABO) and the performance of each of the components of the 5As Model for Treating Tobacco Use according to a scale from 0 ("Never") to 10 ("Always") among HCPs. We performed Wilcoxon signed-rank tests for paired samples and assessed changes in performance by performing linear regression. A total of 255 HCPs completed the pre-post evaluation. All components of the 5As Model increased, with "Assist" and "Arrange a follow-up" showing the greatest improvement. Several KABO dimensions significantly increased, including individual skills (mean score: 3.3-5.7, P < .001), attitudes and beliefs (4.8-5.4, P < .001), individual commitment (5.9-6.6, P < .001), and perception of having positive organizational support (4.3-4.7, P < .001). An increase in each point in individual skills and support of the organization was associated with increased rates of 5As delivery, with the greatest associations found for "Assist" (0.60 and 0.17, respectively) and "Arrange a follow-up" (0.71 and 0.18, respectively). The intervention was successful in increasing HCPs individual skills, attitudes and beliefs, individual commitment, and perception of having positive organizational support and the performance of all components of the 5As. Future research should focus on strategies that promote organizational support, a dimension that is essential to increasing Assist and Arrange, which were less implemented at baseline.

This study aimed to assess the impact of a health system intervention on healthcare professionals' (HCPs) ability to help patients quit tobacco use. The intervention involved exposure to online training for staff and the implementation of a structured organizational change-level practice model that included some strategies, comprising establishing tobacco cessation steering groups with champions in each hospital, developing tailored protocols and guidelines within each organization, conducting on-site workshops for clinicians, and creating posters and pocket materials summarizing the intervention. The study took place in four hospitals in Barcelona province. We measured changes in HCPs' knowledge, attitudes, behaviors, and organizational factors related to tobacco cessation interventions. We also evaluated the performance of different components of the 5As Model, which guides tobacco cessation interventions (Ask, Advise, Assess, Assist, and Arrange a follow-up). The results showed significant improvements in all components of the 5As Model, with "Assist" and "Arrange a follow-up" showing the most substantial enhancement. Several key dimensions, including individual skills, attitudes, commitment, and perception of organizational support, also improved significantly. Furthermore, we found that increased individual skills and organizational support were associated with higher rates of delivering the 5As components, particularly "Assist" and "Arrange a follow-up." In conclusion, the health system intervention successfully enhanced HCPs' skills, attitudes, commitment, and perception of organizational support, leading to improved performance in helping patients quit tobacco use. Future research should explore strategies to further promote organizational support, especially for components like "Assist" and "Arrange a follow-up" that were less commonly implemented initially.

Practice Recommendations for the Management of MASLD in Primary Care: Consensus Results.

BACKGROUND: Despite its high prevalence and impact on health, metabolic dysfunction-associated steatotic liver disease (MASLD) is inadequately addressed in European primary care (PC), with a large proportion of cases going undiagnosed or diagnosed too late. A multi-country European research consortium led a project to design and evaluate a patient-centered, integrated model for MASLD screening, diagnosis, and linkage to specialty care for European PC settings. Based on the lessons from this project, the latest research evidence, and existing guidelines for the management of MASLD, we sought to develop a set of practice recommendations for screening, referral, and management of MASLD in PC. METHODS: The Rand/UCLA modified Delphi panel method, with two rounds, was used to reach consensus on practice recommendations. The international panel consisted of experts from six countries, representing family medicine, gastroenterology, hepatology, cardiology, and public health. Initially, fifteen statements were drafted based on a synthesis of evidence from the literature and earlier findings from our consortium. Prior to the consensus meeting, the statements were rated by the experts in the first round. Then, in a hybrid meeting, the experts discussed findings from round one, adjusted the statements, and reassessed the updated recommendations in a second round. RESULTS: In round one, there was already a high level of consensus on 10 out of 15 statements. After round 2, there were fourteen statements with a high degree of agreement (>90%). One statement was not endorsed. The approved recommendations addressed the following practice areas: risk screening and diagnosis, management of MASLD-lifestyle interventions, pharmacological treatment of MASLD/MASH, pharmacological treatment for co-morbidity, integrated care, surgical management, and other referrals to specialists. CONCLUSIONS: The final set of 14 recommendations focuses on increasing comprehensive care for MASLD in PC. The recommendations provide practical evidence-based guidance tailored to PC practitioners. We expect that these recommendations will contribute to the ongoing discussion on systematic approaches to tackling MASLD and supporting European PC providers by integrating the latest evidence into practice.

IntEgrating Smoking Cessation treAtment into usual online Psychological care for people with common mEntal illness: Protocol for an online randomised feasibility and pilot study (ESCAPE digital).

BACKGROUND: In the UK, smoking prevalence in people with depression (34%) and anxiety (29%) is more than double that of the general population (13%). People who stop smoking improve their mental health with comparable effect sizes found for antidepressants. In England, online psychological therapy is a standard treatment for depression and anxiety. Online therapy is an acceptable setting for smoking cessation support; however, integrated smoking and mental health support is not available. This novel study aims to assess the acceptability and feasibility of an online smoking cessation intervention, and trial procedures, offered alongside online mental health treatment as it offers increased reach to people with common mental health difficulties who smoke. METHODS: A two-armed; Intervention (Integrated SilverCloud smoking cessation support) and control group (SilverCloud usual care), pragmatic, randomised controlled feasibility trial. We aim to recruit 500 adult smokers eligible for online mental health treatment. Follow-up will be conducted at 3-months and 6-months. We will assess the acceptability and feasibility of the trial procedures (i.e., recruitment, data completeness, self-reported acceptability and satisfaction) and the intervention (i.e., self-reported quit attempt, engagement with the smoking cessation and mental health programs, smoking cessation medicine and e-cigarette use, self-reported acceptability and satisfaction) and pilot clinical outcomes (i.e., biologically validated smoking abstinence, anxiety, depression, quality of health). CONCLUSION: If the Trial is successful, a randomised controlled effectiveness trial will follow to examine whether integrated smoking cessation and mental health treatment increases smoking abstinence and improves depression and anxiety compared to usual care. TRIAL REGISTRATION: ISRCTN10612149 (https://doi.org/10.1186/ISRCTN10612149), 02/02/2023.

Effectiveness of telephone-based follow-up support delivered in combination with a multi-component smoking cessation intervention in family practice: a cluster-randomized trial.

OBJECTIVE: To determine whether telephone-based smoking cessation follow-up counseling (FC), when delivered as part of a multi-component intervention program is associated with increased rates of follow-up support and smoking abstinence. METHODS: A cluster randomized controlled-trial was conducted within family medicine practices in Ontario, Canada. Consecutive adult patients who smoked were enrolled at two time points, the baseline period (2009) and the post-intervention period (2009-2011). Smoking abstinence was determined by telephone interview 4 months following enrollment. Both groups implemented a multi-component intervention program. Practices randomized to the FC group could also refer patients to a follow-up support program which involved 5 telephone contacts over a 2-month period. RESULTS: Eight practices, 130 providers, and 928 eligible patients participated in the study. No statistically significant difference in 7-day point-prevalence abstinence was observed between intervention groups. There was a significant increase in referral to follow-up in both intervention groups. Significantly higher rates of smoking abstinence [25.7% vs. 11.3%; adjusted OR 3.1 (95% CI: 1.1, 8.6), p<0.05] were documented among the twenty-nine percent of FC participants who were referred to the follow-up support program compared to the MC group. CONCLUSION: Access to external follow-up support did not increase rates at which follow-up support was delivered.

Development of an eLearning intervention for enhancing health professionals' skills for addressing COVID-19 vaccine hesitancy.

Like many countries, Greece has faced resistance to coronavirus disease 2019 (COVID-19) vaccination among residents for both the initial and booster doses. Supporting healthcare professionals with delivering brief advice on COVID-19 vaccination may assist with reaching national vaccination targets. We sought to rapidly develop, pilot test, and deploy an eLearning intervention on skills training on effective techniques for addressing COVID-19 vaccine hesitancy for primary health and social care professionals in Greece. A five-part, 1.5-h eLearning was produced in Greek which featured two behavior change techniques, Very Brief Advice (VBA) and Motivational Interviewing (MI) adapted for use in addressing COVID-19 vaccine hesitancy. Six-film-based case studies modeling the use of VBA and MI in the context of challenging scenarios typically seen in Greek health and social settings were produced for the eLearning. The CME was pilot tested using a pre-post design in a small convenience sample (n = 17) of health care professionals. Pilot study results found the training provided new knowledge (80%), improved provider skills (80%), and was useful to provider's clinical practice (90%). There was a mixed effect in provider capability, motivation, and opportunity. Ninety percent of providers strongly agreed or agreed that they planned to use the information and skills provided by the training in their clinical practice. This project has resulted in new training assets for use by health and social professional tailored to the nationally context in Greece including supporting uptake of booster doses of the COVID-19 vaccine.

Development and implementation of a continuing medical education program on non-alcoholic fatty liver disease for primary care practitioners in Europe.

Background: Primary care has a crucial role to play in the prevention, early detection, referral, and risk factor management of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis (NAFLD/NASH). In 2021, a team of European collaborators developed a continuing medical education (CME) program on NAFLD/NASH that consolidates evidence and clinical best practices tailored to the primary care setting. This article reports on the methodology used to design and develop the CME and the results of a feasibility study. Methods: An expert advisory group representing both European specialists and general practitioners supported the design of the CME to be implemented in three European settings (Greece, Spain, and Netherlands). The CME features four training modules and problem-based learning using clinical case studies. The CME was tested regarding feasibility and acceptability among a sample of primary care providers (PCPs) in Greece (n = 28) with measurements occurring before, immediately after, and 1 month following the training. Outcome measures included satisfaction with the CME, changes in PCPs' knowledge, attitudes, confidence, and self-reported clinical practices related to NAFLD/NASH. Results: The CME is available as an open-access e-learning course on the European Society for Primary Care Gastroenterology education platform in English, Greek, Spanish, and Dutch. The feasibility study documented high levels of satisfaction, with 96% of PCPs reporting they were extremely or very satisfied with the overall training. Statistically significant increases in PCPs' confidence in NAFLD/NASH-related clinical practices were documented between the pre- and post-assessments. At the follow-up, 62% of GPs reported that the CME had changed their clinical practices related to NAFLD/NASH to a great extent. Conclusion: This CME intervention developed by experts and tailored to PCPs in European settings may serve as an asset for increasing knowledge, confidence, and practice behaviors related to NAFLD/NASH.