Authors' recommendations: The review conclusions are based on the critical appraisal of the current literature published on the effectiveness of interventions aimed at increasing the likelihood of Health Care Professionals delivering elements of the ABC approach in a primary care setting. Being a systematic review, the overall quality of the review and its recommendations are based on the quality of information presented in the individual studies.Studies were selected on the basis that they reflected the New Zealand context/setting as much as possible, at the level of the patient-provider interaction. An exact match is not possible and no studies were identified that were conducted in New Zealand. A large proportion of the research was conducted in the USA, and differences in system and organisational aspects of care may have shaped the findings. Generalisability of findings to New Zealand populations should therefore be considered on a case-by-case basis with regard being given to the possible influences of contextual, environmental and high-level policy factors. Several authors question the effectiveness of interventions aimed at increasing the delivery of smoking cessation treatments outside of controlled clinical trial settings. That is, their feasibility and sustainability when established in typical primary care settings – removed from the external influences of researcher expertise, funding and other resources. While questions of generalisability are applicable to all clinical trials, this may be more problematic when the intervention is ‘operator dependent’, that is, dependent (at least in part) on the attitudes, enthusiasm, competence and motivation of health care professionals, funders, and other stakeholders. It is recommended that any issues of generalisability be carefully considered but that generalisability should not be seen as a barrier to implementation. Programmes that implement these interventions should carefully monitor and evaluate their impact. Policymakers need to consider the wider implications associated with changes in clinical practice and assess their likely impact on resourse utilisation and/or any possible unintended consequences. For example, the ultimate success of any system that increases the rates of referral of smokers to speciality counselling services is contingent on these services being available and adequately resourced. Preventive activities in general (i.e. services directed primarily toward early detection and treatment or prevention of disease, not prevention of smoking initiation per se) are likely to be in competition with the other pressing demands on general practitioners, and providing patients with quality smoking cessation support is no exception. Team approaches, in which the different tasks of the ABC approach are shared between different health professionals and organisations, is one possible solution to this problem. Patient outcomes were not within the scope of this review. However, 12 studies did report patient outcomes in addition to the ABC outcomes of interest and one trend was apparent – that of improved process outcomes but little strong evidence to suggest that the interventions lead to changes in patients’ smoking behaviour. Nevertheless, this lack of evidence is not evidence of lack of efficacy. In most cases, patient outcomes (e.g. quit rates) were not the primary outcomes of interest and some studies were not sufficiently powered to detect what can be relatively small, yet important effects. However, several authors stated largely similar conclusions, that changing patients’ smoking behaviours is much more complicated than changing the behaviour of individual clinicians, and that influencing patient outcomes may require more intensive and sustained efforts, with multiple strategies which are reinforced at higher policy levels.The effectiveness of interventions to increase the delivery of effective smoking cessation treatments in primary care settings - the ABCs There is insufficient information to inform an economic analysis, given the multiple intervention types and/or components identified and the range of ABC outcomes reported. This is complicated further by inconsistent and/or partial reporting of the outcomes and the use of non-standardised measurement instruments. The cost-effectiveness of programmes aimed at increasing Health Care Professionals’ delivery of these smoking cessation interventions is not well documented. Estimating resource utilisation and any possible cost off-sets and/or savings to the health care system remains beyond the scope of this report.It is clear that increasing the delivery of effective smoking cessation treatments in primary care settings is an important if not essential step in achieving better patient care, and the literature indicates that several interventions offer much promise. It is known that changes in health care outcomes tend to lag behind those in physician performance, and this trend has been observedhere. Possible barriers include patients’ not accepting health care professionals’ recommendations, the socioeconomic and educational status of patients, other environmental influences, and the effectiveness of the clinical interventions themselves. Notwithstanding these limitations, smoking cessation remains an important focus, as stopping smoking is probably the best way an individual can improve his or her health. The literature reviewed suggests that health care professionals who are properly trained, supported, resourced, prompted, given personalised feedback are not subject to disincentives, and for whom the task is made uncomplicated, are more likely to deliver smoking cessation interventions to all their patients who smoke when compared to health care professionals delivering usual care.

Project Status: Completed

URL for project: http://www.healthsac.net/downloads/publications/HSAC10_Smoking_Cessation_230709_FINAL.pdf

Year Published: 2009

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: New Zealand

Organisation Name: Health Services Assessment Collaboration

Contact Address: University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand

Contact Name: hsac@canterbury.ac.nz

Contact Email: hsac@canterbury.ac.nz

Copyright: Health Services Assessment Collaboration (HSAC)