[ new program * nouveau programme

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1 [ new program * nouveau programme MOBILIZING PHYSICLANS TO CONDUCT CLINICAL INTERVENTION IN TOBACCO USE THROUGH A MEDICAL-ASSOCIATION PROGRAM: YEARS' EXPERIENCE IN BRITISH COLUMBIA Frederic Bass, MD, DSc Lkg IISEL 3~~~~~~~~~~~~~~~~~~~~~~~~~~~~~... Systematic, brief clinical intervention in tobacco use by physicians is a proven approach to lowering the prevalence of smoking.' The Canadian Guide to Clinical Preventive Health Care2,3 and the US Guide to Clinical Preventive Services4 both assign clinical intervention in tobacco use an A rating, meaning that the intervention is supported by first-class or the highest level of evidence. Randomized controlled trials have shown that, among smokers who are subject to brief intervention by their physician, the smoking cessation rate doubles, from 6% to 12% each year.5 However, systematic clinical intervention in tobacco use does not appear to be widely conducted by physicians.6 Since 1990 the BC Doctors' Stop-Smoking Program has addressed this gap by helping physicians to implement such intervention. ROLE OF PHYSICIANS AND COMPONENTS OF INTERVENTION Most smokers are not ready to stop smoking. Surveys find that, at any time, only 12% to 20% of smokers are actively preparing to stop smoking (Omnibus Survey of British Columbia, Campbell and Goodell Associates, Vancouver: unpublished data, 1994 and 1995).7 Achieving long-term abstinence from smoking takes most smokers 5 to 10 years from the date of their initial at- Dr. Bass is director of BC Doctors'Stop-Smoking Program, Vancouver, BC. Reprint requests to: Dr. Frederic Bass, BC Doctors'Stop-SmokingProgram, British Columbia MedicalAssociation, 1665 WBroadway, Vancouver BC V6J 5A4; fax For prescribing information see page 265 CAN MED ASSOC J * JAN. 15, 1996; 154 (2) 159

2 tempt.8 Physicians, especially general practitioners (GPs), are in a unique position to influence the many smokers who are not ready to quit as well as to aid the ones who are ready. GPs see patients who smoke at many opportune moments when they are concerned about their health. A GP may see the same patient who smokes over decades. In a recent population survey conducted in British Columbia, smokers were asked which kinds of assistance to stop smoking they would choose (they could choose as many as they wished) (Omnibus Survey of British Columbia, Campbell and Goodell Associates, Vancouver: unpublished data, 1995). The largest proportion of respondents (44%) chose the nicotine patch or nicotine gum, 33% chose a program offered by their physician, 23% wanted none of the listed options and 20% chose a program offered by another health care professional. Other methods, ranging from booklets and videotapes to stop-smoking groups, were chosen by 6% to 15% of respondents. This is consistent with the findings of another survey.9 The components of physicians' clinical intervention in tobacco use, in broad terms, are: * asking patients about smoking, * advising smokers to stop smoking and young people not to start, * assisting those who are ready, and motivating those who are not ready, to stop smoking and * following up all smokers and those who have recently stopped smoking.101 To these four basic components, the Guide Your Patients program of the Canadian Council on Smoking and Health adds: ' * assessing the practice's effectiveness in intervening in tobacco use and * advocating effective tobacco-control policies in the community. The specific components of clinical intervention in tobacco use are * asking each smoker and recent ex-smoker about smoking as well as updating the patient record,,2 * putting a label (Fig. 1) or computer-generated reminder in the record to prompt regular attention to smoking,6 12, * offering strong advice and personalized risk information to patients repeatedly,6 4 * listening empathically and reflectively to patients who smoke in order to motivate them to stop smoking,'5-'9 * giving patients printed information about the risks of smoking and how to stop smoking,"2 * stressing behavioural self-management,20'2' * helping those ready to stop smoking to set a target date,' "-l * offering nicotine-replacement therapy to those who are ready to stop and who are addicted to nicotine 10,11,22 * using a stepped-care algorithm to match treatment to patients' needs,23,24 EX SMOKER I Jg- L l H t ti }4wi. } t,!~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ''!+,*1: t... Fig. 1: Sheet of adhesive labels to be placed on patients' records to indicate their status in regard to smoking cessation (pictured here at 57% of actual size). 160 CAN MED ASSOC J * 15 JANV. 1996; 154 (2)

3 * referring patients to community programs and to addiction specialists as required,'0 l1124 * maintaining long-term follow-up of all patients who smoke or who have quit smoking6'2 and * involving office staff in clinical intervention in tobacco use.0 25 A stepped-care approach to smoking cessation involves three steps: self-managed smoking cessation, smoking cessation guided by a physician (with or without nicotine-replacement therapy) and supervision by a clinician trained in treating nicotine addiction.2324 Most smokers stop on their own, without any formal assistance.',23 A small proportion of smokers require the specialized care of physicians who are familiar with the treatment of nicotine addiction.24 Some patients (for example, those with schizophrenia or depression, addicted to other drugs or under great stress) require special care. BC DOCTORS' STOP-SMOKING PROGRAM GOALS AND OBJECTIVES The goal of the BC Doctors' Stop-Smoking Program, launched by the British Columbia Medical Association (BCMA) in May 1990, is to recruit GPs to deliver systematically a clinical smoking-cessation strategy. The program's specific objectives are to:26 * recruit target numbers of physicians each year, * follow up the physicians' clinical intervention in tobacco use, * use the BCMAs physician database to track physicians' involvement, * encourage physicians to involve their office personnel in the program, * improve the program materials and procedures on the basis of physicians' feedback and * count the number of patients who consequently stop smoking. RECRUITING PHYSICIANS Physicians have been recruited through hospital rounds, medical conferences (including the BCMA annual meeting), training conducted as part of the Guide Your Patients program, the British Columbia Medical Joumal, brochures included in mailings from physicians' organizations (the Society of General Practitioners of British Columbia and the British Columbia College of Family Physicians), the Medical Office Assistant Association of British Columbia and direct physician enquiries to the program. The program is located in the same building as the BCMA, which provides the program with mail, telephone, fax and communication services. The program's goal for the first year (up to May 1991) was to train 500 physicians through hospital rounds and to have 10% of them adopt a systematic approach. Each year the program has set, and subsequently met, targets for the number of GPs to be recruited. The numbers of GPs recruited since 1990 are shown in Tables l and 2. DEFINING INVOLVEMENT IN CLINICAL INTERVENTION IN TOBACCO USE Despite the absence of recognized operational criteria, program organizers had to classify the level of intervention in a practice. We chose to consider the ordering of clinical-intervention materials from the program as the principal indicator of a commitment to intervention in the practice. An "active" practice was one in which one or more of the following items were ordered: No. (and %) Status Definition of GPs Active Physician is committed to 655 (23) using a systematic approach to clinical intervention in tobacco use, in addition to using patient-education materials provided by the program Semi-active Physician uses only the 258 (9) program's patient-education materials Kit only Physician is trained in clinical 706 (25) intervention in tobacco use but is not known to be implementing intervention None Physician has.no recorded 1231 (43) contact with program Cumulative no. (and %) Date as of which Cumulative of all GPs recruitment was target no. recruited calculated of GPs n = 2850 December (5) December (7) December (8) December (14) December (21) May 1995 * 655 (23) *Target no. for December 1995 was 785. CAN MED ASSOC J * JAN. 15, 1996; 154 (2) 161

4 * adhesive labels for patient records (to indicate the patient's smoking-cessation status, see Fig. 1), * a rubber date stamp (to track patients' smoking behaviour), * target-date forms (to help patients set quit dates and to structure follow-up) and * a target-date roster (to track all patients who set target dates). The labels and date stamp entail a small cost, signifying a financial commitment by the physician; the targetdate forms and roster involve a modest time commitment. We selected these criteria because research has shown that regular prompting, together with long-term follow-up, lead to significantly increased rates of smoking cessation GPs who do not meet the definition of "active" but who regularly use the materials for patients are considered "semi-active." FOLLOW-UP OF PRACTICES Each year all physicians considered active are mailed a follow-up questionnaire in which they are asked whether the components of clinical intervention in tobacco use are being conducted in the practice. Telephone follow-up of one third of respondents has been necessary to obtain an adequate response rate. In 1994, 77% of 391 physicians completed the follow-up questionnaire (Table 3). PROGRESS The BC Doctors' Stop-Smoking Program today provides smoking-cessation tools and support to one third of GPs in the province. The program now follows up all active and semi-active physicians every year to evaluate how program tools and procedures have been used and to obtain physicians' comments and suggestions for improvements. As a result of this feedback, and of developments in the literature on smoking cessation, the materials and procedures have been revised several times. We have completed a small pilot project to assist practices to evaluate their clinical intervention. However, attempts to encourage physicians to count how many patients try to stop smoking have met with limited success. Inadequate staff support has been a major factor hindering practice self-evaluation. The program's tools and procedures have been presented to health care workers in other sectors, such as hospital-based physicians, dentists, pharmacists and respiratory therapists. We tried on several occasions to offer education in tobacco-use intervention in the physician's office and to involve the office staff in this "in-office" training. However, this approach requires much more staff time than is now available from this program and from the physician's staff. ESTIMATION OF THE PROGRAM'S EFFECTIVENESS Kottke and associates,' in a review of 39 randomized controlled trials of smoking-cessation programs, showed a median difference of 5.8% in smoking-cessation rates between patients attending practices without a systematic tobacco-use intervention program and those attending practices with such a program. The typical GP in British Columbia comes face to face with 150 smokers each year. If British Columbia's 655 GPs active in this program induced 4% of their patients who would not otherwise have stopped smoking to quit, and if the 258 GPs semi-active in the program induced 2% of their patients to quit, in 1995 the program would have resulted in an estimated 4700 smokers quitting and receiving follow-up by their GP as well as smokers receiving improved counselling and follow-up from their GP. DISCUSSION Good treatment of nicotine addiction requires good dissemination of the intervention and good quality assurance. Research has shown, in no uncertain terms, that clinical intervention in tobacco use is effective. Yet we '%of ui-s using intervention component Intervention component Regularly ask patients who smoke whether they are ready to stop 90 Give patients printed information on how to stop smoking 86 Formally set a target (quit) date with patients who smoke 68 Give brief counselling when prescribing the nicotine patch or nicotine gum 62 Begin asking patients 13 years of age or younger about smoking 62 Use adhesive labels on patient records to indicate smoking-cessation status 59 Give patients printed information on conditions caused by smoking 39 Involve office staff in intervention 33 Use rubber follow-up stamp 18 Use target-date form (multiple copies, one of which is for the patient) 15 Keep track of number of smokers who stop *Of 300 responses received, 11 pphysicians (4%) indicated they were dropping out of the program; therefore, proportions are calculated out of the remaining 289 respondents. 162 CAN MED ASSOC J * 15 JANV. 1996; 154 (2)

5 have very little information on how physicians deliver this type of intervention.27 We need better information, from physicians, patients, office staff and patient records, on how this intervention is delivered in actual practice. Medical associations can be very effective in mobilizing physicians to intervene. Provincial, state or regional medical associations represent the physician community. Just as public health units help local communities to mobilize to intervene in tobacco use, so can medical communities mobilize to take action in regard to clinical preventive medicine. A medical association's database represents a unique resource for tobacco-use reduction. It is rare to have a database that contains the entire target population for a program; but, in the case of physician-based intervention programs, that is precisely what we have. We have found that physicians appreciate the support, materials and follow-up that we offer them because we use the database. The physician database provides the means to: * track the intervention conducted by individual physicians, through the annual follow-up questionnaires, * evaluate the progress of the dissemination of the intervention, * direct mailings to subgroups of physicians, by specialty and by the physicians' present level of clinical intervention, * estimate physicians' needs for materials and * sample the population for evaluative research. We have learned much about gaining cooperation from physicians through our efforts in this program. Physicians will cooperate if their time and their judgement are respected. We suggest these rules of thumb. * Keep whatever you offer practical, simple and brief. * Ensure that intervention takes less than 1 to 2 minutes for most patients, since clinical intervention in tobacco use involves the many smokers who are not ready to quit. * Offer physicians a menu of intervention options from which to choose those appropriate to their practice. * After presenting the menu of intervention options, suggest a simple way of getting started, such as affixing stickers about patients' smoking-cessation status to their records. * Send potential participants letters from their colleagues in leadership positions (e.g., the president of the college of family physicians). We have recruited more GPs through mailings from GP organizations than through traditional continuing medical education. As a result of four mailings of flyers to all GPs from the British Columbia College of Family Physicians and from the Society of General Practitioners of British Columbia, we recruited 337 new active physicians during the past 2 years. BARRIERS Three barriers are worth noting: lack of funding, need for reimbursement through the fee-for-service system and physicians' underestimation of their effectiveness. The funding of programs such as the one described in this article is not part of conventional health care expenditure, neither at the program nor at the clinical level. The government of British Columbia estimates that it will receive $505 million from tobacco taxes in 1995,28 yet it has allocated only $ to all of its tobacco-control programs. In contrast, the provincial government will receive $579 million from alcohol sales, and it has allocated more than $50 million to address alcohol problems. If clinical intervention in tobacco use is to be reimbursed through the fee-for-service system, a new type of fee is needed, one for a practice-level service that consists of brief interventions, most of which are too brief to be considered billable. Finally, physicians tend to underestimate their effectiveness in helping people to stop smoking. Much of the clinical intervention in tobacco use does not produce observable, short-term results. In fact, patients may attribute quitting smoking entirely to their own efforts. This may enhance patients' sense of personal effectiveness but may also reduce physicians' sense of efficacy in clinical interventions. FUTURIE PLANS We intend to recruit 200 more physicians each year to deliver clinical intervention in tobacco use. With the GP base well established, we are now working with the Society of Specialist Physicians and Surgeons of British Columbia to focus on the contribution of specialists particularly obstetricians, anesthesiologists, psychiatrists, cardiologists, respirologists and surgeons doing elective surgery - to clinical intervention in tobacco use. With the CMA, the Ontario Medical Association and the Medical Society of Prince Edward Island, we have begun a program called Mobilizing Physicians - Clinical Tobacco Intervention, in order to translate what has been learned in British Columbia to other provincial medical associations and to collaborate with the Guide Your Patients program, through which physicians across Canada are trained in clinical intervention in tobacco use. CONCLUSIONS A medical association's communication system and database constitute a potent means of recruiting physi- CAN MED ASSOC J * JAN. 15, 1996; 154 (2) 163

6 cians to conduct systematic, clinical intervention. This type of program requires support from the leaders of the medical association, expertise in such intervention, a committed staff and adequate financial resources to sustain the long-term effort required to get results. If these are in place, a medical association can play a useful role in mobilizing physicians to adopt and sustain clinical intervention in tobacco use. The BC Doctors' Stop-Smoking Program is funded by Health Canada and the BC Ministry of Health and sponsored by the BCMA. It has also been funded by Hoechst Marion Roussel, the BC Lung Association, Ciba-Geigy and Physicians for a Smoke-Free Canada. Key support is provided by the British Columbia College of Family Physicians, the Society of General Practitioners of British Columbia and the Society of Specialist Physicians of British Columbia. 1. Reid DJ, Killoran AJ, McNeill AD et al: Choosing the most effective health promotion options for reducing a nation's smoking prevalence. Tob Control 1992; 1: Canadian Task Force on the Periodic Health Examination: The periodic health examination: update. Can Med Assoc J 1986; 134: Canadian Task Force on the Periodic Health Examination: Canadian Guide to Clinical Preventive Health Care [cat no H /1994E], Health Canada, Ottawa, US Preventive Services Task Force: Counseling to prevent tobacco use. In Guide to Clinical Preventive Services: an Assessment of the Effectiveness of 169 Interventions, Williams and Wilkins, Baltimore, 1989: Kottke TE, Battista RN, DeFriese GH et al: Attributes of successful smoking cessation interventions in medical practice. JAMAA 1988; 259: Fiore MC, Baker TB: Smoking cessation treatment and the Good Doctor Club. [editorial] Am J Public Health 1995; 85: Survey on Smoking in Canada, Cycle 3: 6. Readiness to Quit Smoking -November 1994 [fact sheet], Health Canada, Ottawa, Pierce JP, Evans N, Farkas AJ et al: Tobacco Use in California: an Evaluation of the Tobacco Control Program, , University of California at San Diego, La Jolla, Calif, Owen N, Davies MJ: Smokers' preferences for assistance with cessation. Prev Med 1990; 19: Wilson D, Wilson E: Guide Your Patients to a Smoke Free Future, Canadian Council on Smoking and Health, Ottawa, How To Help Your Patients Stop Smoking, [National Institutes of Health pub no ], National Cancer Institute, Washington, Manley M, Epps RP, Husten C et al: Clinical interventions in tobacco control: a National Cancer Institute training program for physicians. JAM4A 1991; 266: Davis DA, Thomson MA, Oxman AD et al: Changing physician performance: a systematic review of the effect of continuing medical education strategies. [review] JAMA 1995; 274: Russell MAH, Wilson C, Taylor C et al: Effect of general practitioners' advice against smoking. BMJ 1979; 2: Miller WR, Rollnick S: Motivational Interviewing: Preparing People to Change Addictive Behaviour, Guilford Press, London, England, Velicer WF, DiClemente CC: Understanding and intervening with the total population of smokers. Tob Control 1993; 2: Willms DC, Taylor DW, Best JA et al: Patients' perspectives of a physician-delivered smoking cessation intervention. Am JPrev Med 1991; 7: Bass F: The two faces of counselling: intervention and empathy. BCMed J 1994; 36: Bass F, Boronowski P: Intervention and empathy 11. BC Med J 1995; 37: Best JA, Wainwright PE, Mills DE et al: Biobehavioral approaches to smoking control. In Linden W (ed): Biological Barriers in Behavioral Medicine, Plenum, New York, 1988: Bass F: Invalidating tobacco. In Taylor RB, Ureda JR, Denham JW (eds): Health Promotion: Principles and Clinical Applications, Appleton-Century-Crofts, Winston-Salem, NC, 1982: Tang JL, Law M, Wald N: How effective is nicotine replacement therapy in helping people to stop smoking? BMJ 1994; 308: Abrams DB, Orleans CT, Niaura RS et al: Integrating individual and public health perspectives for smoking cessation treatment under health care reform: a comprehensive stepped care model. Presented at the 7th Nicotine Conference, Americian Society of Addiction Medicine, Boston, Nov 3-6, Bass F: Smoking cessation. In Gray J (ed): Therapeutic Choices, Canadian Pharmaceutical Association, Ottawa, 1995: Duncan C, Stein MJ, Cummings SR: Staff involvement and special follow-up time increase physicians' counselling about smoking cessation: a controlled trial. Am J Public Health 1991; 81: Bass F: A challenge to physicians. BC Med J 1990; 32: Tobacco and the Clinician, Interventions for Medical and Dental Practice, [smoking and tobacco control monograph no 5, National Institutes of Health pub no ], National Cancer Institute, Washington, Estimates, Fiscal Year Ending March 31, 1996, British Columbia Ministry of Finance, Victoria, 1995: CAN MED ASSOC J * 15 JANV. 1996; 154 (2)