This study tested the effectiveness of a brief computer-tailored intervention to increase provision of smoking cessation counseling by physicians and the quit rate among their patients who smoke. Our primary finding is that physicians who received the intervention were more likely to perform the 5As. Specifically, the intervention increased the rate at which physicians advised patients to quit, and more than doubled the rate at which they assessed readiness to quit, assisted in quitting, and arranged follow-up. All “assist” and “arrange” activities, those that have been shown to be most problematic in terms of physician adherence,6,8
were significantly increased by the intervention.
Despite the large intervention effect on physician 5A performance, 6-month smoking cessation rates were only modestly higher among patients who received the intervention, an effect that approached but did not reach statistical significance. The intervention did result in longer quit attempts, one of the strongest determinants of cessation success,28
and greater stage-of-change forward movement, which have been associated with enhanced quit attempts.19
The 12% quit rate observed among intervention patients is consistent with quit rates achieved by other interventions in primary care settings.29–32
However, the control group cessation rate (8%) was higher than that predicted by secular trends,33
resulting in a small between-group difference and treatment effect. One factor that may have contributed to the relatively high control-group quit rate is that smokers in the control condition were exposed to an active treatment ingredient. Namely, as part of the assessment, patients were asked about their smoking status and assessed for readiness to quit, which are two of the 5As. The assessment may have sensitized smokers in the control group to consider quitting smoking.
Another possible reason for the small cessation effect is the less than anticipated sample size and consequent reduction in statistical power to detect group differences. The average patient caseload per physician was lower than that expected on the basis of focus groups conducted before study commencement. In addition, the proportion of patients identified as smokers (15%) was significantly less than the expected 20–30% found in other primary care studies29,34
and less than the estimated 25% smoking prevalence in NYC when the study was designed. Thus, we did not attain our intended enrollment target. The low smoking base rate in the current study may reflect the 11% smoking prevalence decline observed in NYC, presumably attributable to comprehensive citywide tobacco control measures that were implemented concurrently.35
An important limitation of this study is that a minority of the physicians contacted to participate were enrolled because a large proportion refused participation or could not be reached. Although demographic information on nonparticipators is not available, physicians in the current study may be a highly select group.
Even though the intervention had only a modest effect on smoking behaviors, the innovative integration of computer technology during routine medical visits was highly effective in enhancing 5A adherence. In its impact on physicians’ behavior, the current intervention compares favorably to other primary care interventions.29,31,34,36,37
For instance, it produced more comprehensive improvements in 5A performance than interventions that featured a vital sign stamp34
or a smoking assessment questionnaire only.29
It also produced greater gains in “Advise” and “Assist” compared to a significantly more intensive, five-component intervention that included a physician tutorial, vital sign stamp, physician performance feedback, nicotine replacement therapy, and telephone counseling.31
Smoking outcomes with the current intervention were also comparable to an intervention consisting of training physicians in brief cessation counseling.36
Cessation rates surpassed those of an intervention consisting of a 2-hour tutorial plus prompt.37
Because 70% of U.S. smokers visit their physician annually, even modest cessation rates can translate into significant public health benefit. Although other public health approaches, such as telephone quitlines, are available, physician advice and referral are important to maximize use of these resources.38,39
Another important aspect of this intervention is the minimal time burden and staff resources needed for implementation. Intervention physicians spent an average of 3.8 minutes discussing smoking. Minimal burden increases the likelihood of integration into a busy clinical practice. The main requirements for integration are availability of a patient-accessible computer with printer and encouragement of all smokers to complete the assessment before their physician visit. Incorporating computer-tailored programs into routine medical practice can be challenging. The current intervention addressed some previously identified barriers40
by streamlining administration time and directly targeting patients who were current smokers. Research staff recruited patients into the current study. Although this practice helped to reduce demand on office staff, it diminished the number of smokers that could be reached and the possibility of readministering the intervention to returning smokers, both of which may enhance intervention impact. A manuscript describing cost effectiveness of the intervention is currently under review.
The current study shows that a brief computer-tailored intervention can significantly increase primary care physicians’ implementation of the 5As and result in modest effects on smoking outcomes. This intervention holds promise in reaching the main objective of the Smoking Cessation Clinical Practice Guideline: to intervene with all smokers who visit their physician. Increased rates of guideline implementation can potentially have an enormous public health impact. Further research is needed to increase the potency of the intervention with regard to quit rates and to determine how best to integrate it into outpatient health care settings.