Smoking cessation advice from health professionals

Patient Education and Counseling 36 (1999) 13–21

Smoking cessation advice from health professionals: process evaluation of a community-based program a, a a b Tellervo Korhonen *, Antti Uutela , Heikki J. Korhonen , Eeva-Liisa Urjanheimo , c Pekka Puska a

National Public Health Institute, Department of Epidemiology and Health Promotion, Health Education Research Unit, Mannerheimintie 166, FIN-00300 Helsinki, Finland b North Karelia Project, Joensuu, Finland c National Public Health Institute, Department of Epidemiology and Health Promotion, Helsinki, Finland Received 12 October 1997; received in revised form 2 April 1998; accepted 19 April 1998

Abstract The study assessed whether exposure to advice to quit smoking from health care professionals was greater in North Karelia, an area with a community-based, long-term intervention integrated within the health care structure, than in the rest of Finland. Data were collected by health behavior surveys during 1978–1995. Adult regular smokers and those who had quit during the preceding 12 months were surveyed. We measured exposure to cessation advice by questioning, whether the person had been advised by a doctor or public health nurse to give up smoking at least once during the year preceding the survey. Men from the intervention area had a significantly higher likelihood of having been advised to quit than those elsewhere in Finland. The same trend emerged among women, but it was not significant. It is concluded that a community-based intervention program can encourage health professionals to increase their smoking cessation advice.  1999 Elsevier Science Ireland Ltd. Keywords: Counselling; Smoking cessation; Health personnel

1. Introduction The large number of smokers who attend health care each year suggests that the impact of cessation counselling by physicians and other health professionals may be substantial [1,2]. The basic components of a brief counselling session include asking *Corresponding author. Tel.: 1 358 9 47448630; Fax: 1 358 9 47448338; e-mail: [email protected]

each patient whether they smoke, advising all smokers to quit, offering assistance to patients in cessation, and arranging follow-up visits for support [3]. However, some health professionals do not fully utilize this opportunity. Only about half of smokers report having ever been asked about their smoking status by a health professional [4,5]. Based on studies in the USA, a third to half of smokers visiting a physician or having a general health checkup report having been advised to quit [6–10]; advice

0738-3991 / 99 / $ – see front matter  1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0738-3991( 98 )00070-6

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T. Korhonen et al. / Patient Education and Counseling 36 (1999) 13 – 21

rates have reportedly improved from the 1970s to the 1990s [4,5,11]. Age, high cigarette consumption, long smoking history, poor health status, and a high number of contacts with the physician have been found to increase the probability of being advised [4,5,8,10,12,13], and low level of education to decrease the probability [6,11]. According to British studies, the main effect of brief cessation advice may be merely to increase the number of cessation attempts [14], with only a modest effect on successful quitting [15]. In Finland, studies on health professionals’ counselling practices indicate a need for in-service training in the methods of patient counselling [16,17]. There seems to be evidence among smokers of low exposure to health professionals’ advice to quit among smokers. It is not known, however, whether this kind of exposure can be enhanced in integrated community health programs. After a 10-year history of community work in North Karelia, Finland joined the World Health Organization’s countrywide integrated non-communicable disease intervention (CINDI) Programme in 1982, with North Karelia as a demonstration area. Between 1982 and 1987 the project activities were extended to the prevention of chronic diseases generally, and to health promotion in the region’s population. Since 1987, the project has continued with special emphasis on reducing smoking. Preventive health services integrated with the daily work of health centres have been a particularly active focus for the project (for details, see [18]). In this study, we evaluated whether greater exposure to health professional’s advice to quit smoking had been achieved among smokers in an area with community-based, long-term intervention integrated into the health care system.

2. Materials and methods

2.1. Research design Annual population surveys by mail have been carried out in Finland since 1978 to monitor health behavior, especially smoking and health professionals’ cessation advice. The size of the national random sample is 5000, whereas in North Karelia a separate sample of 1200 has been drawn every year.

The questionnaire is always mailed in April, and two reminders sent to the nonrespondents. Data are available for every year from 1978 to 1995, except 1982. Nationwide response rates have varied from 64 to 83% for men and 75 to 86% for women, and in North Karelia from 61 to 82% for men and 78 to 87% for women [19,20].

2.2. Subjects For this study, the subjects derived from the national samples (excluding North Karelia) and the separate North Karelian samples were aged 25–64, and were either regular smokers or had stopped smoking during the past year. The total number of subjects in 1978–1995 (1982 missing) was 3610 in North Karelia (2522 men and 1088 women) and 16 394 in the rest of the country (10 354 men and 6040 women). The proportion of men was 70% in North Karelia and 63% elsewhere. Table 1 shows the characteristics of the subjects by sex and by area. The proportions of study group in the whole samples varied among men from 31% (1985) to 47% (1978) in North Karelia and from 36% (1994) to 45% (1978) elsewhere. For women the figures were 14% (1979) to 27% (1995) in North Karelia and 18% (1980) to 26% (1987) in the rest of Finland.

2.3. Intervention in North Karelia Major strategies were developed in the late 1970s to reduce smoking throughout the nation, including stricter tobacco legislation. Although a nationwide decline in smoking was associated with these developments, an even faster fall occurred in North Karelia accompanying the special activities there. New tobacco legislation was introduced in 1994, and many interest groups subsequently began developing new activities to reduce smoking, with North Karelia as a demonstration area [21]. While the North Karelia Project team helped to define objectives, train personnel, coordinate activities, and assess results, most of the grass roots work in the region has been done in the community and health care system, by doctors, public health nurses and other health professionals. The importance has been emphasized of systematic measurements, counselling, persuasion, and follow-up of

a

Mean (s) Mean (s) Mean (s) Mean (s) Mean (s) Good (%) Poor (%)

41.5 9.5 19.3 19.0 2.7 52.3 47.6

(10.9) (3.5) (10.9) (9.7) (3.4)

North Karelia (n 5 2522)

Men

41.0 10.2 19.3 19.0 2.9 56.3 43.7

(10.7) (3.6) (10.7) (9.7) (4.2)

Rest of the country (n 5 10 354) 0.05 0.001 . 0.05 . 0.05 . 0.05 0.001

P

a

P value: t-test for difference in means, except for ‘perceived status of health’ where Fisher’s exact test for difference in distributions has been used.

Age Educational level Number of smoking years Amount of daily smoking Number of physician visits Perceived status of health

Table 1 Characteristics of the subjects by area

38.1 10.9 12.9 12.0 3.8 64.5 35.5

(10.2) (3.4) (7.9) (7.4) (4.5)

North Karelia (n 5 1088)

Women

38.8 10.9 14.6 12.9 4.0 65.4 34.6

(10.1) (3.4) (8.8) (7.6) (4.7)

Rest of the country (n 5 6040)

0.029 . 0.05 , 0.001 , 0.001 . 0.05 . 0.05

Pa

T. Korhonen et al. / Patient Education and Counseling 36 (1999) 13 – 21 15

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T. Korhonen et al. / Patient Education and Counseling 36 (1999) 13 – 21

people’s health-related habits such as smoking. Other activities in North Karelia have included smoke-free campaigns at workplaces and sport clubs, and smoking cessation contests on local radio. The smokefree North Karelia project, a regional anti-smoking programme, began in 1994; practical activities were integrated into the existing official and voluntary service network and into community organizations [22,23]. Health care personnel in North Karelia have received continuous training in methods supporting cessation. Training seminars have included how to motivate smokers to quit, how to tailor advice according to the stages of change, and how to support quitters. Special themes have included nicotine replacement therapy, smoking cessation miniinterventions, smoking cessation during pregnancy, organizing smoking cessation groups, and smoking cessation at workplaces. Two or three training seminars were arranged in 1994 and 1995, an increase from the once-yearly rate earlier in the intervention. Numbers of attending health care personnel — physicians and public health nurses — varied from 40 to 120. Cessation problems among female smokers received special attention during the intensive period 1994–1995.

Finally, exposure to health professionals’ advice was calculated as the proportion of those who had been advised by a physician and / or public health nurse during the past year. To increase the power of the statistical analysis, the measurements were made as four time periods: 1978–1981, 1983–1986, 1987– 1990 and 1991–1995. The background variables adjusted for as possible confounders when comparing the areas were those found to be associated with cessation advice in earlier studies. Length of education, number of years smoking and amount of daily smoking (number of cigarettes, cigars and pipefuls smoked per day) as well as number of physician visits during the year preceding the survey were considered continuous variables. Only the perceived health status at the time of the survey was considered a categorical variable: good, rather good or average was coded as good health status, and rather poor or poor was coded as poor health status. The background factors controlled for were selected for the multivariate analysis based on the tests for differences in the distributions between areas (Table 1). The number of physician visits was excluded for both sexes, since the distributions by region did not differ significantly (P . .05).

2.4. Variables

2.5. Statistical methods

Among the components of counselling for smoking cessation [3], this study looked at brief advice only. We recorded exposure to quit advice by asking, whether a doctor or public health nurse had advised the person to give up smoking at least once during the year preceding the survey. Exposure to a doctor’s advice was measured as the proportion of those who had had at least one physician visit during the past year. Among the male subjects, on average 75% (1888) in North Karelia and 74% (7614) elsewhere (P . .05), reported having visited their physician in the past year. Among females, the figures were 86% (932) in North Karelia and 87% (n 5 5 249) elsewhere (P . .05). Exposure to a public health nurse’s advice was measured simply as a proportion of all subjects by questioning whether the person had received cessation advice from this source. Moreover, this exposure was not measured in 1989, which was excluded.

Logistic regression was used as a multivariate method. The results are given as odds ratios (OR) with 95% confidence intervals (CI), expressing the impact of each independent variable on the dependent one, adjusted simultaneously for the others in the model [24]. The area variable, North Karelia compared to the rest of the country, was added in the first step of the modeling. The background factors to be controlled for were added one at a time into the model. Finally, the linear and nonlinear trends, and interaction of trend with area, were tested [25]. The final conclusions were based on information on the likelihood of receiving advice in North Karelia, adjusted for confounders, periodic variation and possible interaction between periodic variation and area. Separate models including the background variables with area differences (Table 1) were computed for men and women. For men the variables were: age, education and health status, and for

T. Korhonen et al. / Patient Education and Counseling 36 (1999) 13 – 21

women, age, years of smoking and amount of daily smoking.

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were identical in form for the two areas. The rates for women were 22 to 29% and 22 to 26%, respectively, North Karelia showing more periodic variation than the rest of the country.

3. Results

3.2. Comparison of areas 3.1. Advice rates The self-reported rates of cessation advice from a physician and from a public health nurse during the preceding year of the survey are shown by time period in Fig. 1. The proportions of men advised by a physician varied by time period 28–34% in North Karelia and 22–25% elsewhere. The respective rates for women varied from 18 to 24% and from 18 to 22%. The proportions of men advised by a public health nurse varied from 26 to 28% in North Karelia and 18 to 19% elsewhere, and of women 15 to 26% and 14 to 18%, respectively. Fig. 2 presents the proportions of smokers who had been advised by at least one health professional during the preceding year. For men the rates varied from 33 to 34% in North Karelia and 24 to 26% elsewhere. The trends

The results of logistic regression for men, adjusted for age, education, health status, periodic variation, and including interaction with area, are shown in Table 2. Older, less educated male smokers with poorer health status were more likely to be advised. Periodic variation or the interaction of this with the area did not change the significantly higher likelihood of North Karelian men being advised; the OR of North Karelia was 1.49 (CI 95% 5 1.26–1.75). The corresponding results for women, adjusted for age, years of smoking, amount of daily smoking, periodic variation, including interaction with area, are presented in Table 3. Female smokers with longer smoking histories and a higher amount of smoking were more likely to be advised. After adjusting for these background factors, the average

Fig. 1. Proportions of subjects advised to quit during the past year (%).

T. Korhonen et al. / Patient Education and Counseling 36 (1999) 13 – 21

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Fig. 2. Proportions of subjects advised to quit by a physician or a public health nurse during the past year (%).

exposure was higher in North Karelia. When the periodic variation, such as linear increasing trend, and its interaction with area were taken into account, the difference between the areas was not significant; the OR of North Karelia being 1.21 (CI 95% 5 0.77– 1.91).

4. Discussion This study aimed to serve as a process evaluation of the North Karelia project, focusing on smoking cessation counselling activities during a long-term programme integrated into the health care structure of the community. One purpose of a process evaluation is to determine the extent and quality of the intervention implemented. Process variables include exposure to the various intervention measures [26,27], such as health professionals’ advice to quit smoking in this case. North Karelian men had a significantly higher likelihood of being advised to quit compared to men elsewhere in Finland. This difference remained significant after adjustment for possible confounders. The advice-giving activity has been fairly constant throughout most of the 20 years’ evaluation period, reflecting a well-established emphasis on this risk group. On average there was a higher likelihood of North Karelian women receiving advice than others,

after adjusting for age, years of smoking and amount of daily smoking. However, the difference disappeared when the trends and interactions were taken into account. There was a slight increasing trend over time, with one exception: a decline in exposure among North Karelian women in 1987–1990. This seems to be associated with the area variable becoming nonsignificant in the multivariate model when adjusting for the interaction of trend and area. Thus, intervention for women was less stable than for men. Although the advice rates both in North Karelia and elsewhere in Finland seem to be quite low in comparison to other countries [4,6–10], the results show that higher exposure can be achieved through long-term community intervention. The sex difference suggests that women were less likely to be advised than men. After 1990, however, women’s rates seemed to increase, reaching those of men in 1995. This trend is particularly evident for advice from public health nurses in North Karelia, probably partly due to the growing awareness of the detrimental effects of smoking during pregnancy [28]. We also found poor health status in men, and years of smoking and amount of daily smoking in women, to be related to the likelihood of advice, which supports earlier findings [10,12,13] that health professionals tend to regard advice to quit more as a secondary than a primary prevention. Less educated men were more likely to receive advice, a different

Table 2 Exposure to health professionals’ smoking cessation advice among men; odds ratios and 95% confidence intervals based on logistic regressions by variable added stepwise II model 1 Age P , 0.001 (n 5 12 594)

III model 1 Educational level P , 0.001 (n 5 12 393)

IV model 1 Status of health P , 0.001 (n 5 11 428)

V model 1 Linear trend b P . 0.05 (n 5 11 428)

VI model 1 Area 3 linear trend P . 0.05 (n 5 11 428)

VII model 1 Nonlinear trend c P 5 0.004 (n 5 11 428)

VIII model 1 Area 3 nonlinear trend P . 0.05 (n 5 11 428)

1.00 1.48 (1.35–1.63)

1.00 1.48 (1.34–1.62) 1.03 (1.02–1.03)

1.00 1.44 (1.30–1.58) 1.02 (1.02–1.03) 0.96 (0.95–0.98)

1.00 1.43 (1.29–1.58) 1.02 (1.01–1.02) 0.97 (0.96–0.99)

1.00 1.43 (1.29–1.58) 1.02 (1.01–1.02) 0.97 (0.96–0.99)

1.00 1.39 (1.08–1.80) 1.02 (1.01–1.02) 0.97 (0.96–0.99)

1.00 1.44 (1.30–1.59) 1.02 (1.01–1.02) 0.97 (0.96–0.99)

1.00 1.49 (1.26–1.75) 1.02 (1.01–1.02) 0.97 (0.96–0.98)

1.00 1.81 (1.66–1.98)

1.00 1.81 (1.66–1.98) 1.00 (0.96–1.04)

1.00 1.81 (1.66–1.98) 1.00 (0.96–1.04) 1.01 (0.92–1.11)

1.00 1.82 (1.66–1.98)

1.00 1.82 (1.66–1.99)

1.06 (1.02–1.11)

1.07 (1.02–1.12) 0.97 (0.88–1.07)

a

Continuous variables. Period as continuous variable: 1978–1981 5 1, 1983–1986 5 2, 1987–1990 5 3, 1991–1995 5 4. c (period-2.5)** 2. b

Table 3 Exposure to health professionals’ smoking cessation advice among women; odds ratios and 95% confidence intervals based on logistic regressions by variable added stepwise

Area Rest of country North Karelia Age a Smoking years a Amount of daily smoking a Linear trend Interaction Area 3 linear trend Nonlinear trend Interaction Area 3 nonlinear trend

I model Area alone P 5 0.041 (n 5 6984)

II model 1 Age P . 0.05 (n 5 6984)

III model 1 Smoking years P , 0.001 (n 5 6431)

IV model 1 Amount of daily smoking P , 0.001 (n 5 6190)

V model 1 Linear trend b P 5 0.005 (n 5 6190)

VI model 1 Area 3 linear trend P . 0.05 (n 5 6190)

VII model 1 Nonlinear trend c P . 0.05 (n 5 6190)

VIII model 1 Area 3 nonlinear trend P . 0.05 (n 5 6190)

1.00 1.17 (1.01--1.35)

1.00 1.17 (1.01--1.36) 1.00 (1.00--1.01)

1.00 1.22 (1.05--1.43) 0.98 (0.97--0.99) 1.04 (1.03--1.05)

1.00 1.24 0.98 1.03 1.04

1.00 1.24 (1.05--1.45) 0.98 (0.98--0.99) 1.03 (1.02--1.04) 1.04 (1.03--1.05) 1.08(1.02--1.14)

1.00 1.21 (0.77--1.91) 0.98 (0.98--0.99) 1.03 (1.02--1.04) 1.04 (1.03--1.05) 1.08(1.02--1.14) 1.01(0.87--1.17)

1.00 1.24 0.98 1.03 1.04

1.00 1.12 0.98 1.03 1.04

(1.06--1.46) (0.98--0.99) (1.02--1.04) (1.03--1.05)

(1.06--1.46) (0.98--0.99) (1.02--1.04) (1.03--1.05)

1.05(0.99--1.11)

(0.86–1.45) (0.98–0.99) (1.02–1.04) (1.03–1.05)

T. Korhonen et al. / Patient Education and Counseling 36 (1999) 13 – 21

Area Rest of the country North Karelia Age a Educational level a Health status Good Poor Linear trend Interaction Area 3 Linear trend Nonlinear trend Interaction Area 3 nonlinear trend

I model Area alone P , 0.001 (n 5 12 594)

1.04 (0.97–1.11) 1.08 (0.92–1.27)

a

19

Continuous variables. Period as continuous variable: 1978–1981 5 1, 1983–1986 5 2, 1987–1990 5 3, 1991–1995 5 4. c (period-2.5)**2. b

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T. Korhonen et al. / Patient Education and Counseling 36 (1999) 13 – 21

result compared to earlier studies [6,11] yet a positive finding from the process evaluation perspective. There are some threats to validity in our study. Regular smokers were included along with those who had quit during the past year. Because smoking status at the time of the doctor’s visit was not controlled for, some respondents may no longer have been smoking at the time and would not be candidates for advice. As the reasons for the visit could not be monitored in this study, some visits may have been for emergencies and other conditions for which counselling would not have been appropriate. In addition, exposure to a public health nurse’s advice was measured simply as a proportion of all subjects, which gave a lower estimate of the advice prevalence. Moreover, in 1989 the advice rates for public health nurses were not measured, so this year only included the rates for physicians. We estimated the advice rate based only on smokers’ self-reports in a population survey; we did not interview the health professionals on their advising activity. Some discrepancy might exist between what health professionals say they do and what smokers say they hear [29]. Besides, the advice may not be given in a memorable manner [30]. However, a recent study [31] suggests that patient recall may be systematically biased towards over-reporting of advice to quit. Overall, most of the sources of possible bias described above probably exerted a similar influence in both of the areas. We adjusted the comparison for possible confounders based on earlier studies and on a test of distributions by area. We conclude that for the comparison of areas — the main objective of this study — our design was valid.

health professionals for quitting, viz. the less educated with high smoking levels and poor health status, have received more attention. The reason behind the recent decline in exposure among North Karelian women requires deeper analysis of the intervention during various periods. It is concluded that a long-term community-based intervention program integrated within the health care structure can encourage health professionals to increase the level of smoking cessation advice.

6. Practical implications Given the large number of smokers who visit physicians and other health professionals each year, the potential public health impact of smoking cessation counselling is substantial. Smokers’ exposure to health professionals’ cessation advice is low. However, higher exposure has been found among male smokers during a long-term intervention program, in which smoking cessation activities have been integrated into the health care structure. Although the exposure among women was found to be unstable in long-term evaluation, the advice rates increased towards the end of the period. Community-based intervention programs may encourage health professionals to intensify their smoking cessation advice.

Acknowledgements The study has been supported by the Academy of Finland. We thank MSc, senior researcher Mari-Anna Berg of the National Public Health Institute for statistical advice.

5. Conclusions The North Karelia project initially focused on the health problems of North Karelian men, who had the highest mortality from CVD in the world. The present analysis of exposure to antismoking advice from health professionals suggests that the project has partially succeeded in reaching this group, although the number of smokers being advised is still relatively low in international terms. The results also suggest that those most in need of the attention of

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