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Dorothee Twardella, Hermann Brenner, Lack of training as a central barrier to the promotion of smoking cessation: a survey among general practitioners in Germany, European Journal of Public Health, Volume 15, Issue 2, April 2005, Pages 140–145, https://doi.org/10.1093/eurpub/cki123
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Abstract
Background: General practitioners (GPs) can contribute substantially to the promotion of smoking cessation in the general population. However, engagement of GPs in helping their patients to quit remains very limited in many countries, including Germany. Therefore, new strategies to foster implementation of evidence-based methods in smoking cessation assistance have to be identified, and data for current practice of and barriers against smoking cessation promotion in general practice are needed. Methods: A cross-sectional survey among all 657 general practitioners practising in the Rhein-Neckar Region of Germany was conducted in spring 2002 using a postal questionnaire (response rate 48%). Results: The majority (54%) of GPs reported having treated less than 10 patients for smoking cessation (by any means including mere advice to quit) within the last three months, 23% of GPs never received any education or training in smoking cessation promotion, and only one-third of GPs rated their training as adequate. The factor most strongly associated with low activity in smoking cessation promotion (defined as having treated less than 10 patients within the last three months) was perceived lack of training (odds ratio 2.70, 95% confidence interval 1.68 – 4.32), followed by perceived lack of demonstration material (2.10, 1.31 – 3.39) and perceived lack of time (1.65, 1.02 – 2.66). Furthermore, there was a clear dose–response relationship between the time spent on training and the activity in smoking cessation promotion. Conclusion: Adequate training may be a key factor to enhance engagement of general practitioners in the promotion of smoking cessation.
The deleterious effects of smoking on health have been described extensively. Cigarette smoking has been found to be associated with increased risk for about 40 diseases or causes of death.1 In much of the developed world tobacco-related disease is the leading cause of preventable death and accounts for an estimated one in every five deaths.2 In Germany about 9% of total mortality in women aged 35 years or more and 26% of total mortality in men aged 35 years or more are estimated to be associated with smoking.3
Besides primary prevention, promotion of smoking cessation plays a major role in the reduction of smoking prevalence. Health consequences can be prevented considerably if smokers quit even into middle age. Smoking cessation at age 35 leads on average to an increase in life expectancy of about 7 years in comparison to continued smoking, and even quitting at age 65 is associated with an increase of about 2 years.4 Smokers quitting at age 30 avoid more than 90% of the lung cancer risk attributable to tobacco, and even quitting at age 50 or 60 results in prevention of most of the subsequent risk.5
The search for strategies to foster smoking cessation is therefore of central public health interest. In this context physicians, in particular general practitioners, can play a major role. Studies have shown that even a minimal intervention in doctors’ practice, e.g. one consultation of less than 20 minutes plus up to one follow-up visit, has a small but significant impact on cessation rates.6 Cessation rates can be further increased by intensifying the physicians’ consultations, and by use of pharmacological support such as nicotine replacement and bupropion therapy.7,8
To explore the full potential of physicians’ promotion of smoking cessation up-to-date information is needed on what activities physicians undertake and what hinders their commitment to smoking cessation promotion. Practice of and barriers against the promotion of smoking cessation may be dependent on organization and remuneration of general practitioners, which vary widely between countries.
In the German compulsory health insurance (CHI) system the Kassenärztliche Vereinigung (Association of CHI physicians) is responsible for the accreditation of physicians and the specification of monetary reimbursement for services provided by physicians within the CHI. Smoking cessation promotion is not included in the list of services covered by insurance and no reimbursement for GPs is provided.
Other services for smokers wishing to quit include internet resources and a telephone quit line. Smoking cessation courses are provided by physicians, clinical departments and insurance companies but may not necessarily be cost-free for smokers, depending on insurance company policy.
In this paper, we report on a survey aimed at examining general practitioners’ practice of and barriers against the promotion of smoking cessation under the conditions of the German health care system.
Methods
All general practitioners (GPs) practising in the Rhein-Neckar Region of Germany as of 1.1.2002 were eligible for participation in the survey. Information was collected by mailed questionnaires which were sent in March 2002. To increase response, an allowance of 10 € was provided for the return of the questionnaire and a price of 1000 € was raffled among all responders. Non-responders were sent two reminder letters followed by two telephone reminders.
In the questionnaire information was collected on the current practice of smoking cessation promotion, characteristics of the practice and personal characteristics of the GPs (including training in smoking cessation, number of patients treated, methods used to support patients in smoking cessation, barriers to implementation of smoking cessation promotion, GPs’ own smoking status).
The main outcome of interest was the activity of GPs in smoking cessation promotion. This outcome was operationalised through the number of patients in whom efforts to support smoking cessation were made within the last three months (either by specific own treatment, referral to treatment by somebody else, or by mere advice to quit). GPs who reported having treated (or advised) less than 10 patients were categorized as ‘less active’ and those who recorded having treated 10 or more patients were categorized as ‘more active’. If this number of patients was missing it was substituted by the maximum number of patients treated in the last three months with one of the specific smoking cessation methods that were being asked for.
The following factors suspected to be possibly associated with low activity in smoking cessation were evaluated: age (two categories: 30-49 years, 50-69 years), gender, physicians’ own smoking status (never smoker, ex-smoker, current smoker), training in smoking cessation promotion and perceived barriers against smoking cessation promotion (not in the area of responsibility, lack of interest, lack of time, lack of adequate reimbursement, lack of adequate training, lack of demonstration material).
GPs treating a larger number of patients have more opportunities to promote smoking cessation in patients than GPs with lower patient numbers. To account for this fact, the analysis was repeated relating the number of patients treated for smoking cessation to the total number of patients seen in the last three months. However, results of this analysis were very similar to the results of the analysis using the absolute numbers of patients assisted in smoking cessation, and therefore only the latter are shown in this paper.
The analyses were carried out using the statistical software package SAS, release 8.2.9 The association between the aforementioned factors and low activity in smoking cessation promotion was quantified by crude and age and sex adjusted odds ratios and their 95% confidence intervals, which were estimated by unconditional logistic regression.
Results
Among 657 GPs in the Rhein-Neckar Region meeting the eligibility criteria, who were sent a questionnaire, 315 participated in the survey (response rate: 48%). There were no major differences between participants and non-participants according to gender but the response rate was somewhat lower (39%) in Mannheim, a city with about 310,000 inhabitants, than in the city of Heidelberg (about 140,000 inhabitants)(55%) and the more rural Rhein-Neckar district (about 530,000 inhabitants)(51%).
Participating physicians were mostly of German nationality (98.7%) and two-thirds were male (table 1). About half of the participants were below age 50, females being on average younger than males. While almost half of the GPs had smoked, only a minority of 10% were current smokers and about half of these reported consumption of more than 10 cigarettes per day.
About one out of four GPs reported that they had not received any training or education in promotion of smoking cessation and less than 20% had had more than 10 hours of training (table 2). The most commonly used source of information was medical literature (68%), only a minority of GPs had made use of other sources, such as lectures or seminars on smoking cessation promotion. Only one-third of the GPs perceived themselves as adequately trained for smoking cessation promotion.
The numbers and proportions of patients assisted in smoking cessation (by any method including mere advice to quit) are shown in table 3. More than half of the GPs reported engagement in smoking cessation assistance with less than 10 patients and fewer than 1% of all patients treated within the last three months. Personal counselling was the most commonly employed strategy by GPs. Nicotine replacement therapy also played an important role, especially the use of nicotine patches, which were prescribed by 60% of GPs. Bupropion was used by about half of the GPs. Besides methods of conventional western medicine more than 40% of GPs reported the application of or referral to acupuncture to support smoking cessation.
Being asked for specific possible barriers against engagement in smoking cessation promotion, lack of adequate reimbursement, of training in smoking cessation promotion and of demonstration materials were most often judged as barriers (table 4). Lack of interest or the perception that smoking cessation is not their responsibility were rated as barriers by only a minority of GPs.
In the bivariate analysis of factors related to low smoking cessation activity (defined as less than 10 patients treated for smoking cessation within the last three months) male physicians reported low activity less often than female physicians (table 5). Previous training in smoking cessation promotion was likewise associated with a decreased risk of low activity, with a p-value for trend of p=0.003. Furthermore, low activity was found more often among those physicians who felt restricted by time constraints and lack of demonstration material. However, the strongest predictor of low activity was perceived lack of adequate training: 64% of GPs perceiving this barrier compared to 39% of other GPs showed low activity in smoking cessation promotion.
Adjustment for age and gender did not materially alter the results. A significantly increased risk for low activity in smoking cessation promotion was found again in those GPs who perceived lack of adequate training as a barrier (OR = 2.70, 95% confidence interval: 1.68 to 4.32), and those who perceived lack of demonstration material (OR = 2.10, 95% confidence interval: 1.31, 3.39), or lack of time (OR = 1.65, 95% confidence interval: 1.02 to 2.66) barriers. Furthermore, the clear inverse trend of time spent on training in smoking cessation promotion and the odds of low activity in smoking cessation promotion was essentially unchanged. General practitioners who reported current smoking were less likely to promote smoking cessation than never smokers, while ex-smokers reported slightly increased activity. However, these latter associations were not statistically significant.
Discussion
This is the first survey ever published on the practice of smoking cessation promotion by GPs in Germany. Similar studies have been undertaken in other countries but results may not necessarily be comparable due to differences in health care systems.
The motivation of GPs to engage in smoking cessation is high. Promotion of smoking cessation is in general accepted to be part of physicians’ role, which has also been observed in other studies.10 Still the potential for smoking cessation is only used partially, which can be deduced from the comparatively low numbers of patients treated in many practices. More than 43% of male and 30% of female adults smoke in Germany.11 According to international guidelines, GPs should address smoking habits every time a smoker visits their practice.12,13 Among all patients (smokers and non-smokers) visiting GPs in this German survey, on average only 1% have been treated or counselled for smoking cessation, according to physicians’ reports. Hence, occasions for smoking cessation promotion could be used much more often.
The physician or structure related barrier to smoking cessation promotion most commonly reported to be important by GPs in other studies was the lack of time. Other barriers such as lack of reimbursement and lack of knowledge or training have been rated as important by fewer GPs.14–17 Among physicians of the Rhein-Neckar Region lack of time was also perceived as a barrier by more than one-third of GPs, but the most frequently perceived barrier was lack of reimbursement (77%). In the German health system reimbursement of GPs for counselling in smoking cessation promotion is low. In particular, if a more time consuming method is used, counselling is unprofitable for the physician. This lack of reimbursement may therefore be one reason for the unused potential of smoking cessation promotion.
In this study we tried to identify not only those factors, which are perceived as barriers against smoking cessation promotion by GPs, but also those which are in fact related to low levels of engagement in smoking cessation assistance. In contrast to results of studies from the United Kingdom and from Austria, where no association between GPs’ characteristics such as age or gender10 or GPs’ own smoking status and smoking cessation assistance18 was found, in our survey male GPs were significantly more likely to promote smoking cessation than female GPs. There was also a tendency, though not statistically significant, for older GPs to be more active.
Smoking prevalence among GPs participating in this study was much lower (10%) than among the general population. A similar figure (11%) has recently been reported from an Austrian survey of GPs and internists.19 Although a lower prevalence of smoking among GPs than in the general population is not unexpected, it may to some part be due to self-selection, since smoking GPs might be less likely to return a questionnaire on smoking cessation. Our survey suggests reduced activity of smoking physicians in promotion of smoking cessation, although this result was not statistically significant.
The association of perception of lack of time as a barrier with low activity in promotion of smoking cessation is not surprising, since lack of time has been frequently reported as a major barrier in the literature.14–17 What turns out as a major obstacle besides lack of time in our study is the matter of education or training in smoking cessation assistance. The more training physicians had received in smoking cessation assistance, the more active they were in smoking cessation, and the perception of lack of adequate training as a barrier was the factor most strongly associated to low activity.
A study conducted in Nordic countries detected a proportion of 40% (Sweden), 45% (Norway), 52% (Iceland) and even 72% (Finland) of GPs who had never received any training or otherwise attempted to increase their knowledge on how to support patients to give up smoking.15 Compared to these numbers the level of education in Germany appears not particularly low (22% of GPs reported no training in smoking cessation assistance). However, it is unclear if the numbers are comparable, e.g. if education by the use of literature, which was most often mentioned by German GPs, was included in the aforementioned study's definition of training. If we exclude education by the use of literature from our definition of training, the proportion of physicians with no training increases to 81%, a proportion even worse than in the Nordic countries. The need for improved training of GPs in Germany is underlined by the fact that only 34% of GPs rated themselves as adequately trained. Enhanced training might also increase access to demonstration material, which was also significantly associated to smoking cessation promotion.
In Germany printed material (mostly cost-free) for smoking cessation assistance by health care providers is widely available.20–22 Literature has been used as a resource by many of the surveyed GPs’ while the attendance of courses or seminars was reported by only few. An improved offer of training facilities tailored to the needs of GPs might help to enhance GP's objective and self-perceived competence and thus remove this central barrier to smoking cessation promotion.
The suboptimal use of medications for the support of smoking cessation, e.g. nicotine replacement therapy and bupropion, might be related to the fact that in Germany, in contrast to other countries such as the United Kingdom,23 the costs are not covered by health insurance but have to be paid by the patients themselves. However, acupuncture was employed almost as frequently, though treatment is likewise not covered by health insurance. The frequent choice of means to support smoking cessation, for which long-term efficacy has not been proven and the suboptimal use of evidence-based methods, underlines the need for education of GPs in smoking cessation methods.
In the interpretation of our results, the following limitations have to be taken into account. Though several evidence-based strategies to increase response were employed, including monetary incentives, stamped return envelopes, repeated mailings providing non-responders with a second copy of the questionnaire, and telephone reminders,24,25 a response rate of only about 50% could be reached. Although this response rate is considerably higher than the response rate achieved in many other surveys among GPs (and may actually be close to the upper limit of what can be achieved in surveys in this professional group which notoriously suffers from severe time pressure), and participants were comparable regarding gender and age to GPs in Germany overall, physicians interested and active in smoking cessation promotion may have been more likely to respond. Similarly, an overreporting of activities in smoking cessation promotion cannot be excluded, since data rely on self-reporting by physicians. Thus the levels of activity in smoking cessation promotion might on average be somewhat lower than found in this study.
Although we cannot exclude with certainty difficulties with the use of negations in the statements regarding perceived barriers, as answer categories again included negations (see table 4), this issue did not seem to cause major problems in this highly educated population. Answers were almost complete, and results were generally consistent with expectations.
Our definition of physicians’ activity in smoking cessation promotion is broad and may not necessarily reflect the intensity or quality of activity in terms of time spent or evidence-based advice and methods used. A more detailed survey on methods used would be desirable, but it would probably be even more difficult if not impossible to achieve with an acceptable response rate among GPs.
Notwithstanding these limitations, our study suggests that improved reimbursement of counselling activities and improved training or education of general physicians in smoking cessation promotion may be central to increasing the activity in and the use of evidence-based methods to support smoking cessation in general practice in Germany. Implementation of enhanced training opportunities appears to be particularly promising. However, since its efficacy can only be suggested but not proven in a cross-sectional survey such as the one presented, implementation of such training opportunities should be accompanied by further research to evaluate to what extent they are used by GPs and to what extent these measures or improved reimbursement in fact lead to increased smoking cessation promotion effort by GPs and eventually to increased cessation rates among their patients.
Funding: This work was funded by the German Ministry of Education and Research (Bundesministerium für Bildung und Forschung BmBF) within the context of the Research Network on Addiction of Baden-Wurttemberg (project 01EB0113).
. | n . | % . | ||
---|---|---|---|---|
Gender | ||||
Male | 209 | 66.4 | ||
Female | 106 | 33.6 | ||
Age (missing=4) | ||||
30–39 | 26 | 8.4 | ||
40–49 | 118 | 37.9 | ||
50–59 | 121 | 38.9 | ||
60–69 | 46 | 14.8 | ||
Nationality | ||||
German | 310 | 98.7 | ||
Other | 4 | 1.3 | ||
Number of physicians in practice (missing=6) | ||||
1 (single handed practice) | 199 | 64.4 | ||
2 | 82 | 26.5 | ||
more than two | 28 | 9.1 | ||
Number of patients visiting the practice within the last three months (missing=6) | ||||
< 500 | 31 | 10.0 | ||
500–1000 | 127 | 41.1 | ||
1001–1500 | 89 | 28.8 | ||
>1500 | 62 | 20.1 | ||
Smoking status (missing=1) | ||||
never smoker | 158 | 50.3 | ||
ex-smoker | 126 | 40.1 | ||
current smoker | 30 | 9.6 | ||
Cigarette consumption among current smokers (missing=1) | ||||
≤ 10 cigarettes/day | 15 | 4.8 | ||
11–20 cigarettes/day | 12 | 3.8 | ||
21–30 cigarettes/day | 2 | 0.6 |
. | n . | % . | ||
---|---|---|---|---|
Gender | ||||
Male | 209 | 66.4 | ||
Female | 106 | 33.6 | ||
Age (missing=4) | ||||
30–39 | 26 | 8.4 | ||
40–49 | 118 | 37.9 | ||
50–59 | 121 | 38.9 | ||
60–69 | 46 | 14.8 | ||
Nationality | ||||
German | 310 | 98.7 | ||
Other | 4 | 1.3 | ||
Number of physicians in practice (missing=6) | ||||
1 (single handed practice) | 199 | 64.4 | ||
2 | 82 | 26.5 | ||
more than two | 28 | 9.1 | ||
Number of patients visiting the practice within the last three months (missing=6) | ||||
< 500 | 31 | 10.0 | ||
500–1000 | 127 | 41.1 | ||
1001–1500 | 89 | 28.8 | ||
>1500 | 62 | 20.1 | ||
Smoking status (missing=1) | ||||
never smoker | 158 | 50.3 | ||
ex-smoker | 126 | 40.1 | ||
current smoker | 30 | 9.6 | ||
Cigarette consumption among current smokers (missing=1) | ||||
≤ 10 cigarettes/day | 15 | 4.8 | ||
11–20 cigarettes/day | 12 | 3.8 | ||
21–30 cigarettes/day | 2 | 0.6 |
. | n . | % . | ||
---|---|---|---|---|
Gender | ||||
Male | 209 | 66.4 | ||
Female | 106 | 33.6 | ||
Age (missing=4) | ||||
30–39 | 26 | 8.4 | ||
40–49 | 118 | 37.9 | ||
50–59 | 121 | 38.9 | ||
60–69 | 46 | 14.8 | ||
Nationality | ||||
German | 310 | 98.7 | ||
Other | 4 | 1.3 | ||
Number of physicians in practice (missing=6) | ||||
1 (single handed practice) | 199 | 64.4 | ||
2 | 82 | 26.5 | ||
more than two | 28 | 9.1 | ||
Number of patients visiting the practice within the last three months (missing=6) | ||||
< 500 | 31 | 10.0 | ||
500–1000 | 127 | 41.1 | ||
1001–1500 | 89 | 28.8 | ||
>1500 | 62 | 20.1 | ||
Smoking status (missing=1) | ||||
never smoker | 158 | 50.3 | ||
ex-smoker | 126 | 40.1 | ||
current smoker | 30 | 9.6 | ||
Cigarette consumption among current smokers (missing=1) | ||||
≤ 10 cigarettes/day | 15 | 4.8 | ||
11–20 cigarettes/day | 12 | 3.8 | ||
21–30 cigarettes/day | 2 | 0.6 |
. | n . | % . | ||
---|---|---|---|---|
Gender | ||||
Male | 209 | 66.4 | ||
Female | 106 | 33.6 | ||
Age (missing=4) | ||||
30–39 | 26 | 8.4 | ||
40–49 | 118 | 37.9 | ||
50–59 | 121 | 38.9 | ||
60–69 | 46 | 14.8 | ||
Nationality | ||||
German | 310 | 98.7 | ||
Other | 4 | 1.3 | ||
Number of physicians in practice (missing=6) | ||||
1 (single handed practice) | 199 | 64.4 | ||
2 | 82 | 26.5 | ||
more than two | 28 | 9.1 | ||
Number of patients visiting the practice within the last three months (missing=6) | ||||
< 500 | 31 | 10.0 | ||
500–1000 | 127 | 41.1 | ||
1001–1500 | 89 | 28.8 | ||
>1500 | 62 | 20.1 | ||
Smoking status (missing=1) | ||||
never smoker | 158 | 50.3 | ||
ex-smoker | 126 | 40.1 | ||
current smoker | 30 | 9.6 | ||
Cigarette consumption among current smokers (missing=1) | ||||
≤ 10 cigarettes/day | 15 | 4.8 | ||
11–20 cigarettes/day | 12 | 3.8 | ||
21–30 cigarettes/day | 2 | 0.6 |
. | n . | % . | ||
---|---|---|---|---|
Reported time spent for education and training in smoking cessation promotion (missing=12) | ||||
0 hours | 69 | 22.7 | ||
1–5 hours | 108 | 35.6 | ||
6–10 hours | 69 | 22.7 | ||
more than 10 hours | 57 | 18.8 | ||
Type of education/training (more than one type could be selected) | ||||
literature | 213 | 67.6 | ||
lectures/seminars | 46 | 14.6 | ||
acupuncture training | 22 | 6.7 | ||
education in psychotherapy / drug addiction medicine | 10 | 3.2 | ||
information on medication for smoking cessation assistance | 9 | 2.9 | ||
Other | 19 | 6.4 | ||
Education/training perceived as adequate (missing=5) | 106 | 34.2 |
. | n . | % . | ||
---|---|---|---|---|
Reported time spent for education and training in smoking cessation promotion (missing=12) | ||||
0 hours | 69 | 22.7 | ||
1–5 hours | 108 | 35.6 | ||
6–10 hours | 69 | 22.7 | ||
more than 10 hours | 57 | 18.8 | ||
Type of education/training (more than one type could be selected) | ||||
literature | 213 | 67.6 | ||
lectures/seminars | 46 | 14.6 | ||
acupuncture training | 22 | 6.7 | ||
education in psychotherapy / drug addiction medicine | 10 | 3.2 | ||
information on medication for smoking cessation assistance | 9 | 2.9 | ||
Other | 19 | 6.4 | ||
Education/training perceived as adequate (missing=5) | 106 | 34.2 |
. | n . | % . | ||
---|---|---|---|---|
Reported time spent for education and training in smoking cessation promotion (missing=12) | ||||
0 hours | 69 | 22.7 | ||
1–5 hours | 108 | 35.6 | ||
6–10 hours | 69 | 22.7 | ||
more than 10 hours | 57 | 18.8 | ||
Type of education/training (more than one type could be selected) | ||||
literature | 213 | 67.6 | ||
lectures/seminars | 46 | 14.6 | ||
acupuncture training | 22 | 6.7 | ||
education in psychotherapy / drug addiction medicine | 10 | 3.2 | ||
information on medication for smoking cessation assistance | 9 | 2.9 | ||
Other | 19 | 6.4 | ||
Education/training perceived as adequate (missing=5) | 106 | 34.2 |
. | n . | % . | ||
---|---|---|---|---|
Reported time spent for education and training in smoking cessation promotion (missing=12) | ||||
0 hours | 69 | 22.7 | ||
1–5 hours | 108 | 35.6 | ||
6–10 hours | 69 | 22.7 | ||
more than 10 hours | 57 | 18.8 | ||
Type of education/training (more than one type could be selected) | ||||
literature | 213 | 67.6 | ||
lectures/seminars | 46 | 14.6 | ||
acupuncture training | 22 | 6.7 | ||
education in psychotherapy / drug addiction medicine | 10 | 3.2 | ||
information on medication for smoking cessation assistance | 9 | 2.9 | ||
Other | 19 | 6.4 | ||
Education/training perceived as adequate (missing=5) | 106 | 34.2 |
. | n . | % . | ||
---|---|---|---|---|
Number of patients assisted in smoking cessation by any method in the last three months (missing=3) | ||||
0 patients | 29 | 9.3 | ||
1–4 patients | 83 | 26.6 | ||
5–9 patients | 56 | 17.9 | ||
10–19 patients | 71 | 22.8 | ||
20 or more patients | 73 | 23.4 | ||
Proportion of all patients assisted in smoking cessation by any method in the last three months (missing=14) | ||||
0% | 29 | 9.6 | ||
>0% and <0.5% | 58 | 19.3 | ||
0.5% to <1% | 73 | 24.3 | ||
1% to <2% | 56 | 18.6 | ||
2% or more | 85 | 28.2 | ||
Specific measurements for smoking cessation assistance used by the GPs (including referrals to other doctors) | ||||
Personal counselling | 258 | 81.9 | ||
Group programmes | 24 | 7.6 | ||
Books or brochures | 183 | 58.1 | ||
Prescription of nicotine gum | 87 | 27.6 | ||
Prescription of nicotine patches | 190 | 60.3 | ||
Prescription of nicotine nasal spray | 10 | 3.2 | ||
Prescription of some form of NRT (gum, patch, or spray) | 195 | 61.9 | ||
Prescription of bupropion (Zyban ®) | 162 | 51.4 | ||
Acupuncture | 137 | 43.5 | ||
Hypnosis | 15 | 4.8 |
. | n . | % . | ||
---|---|---|---|---|
Number of patients assisted in smoking cessation by any method in the last three months (missing=3) | ||||
0 patients | 29 | 9.3 | ||
1–4 patients | 83 | 26.6 | ||
5–9 patients | 56 | 17.9 | ||
10–19 patients | 71 | 22.8 | ||
20 or more patients | 73 | 23.4 | ||
Proportion of all patients assisted in smoking cessation by any method in the last three months (missing=14) | ||||
0% | 29 | 9.6 | ||
>0% and <0.5% | 58 | 19.3 | ||
0.5% to <1% | 73 | 24.3 | ||
1% to <2% | 56 | 18.6 | ||
2% or more | 85 | 28.2 | ||
Specific measurements for smoking cessation assistance used by the GPs (including referrals to other doctors) | ||||
Personal counselling | 258 | 81.9 | ||
Group programmes | 24 | 7.6 | ||
Books or brochures | 183 | 58.1 | ||
Prescription of nicotine gum | 87 | 27.6 | ||
Prescription of nicotine patches | 190 | 60.3 | ||
Prescription of nicotine nasal spray | 10 | 3.2 | ||
Prescription of some form of NRT (gum, patch, or spray) | 195 | 61.9 | ||
Prescription of bupropion (Zyban ®) | 162 | 51.4 | ||
Acupuncture | 137 | 43.5 | ||
Hypnosis | 15 | 4.8 |
. | n . | % . | ||
---|---|---|---|---|
Number of patients assisted in smoking cessation by any method in the last three months (missing=3) | ||||
0 patients | 29 | 9.3 | ||
1–4 patients | 83 | 26.6 | ||
5–9 patients | 56 | 17.9 | ||
10–19 patients | 71 | 22.8 | ||
20 or more patients | 73 | 23.4 | ||
Proportion of all patients assisted in smoking cessation by any method in the last three months (missing=14) | ||||
0% | 29 | 9.6 | ||
>0% and <0.5% | 58 | 19.3 | ||
0.5% to <1% | 73 | 24.3 | ||
1% to <2% | 56 | 18.6 | ||
2% or more | 85 | 28.2 | ||
Specific measurements for smoking cessation assistance used by the GPs (including referrals to other doctors) | ||||
Personal counselling | 258 | 81.9 | ||
Group programmes | 24 | 7.6 | ||
Books or brochures | 183 | 58.1 | ||
Prescription of nicotine gum | 87 | 27.6 | ||
Prescription of nicotine patches | 190 | 60.3 | ||
Prescription of nicotine nasal spray | 10 | 3.2 | ||
Prescription of some form of NRT (gum, patch, or spray) | 195 | 61.9 | ||
Prescription of bupropion (Zyban ®) | 162 | 51.4 | ||
Acupuncture | 137 | 43.5 | ||
Hypnosis | 15 | 4.8 |
. | n . | % . | ||
---|---|---|---|---|
Number of patients assisted in smoking cessation by any method in the last three months (missing=3) | ||||
0 patients | 29 | 9.3 | ||
1–4 patients | 83 | 26.6 | ||
5–9 patients | 56 | 17.9 | ||
10–19 patients | 71 | 22.8 | ||
20 or more patients | 73 | 23.4 | ||
Proportion of all patients assisted in smoking cessation by any method in the last three months (missing=14) | ||||
0% | 29 | 9.6 | ||
>0% and <0.5% | 58 | 19.3 | ||
0.5% to <1% | 73 | 24.3 | ||
1% to <2% | 56 | 18.6 | ||
2% or more | 85 | 28.2 | ||
Specific measurements for smoking cessation assistance used by the GPs (including referrals to other doctors) | ||||
Personal counselling | 258 | 81.9 | ||
Group programmes | 24 | 7.6 | ||
Books or brochures | 183 | 58.1 | ||
Prescription of nicotine gum | 87 | 27.6 | ||
Prescription of nicotine patches | 190 | 60.3 | ||
Prescription of nicotine nasal spray | 10 | 3.2 | ||
Prescription of some form of NRT (gum, patch, or spray) | 195 | 61.9 | ||
Prescription of bupropion (Zyban ®) | 162 | 51.4 | ||
Acupuncture | 137 | 43.5 | ||
Hypnosis | 15 | 4.8 |
. | entirely true . | rather true . | rather not true . | not at all true . |
---|---|---|---|---|
It is not my responsibility | 1 | 9 | 32 | 58 |
I am not interested | 1 | 6 | 27 | 66 |
I do not have time | 6 | 32 | 30 | 32 |
I do not get adequate reimbursement | 37 | 40 | 11 | 12 |
I do not have adequate training | 10 | 47 | 29 | 14 |
I do not have any demonstration materials | 22 | 40 | 25 | 13 |
. | entirely true . | rather true . | rather not true . | not at all true . |
---|---|---|---|---|
It is not my responsibility | 1 | 9 | 32 | 58 |
I am not interested | 1 | 6 | 27 | 66 |
I do not have time | 6 | 32 | 30 | 32 |
I do not get adequate reimbursement | 37 | 40 | 11 | 12 |
I do not have adequate training | 10 | 47 | 29 | 14 |
I do not have any demonstration materials | 22 | 40 | 25 | 13 |
. | entirely true . | rather true . | rather not true . | not at all true . |
---|---|---|---|---|
It is not my responsibility | 1 | 9 | 32 | 58 |
I am not interested | 1 | 6 | 27 | 66 |
I do not have time | 6 | 32 | 30 | 32 |
I do not get adequate reimbursement | 37 | 40 | 11 | 12 |
I do not have adequate training | 10 | 47 | 29 | 14 |
I do not have any demonstration materials | 22 | 40 | 25 | 13 |
. | entirely true . | rather true . | rather not true . | not at all true . |
---|---|---|---|---|
It is not my responsibility | 1 | 9 | 32 | 58 |
I am not interested | 1 | 6 | 27 | 66 |
I do not have time | 6 | 32 | 30 | 32 |
I do not get adequate reimbursement | 37 | 40 | 11 | 12 |
I do not have adequate training | 10 | 47 | 29 | 14 |
I do not have any demonstration materials | 22 | 40 | 25 | 13 |
. | . | Total n . | Low activity n . | Crude odds ratio . | Adjusted odds ratiob . | |||||
---|---|---|---|---|---|---|---|---|---|---|
. | . | . | (%) . | (95% CIa) . | (95% CI) . | |||||
Gender | female | 105 | 67 (63.8) | 1.00 | ||||||
male | 207 | 101 (48.8) | 0.54 (0.33, 0.88) | NA | ||||||
Age | 30–49 years | 144 | 83 (57.6) | 1.00 | ||||||
50–69 years | 165 | 85 (51.5) | 0.78 (0.50, 1.23) | NA | ||||||
Smoking status | never smoker | 157 | 87 (55.4) | 1.00 | 1.00 | |||||
ex-smoker | 125 | 62 (49.6) | 0.79 (0.49, 1.27) | 0.89 (0.52, 1.52) | ||||||
current smoker | 29 | 18 (62.1) | 1.32 (0.58, 2.97) | 1.44 (0.58, 3.58) | ||||||
Time spent for training in smokingcessation promotion | 0 hours | 67 | 43 (64.2) | 1.00 | 1.00 | |||||
1–5 hours | 108 | 62 (57.4) | 0.75 (0.40, 1.41) | 0.77 (0.41, 1.45) | ||||||
> 5 hours | 126 | 54 (42.9) | 0.42 (0.23, 0.77) | 0.43 (0.23, 0.81) | ||||||
Perceived barriers: | ||||||||||
Not in the area of responsibility | no | 279 | 151 (54.1) | 1.00 | 1.00 | |||||
yes | 30 | 15 (50.0) | 0.84 (0.40, 1.80) | 0.84 (0.39, 1.81) | ||||||
Lack of interest | no | 288 | 154 (53.5) | 1.00 | 1.00 | |||||
yes | 21 | 11 (52.4) | 0.96 (0.39, 2.32) | 1.04 (0.42, 2.56) | ||||||
Lack of time | no | 192 | 93 (48.4) | 1.00 | 1.00 | |||||
yes | 117 | 72 (61.5) | 1.70 (1.07, 2.72) | 1.65 (1.02, 2.66) | ||||||
Lack of adequate reimbursement | no | 69 | 33 (47.8) | 1.00 | 1.00 | |||||
yes | 239 | 131 (54.8) | 1.32 (0.77, 2.26) | 1.42 (0.82, 2.47) | ||||||
Lack of adequate training | no | 133 | 52 (39.1) | 1.00 | 1.00 | |||||
yes | 175 | 112 (64.0) | 2.77 (1.74, 4.41) | 2.70 (1.68, 4.32) | ||||||
Lack of demonstration material | no | 117 | 49 (41.9) | 1.00 | 1.00 | |||||
yes | 190 | 114 (60.0) | 2.08 (1.30, 3.32) | 2.10 (1.31, 3.39) |
. | . | Total n . | Low activity n . | Crude odds ratio . | Adjusted odds ratiob . | |||||
---|---|---|---|---|---|---|---|---|---|---|
. | . | . | (%) . | (95% CIa) . | (95% CI) . | |||||
Gender | female | 105 | 67 (63.8) | 1.00 | ||||||
male | 207 | 101 (48.8) | 0.54 (0.33, 0.88) | NA | ||||||
Age | 30–49 years | 144 | 83 (57.6) | 1.00 | ||||||
50–69 years | 165 | 85 (51.5) | 0.78 (0.50, 1.23) | NA | ||||||
Smoking status | never smoker | 157 | 87 (55.4) | 1.00 | 1.00 | |||||
ex-smoker | 125 | 62 (49.6) | 0.79 (0.49, 1.27) | 0.89 (0.52, 1.52) | ||||||
current smoker | 29 | 18 (62.1) | 1.32 (0.58, 2.97) | 1.44 (0.58, 3.58) | ||||||
Time spent for training in smokingcessation promotion | 0 hours | 67 | 43 (64.2) | 1.00 | 1.00 | |||||
1–5 hours | 108 | 62 (57.4) | 0.75 (0.40, 1.41) | 0.77 (0.41, 1.45) | ||||||
> 5 hours | 126 | 54 (42.9) | 0.42 (0.23, 0.77) | 0.43 (0.23, 0.81) | ||||||
Perceived barriers: | ||||||||||
Not in the area of responsibility | no | 279 | 151 (54.1) | 1.00 | 1.00 | |||||
yes | 30 | 15 (50.0) | 0.84 (0.40, 1.80) | 0.84 (0.39, 1.81) | ||||||
Lack of interest | no | 288 | 154 (53.5) | 1.00 | 1.00 | |||||
yes | 21 | 11 (52.4) | 0.96 (0.39, 2.32) | 1.04 (0.42, 2.56) | ||||||
Lack of time | no | 192 | 93 (48.4) | 1.00 | 1.00 | |||||
yes | 117 | 72 (61.5) | 1.70 (1.07, 2.72) | 1.65 (1.02, 2.66) | ||||||
Lack of adequate reimbursement | no | 69 | 33 (47.8) | 1.00 | 1.00 | |||||
yes | 239 | 131 (54.8) | 1.32 (0.77, 2.26) | 1.42 (0.82, 2.47) | ||||||
Lack of adequate training | no | 133 | 52 (39.1) | 1.00 | 1.00 | |||||
yes | 175 | 112 (64.0) | 2.77 (1.74, 4.41) | 2.70 (1.68, 4.32) | ||||||
Lack of demonstration material | no | 117 | 49 (41.9) | 1.00 | 1.00 | |||||
yes | 190 | 114 (60.0) | 2.08 (1.30, 3.32) | 2.10 (1.31, 3.39) |
Confidence interval
Adjusted for age and gender
. | . | Total n . | Low activity n . | Crude odds ratio . | Adjusted odds ratiob . | |||||
---|---|---|---|---|---|---|---|---|---|---|
. | . | . | (%) . | (95% CIa) . | (95% CI) . | |||||
Gender | female | 105 | 67 (63.8) | 1.00 | ||||||
male | 207 | 101 (48.8) | 0.54 (0.33, 0.88) | NA | ||||||
Age | 30–49 years | 144 | 83 (57.6) | 1.00 | ||||||
50–69 years | 165 | 85 (51.5) | 0.78 (0.50, 1.23) | NA | ||||||
Smoking status | never smoker | 157 | 87 (55.4) | 1.00 | 1.00 | |||||
ex-smoker | 125 | 62 (49.6) | 0.79 (0.49, 1.27) | 0.89 (0.52, 1.52) | ||||||
current smoker | 29 | 18 (62.1) | 1.32 (0.58, 2.97) | 1.44 (0.58, 3.58) | ||||||
Time spent for training in smokingcessation promotion | 0 hours | 67 | 43 (64.2) | 1.00 | 1.00 | |||||
1–5 hours | 108 | 62 (57.4) | 0.75 (0.40, 1.41) | 0.77 (0.41, 1.45) | ||||||
> 5 hours | 126 | 54 (42.9) | 0.42 (0.23, 0.77) | 0.43 (0.23, 0.81) | ||||||
Perceived barriers: | ||||||||||
Not in the area of responsibility | no | 279 | 151 (54.1) | 1.00 | 1.00 | |||||
yes | 30 | 15 (50.0) | 0.84 (0.40, 1.80) | 0.84 (0.39, 1.81) | ||||||
Lack of interest | no | 288 | 154 (53.5) | 1.00 | 1.00 | |||||
yes | 21 | 11 (52.4) | 0.96 (0.39, 2.32) | 1.04 (0.42, 2.56) | ||||||
Lack of time | no | 192 | 93 (48.4) | 1.00 | 1.00 | |||||
yes | 117 | 72 (61.5) | 1.70 (1.07, 2.72) | 1.65 (1.02, 2.66) | ||||||
Lack of adequate reimbursement | no | 69 | 33 (47.8) | 1.00 | 1.00 | |||||
yes | 239 | 131 (54.8) | 1.32 (0.77, 2.26) | 1.42 (0.82, 2.47) | ||||||
Lack of adequate training | no | 133 | 52 (39.1) | 1.00 | 1.00 | |||||
yes | 175 | 112 (64.0) | 2.77 (1.74, 4.41) | 2.70 (1.68, 4.32) | ||||||
Lack of demonstration material | no | 117 | 49 (41.9) | 1.00 | 1.00 | |||||
yes | 190 | 114 (60.0) | 2.08 (1.30, 3.32) | 2.10 (1.31, 3.39) |
. | . | Total n . | Low activity n . | Crude odds ratio . | Adjusted odds ratiob . | |||||
---|---|---|---|---|---|---|---|---|---|---|
. | . | . | (%) . | (95% CIa) . | (95% CI) . | |||||
Gender | female | 105 | 67 (63.8) | 1.00 | ||||||
male | 207 | 101 (48.8) | 0.54 (0.33, 0.88) | NA | ||||||
Age | 30–49 years | 144 | 83 (57.6) | 1.00 | ||||||
50–69 years | 165 | 85 (51.5) | 0.78 (0.50, 1.23) | NA | ||||||
Smoking status | never smoker | 157 | 87 (55.4) | 1.00 | 1.00 | |||||
ex-smoker | 125 | 62 (49.6) | 0.79 (0.49, 1.27) | 0.89 (0.52, 1.52) | ||||||
current smoker | 29 | 18 (62.1) | 1.32 (0.58, 2.97) | 1.44 (0.58, 3.58) | ||||||
Time spent for training in smokingcessation promotion | 0 hours | 67 | 43 (64.2) | 1.00 | 1.00 | |||||
1–5 hours | 108 | 62 (57.4) | 0.75 (0.40, 1.41) | 0.77 (0.41, 1.45) | ||||||
> 5 hours | 126 | 54 (42.9) | 0.42 (0.23, 0.77) | 0.43 (0.23, 0.81) | ||||||
Perceived barriers: | ||||||||||
Not in the area of responsibility | no | 279 | 151 (54.1) | 1.00 | 1.00 | |||||
yes | 30 | 15 (50.0) | 0.84 (0.40, 1.80) | 0.84 (0.39, 1.81) | ||||||
Lack of interest | no | 288 | 154 (53.5) | 1.00 | 1.00 | |||||
yes | 21 | 11 (52.4) | 0.96 (0.39, 2.32) | 1.04 (0.42, 2.56) | ||||||
Lack of time | no | 192 | 93 (48.4) | 1.00 | 1.00 | |||||
yes | 117 | 72 (61.5) | 1.70 (1.07, 2.72) | 1.65 (1.02, 2.66) | ||||||
Lack of adequate reimbursement | no | 69 | 33 (47.8) | 1.00 | 1.00 | |||||
yes | 239 | 131 (54.8) | 1.32 (0.77, 2.26) | 1.42 (0.82, 2.47) | ||||||
Lack of adequate training | no | 133 | 52 (39.1) | 1.00 | 1.00 | |||||
yes | 175 | 112 (64.0) | 2.77 (1.74, 4.41) | 2.70 (1.68, 4.32) | ||||||
Lack of demonstration material | no | 117 | 49 (41.9) | 1.00 | 1.00 | |||||
yes | 190 | 114 (60.0) | 2.08 (1.30, 3.32) | 2.10 (1.31, 3.39) |
Confidence interval
Adjusted for age and gender
General practitioners (GP) can play a major role in reducing smoking prevalence among their patients by promoting well known effective smoking cessation strategies.
The provision of easy-to-reach training opportunities may be a key factor to ensure the optimal use of this potential by enhancing the engagement of general practitioners in the promotion of smoking cessation.
This work was funded by the German Ministry of Education and Research (Bundesministerium für Bildung und Forschung BmBF) within the context of the Research Network on Addiction of Baden-Wurttemberg (project 01EB0113).
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