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A Systematic Literature Review of Self-Reported Smoking Cessation Counseling by Primary Care Physicians

  • Anna-Lena Bartsch ,

    a.bartsch@uke.de

    Affiliation Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

  • Martin Härter,

    Affiliation Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

  • Jasmin Niedrich,

    Affiliation Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

  • Anna Levke Brütt ,

    Contributed equally to this work with: Anna Levke Brütt, Angela Buchholz

    Affiliation Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

  • Angela Buchholz

    Contributed equally to this work with: Anna Levke Brütt, Angela Buchholz

    Affiliation Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

A Systematic Literature Review of Self-Reported Smoking Cessation Counseling by Primary Care Physicians

  • Anna-Lena Bartsch, 
  • Martin Härter, 
  • Jasmin Niedrich, 
  • Anna Levke Brütt, 
  • Angela Buchholz
PLOS
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Abstract

Tobacco consumption is a risk factor for chronic diseases and worldwide around six million people die from long-term exposure to first- or second-hand smoke annually. One effective approach to tobacco control is smoking cessation counseling by primary care physicians. However, research suggests that smoking cessation counseling is not sufficiently implemented in primary care. In order to understand and address the discrepancy between evidence and practice, an overview of counseling practices is needed. Therefore, the aim of this systematic literature review is to assess the frequency of smoking cessation counseling in primary care. Self-reported counseling behavior by physicians is categorized according to the 5A’s strategy (ask, advise, assess, assist, arrange). An electronic database search was performed in Embase, Medline, PsycINFO, CINAHL and the Cochrane Library and overall, 3491 records were identified. After duplicates were removed, the title and abstracts of 2468 articles were screened for eligibility according to inclusion/exclusion criteria. The remaining 97 full-text articles reporting smoking cessation counseling by primary care physicians were assessed for eligibility. Eligible studies were those that measured physicians’ self-reported smoking cessation counseling activities via questionnaire. Thirty-five articles were included in the final review (1 intervention and 34 cross-sectional studies). On average, behavior corresponding to the 5A’s was reported by 65% of physicians for “Ask”, 63% for “Advise”, 36% for “Assess”, 44% for “Assist”, and 22% of physicians for “Arrange”, although the measurement and reporting of each of these counseling practices varied across studies. Overall, the results indicate that the first strategies (ask, advise) were more frequently reported than the subsequent strategies (assess, assist, arrange). Moreover, there was considerable variation in the items used to assess counseling behaviour and developing a standardized instrument to assess the counseling strategies implemented in primary care would help to identify and address current gaps in practice.

Introduction

Tobacco consumption is a preventable risk factor for non-communicable diseases such as chronic obstructive pulmonary disease (COPD) and cardiovascular disease. Each year, around six million people die from long-term exposure to first- or second-hand smoke worldwide [1]. Globally, one of the guiding instruments for tobacco control is the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) [2]. The convention gives specific recommendations for a number of different tobacco control strategies that should be implemented, such as developing comprehensive smoking cessation guidelines and introducing warning labels on cigarette packages [2]. One approach to reduce tobacco consumption that is recommended in guidelines for the treatment of tobacco dependence is to offer smoking cessation counseling in the primary care setting [35]. Smoking cessation counseling by general practitioners (GP’s) has been shown to increase quit rates [6]. The general practice is an appropriate setting for smoking cessation counseling for a number of reasons [7]. First, GP’s have suitable access to the target group because around 80% of the German population visit their GP at least once per year [8]. Second, regular personal contact builds trust between GP’s and patients and facilitates the provision of quit advice [9]. Third, face-to-face contact allows for the delivery of individual smoking cessation advice [10].

The clinical practice guideline of the US Public Health Service contains a comprehensive approach to smoking cessation counseling in primary care settings, which specifies individual counseling steps such as asking about tobacco consumption and recommending the use of pharmacological aids; the 5A’s strategy [5]. The 5A’s refer to a sequence of 5 different counseling strategies: “Ask” (ask all patients about tobacco use), “Advise” (advise all tobacco users to quit), “Assess” (assess the willingness to quit), “Assist” (assist with quitting) and “Arrange” (arrange follow-up) [5]. Examples of other approaches are the ABC model (Ask about and document smoking status, give brief advice and encourage the use of cessation support) and the recommendation of the American Association of Family Physicians (AAFP; Ask about tobacco use, advise to stop using tobacco products and provide behavioral interventions). We focus on the 5 A’s strategy because it distinguishes between 5 counseling steps and is therefore more inclusive than the ABC model and AAFP recommendation which describe 3 counseling steps [4, 5, 11].

Although smoking cessation counseling is effective and recommended in clinical guidelines, it is not fully implemented in primary care [10, 12]. In order to further understand and address the discrepancy between evidence and practice, an overview of current counseling practices is needed. A systematic literature review has examined the frequency of behavioral counseling by physicians for multiple behaviors (tobacco consumption, physical activity and nutrition) and found that the use of educational materials and referral to smoking cessation courses were frequently reported counseling strategies [13]. For example, educational materials were recommended by 58% of Scottish physicians and 61% of Canadian physicians [14, 15]. However, comparability of quantitative information on smoking cessation counseling practices was limited and it is not clear which counseling steps are implemented in practice. Therefore, the aim of this literature review is to systematically assess physician-reported smoking cessation counseling in primary care by classifying counseling practices according to the 5A’s strategy.

Methods

Protocol registration and search strategy

The present literature review was reported according to the PRISMA statement [16]. A protocol for this literature review was not registered. The database search was limited to studies published between 2000 and June 2015 because counseling behavior was categorized according to the 5A’s strategy, which was published by the US Public Health Service in the year 2000 and the literature search was conducted in June 2015. A preliminary search of Medline via OVID served to identify relevant keywords. The core search strategy was developed using the keywords and relevant synonyms to capture smoking cessation counseling by physicians and reviewed by a librarian experienced in database searches. Among the main keywords used in the search were: “smoking cessation”, “counseling” and “primary care physician”. The search strategy was then adapted in order to perform an extensive literature search in the following databases: Embase, Medline and PsycINFO via OVID as well as CINAHL and the Cochrane library (Please see S1 File for the detailed search strategy per database). Further articles were identified by screening the bibliographies of articles retrieved from the initial search.

Study selection

Two independent reviewers (ALBa and JN) performed the title and abstract screening of the studies identified by the search based on a checklist for the inclusion/exclusion of studies framed in relation to PICOS (Population, intervention, comparator, outcome and study design; see Table 1). The reliability of the checklist was tested on a random selection of 100 articles prior to the title and abstract screening. Studies for which all items on the checklist were answered with “yes” were included in the review. There was substantial agreement (Cohen’s Kappa = 0.66) between the two reviewers (JN and ALBa), who then performed the full-text screening independently. Any discrepancies were resolved by discussion until consensus was reached.

Study inclusion/exclusion criteria

Studies were included in the review if they were published in either English or German language and measured physicians’ self-reported smoking cessation counseling activities via questionnaire. The main outcome was the proportion of physicians reporting smoking cessation counseling. We excluded studies that reported the proportion of patients receiving smoking cessation counseling because it has been shown that physician and patient-reported data differ [17]. Research articles that defined the majority of the study population as either general practitioners, family physicians or internists (referred to as physicians in the following) were included in the review [18]. Research has shown that physicians provide smoking cessation counseling to young patients more frequently than to adults. We therefore excluded articles with study populations consisting only of paediatricians or young patients (below age 18) [19].

Data extraction

A data extraction sheet was pilot-tested and adjusted as necessary in order to obtain relevant data from the articles. One reviewer (ALBa) performed the initial data extraction and a second reviewer (BS) checked whether the data were extracted accurately. The following information was extracted: study identifiers (Author, year, and country), the sample (physician characteristics), the methods (data collection method) and results (response rate, sample characteristics and smoking cessation counseling behavior). The proportion of physicians providing smoking cessation counseling to patients was extracted and categorized according the 5A’s. [5].

Quality assessment

Quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT) to assess the quality of various study types (e.g. quantitative studies, mixed methods studies etc.) [20]. The tool’s validity and reliability have been established [21, 22]. An overall quality score is determined using criteria that vary by study design. Quality assessment was performed independently by two reviewers (ALBa and BS) and the quality assessment for each study is shown in Table 2.

Data synthesis

The main outcome was the proportion of physicians reporting counseling and in cases where multiple items were used to measure smoking cessation counseling behavior, the item that best represented the respective 5A’s strategy was chosen. In the case of rating scales, we reported the responses to the end point of the scale. For example, for the response options “Never”, “Occasionally”, “Almost always” and “Always”, the proportions of physicians that selected “Always” were reported. If multiple forms of assistance were reported (e.g. prescribing NRT, handing out leaflets, referral to expert), we reported only the most frequently offered form of assistance.

Results

Study selection

Overall, 3491 records were identified by the electronic database search. After duplicates were removed, the title and abstracts of 2468 articles were screened according to inclusion/exclusion criteria. The remaining 97 full-text articles were assessed for eligibility. Of these articles, 62 were excluded (see S3 File for a list of the reasons for exclusion). The remaining 35 articles were included in the final review. The process for including/excluding studies is illustrated in the flow diagram in Fig 1 [16].

Description of included articles

In total, 35 articles were included in the review and reported studies from 17 countries (see Table 2 for details). Sample sizes from studies included in the review ranged from 37 to 4074 (mean = 809). Thirty-one studies reported response rates, with a mean response rate of 64% (range: 18% to 95%). Thirty-four studies used survey designs and 1 article reported an intervention study (single group, pre-post design) [9] of which baseline data were included. Surveys were mainly distributed via post (16 studies) or in person (7 studies). Descriptive data of all studies included in the review are shown in Table 2.

Smoking cessation counseling

Of the 35 articles, 8 articles reported counseling behavior corresponding to all 5 counseling strategies (ask, advise, assess, assist and arrange) [7, 23, 26, 29, 31, 32, 36, 46]. The strategies “Ask” and “Advise” were most frequently reported. “Ask” was reported in 29 articles and on average 65% (range: 7% to 100%) of physicians asked about their patient’s smoking behavior. Twenty-five articles reported “Advise” and on average, 63% of physicians (range: 13% to 99%) advised their patients to stop smoking. Fourteen articles reported behavior corresponding to “Assess” with an average of 36% (range: 11% to 72%) of physicians assessing their patient’s smoking status. Twenty-three articles reported “Assist”, with an average of 44% (range: 2% to 98%) of physicians providing assistance. Fourteen articles reported “Arrange” and on average 22% (range: 2% to 54%) of physicians arranged follow-up consultations. Table 2 shows the proportions of physicians offering smoking cessation counseling, categorized according to the 5A’s.

The items and response options used in each study are shown in Table 2. Whereas some researchers used a single item to measure counseling behavior, others used multiple items. For example, counseling behavior corresponding to the “Ask” strategy was assessed with the item "During a consultation, do you ask patients whether they smoke?" in one study [44], whereas another study [35] used the items "I ask patients at their annual visits if they use tobacco", "When patients come in for unrelated problems, I ask them about tobacco use" to measure behavior. When multiple items were used to measure counseling behavior in a single article, the responses to the item that most accurately represented the strategy of interest was reported. For example, the items ‘‘Do you assess the smoking status when a patient attends the practice for the first time?” and “Do you routinely assess the smoking status when a patient attends the practice?” [9] both concern asking patients about tobacco use and therefore relate to the strategy “Ask” (systematically identify all tobacco users at every visit). However, the second item corresponds to the strategy more closely because it concerns asking all patients about tobacco use (not only upon the first visit to the practice office). Therefore, the responses to the second item are reported in the review.

The questionnaires used also differed between studies and some researchers used adapted versions of existing questionnaires to measure counseling behavior. For example, one study used a 45-item questionnaire that was based on a questionnaire by the World Health Organization [28, 56]. In contrast, other studies included questionnaires developed by the researchers during project group discussions or expert consultations (e.g. in-depth interviews). Further differences were seen in the response options of questionnaire items. Dichotomous response scales (“Do you ask patients whether he or she smokes?”; “yes”,”no”) [37] were used in some studies, whereas others used rating scales (“During a consultation, do you ask patients whether they smoke?”; “never”, “occasionally”, “almost always” and “always”) [44]. When a rating scale was used to assess counseling behavior, only data from the end point of the scale was reported. For example, in order to extract counseling behavior for the strategy “Ask”, we reported the proportion of physicians who responded “always” to the item “During a consultation, do you ask patients whether they smoke?”

Quality of included articles

The quality assessment is included in Table 2. Details of the quality assessment are shown in S4 File. There was moderate agreement between the two raters on the assessment of study quality (Cohen’s Kappa = 0.59). Any discrepancies were resolved by discussion. The methodological quality of the included studies varied and the population sizes were between N = 37 to N = 4074. Also, information on the instruments used to measure physicians’ smoking cessation counseling was often insufficient or lacking and the information available is displayed in Table 2. However, no study was excluded due to its methodological quality.

Discussion

The aim of this review was to systematically assess the frequency of behavioral counseling for smoking cessation in primary care and the 5A’s strategy was used to structure smoking cessation counseling. Main findings are that the first strategies “Ask” and “Advise” were more often reported than the subsequent strategies “Assess”, “Assist” and “Arrange”. This finding corresponds to research that found the last two strategies (assist, arrange) to be least reported [57]. However, it is not possible to say whether individual steps were not performed by physicians or simply not measured or reported by the researchers. Secondary findings are that the proportions of physicians reported differed considerably per 5A strategy. For example, 81% (95% CI = 74%, 88%) of physicians reported to give advice in one study [29], whereas only 13% (10%, 16%) of physicians gave advice according to another study [50]. While differences in proportions may result from variations in sample characteristics and settings, they may also be due to the wording of questionnaire items used to assess counseling behavior [13]. More physicians may have indicated advising patients in the first study [29] because the item (“Do you advise the patient to quit smoking?”) can be understood to refer to only some or all patients. In contrast, physicians in the second study [50] were specifically asked if they offered advice to all of their patients. These differences could also explain why fewer physicians indicated giving advice in the second study.

Also, there are different forms of assistance, such as providing supporting information, referring to quitlines or recommending the use of pharmacotherapy. According to a literature review, assistance was most frequently offered in form of educational materials [13]. In contrast, the results of the present review suggest that nicotine replacement therapy (NRT) was the most frequently offered form of assistance. For example, one study reported that 61% (57%, 65%) of physicians recommended NRT, whereas only 25% (22%, 28%) provided self-help materials [25]. However, it is difficult to clearly determine which form of assistance was offered most frequently because not all articles included in this review distinguished between different assistance types.

Limitations

Risk of bias is seen in the self-report questionnaires used to measure physicians’ smoking cessation counseling activities. Self-report measures may introduce social desirability or recall bias [58]. In particular, physicians may overestimate their adherence to guidelines and the frequency with which they deliver preventive services [13, 17]. Therefore, a limitation is that studies presenting physician-reported but not patient-reported data were included in this review [17]. Besides, it has been proposed that instruments to assess the delivery of preventive services should take into account the perspective of both, physicians and patients [59, 60]. Also, physicians who participate in surveys on smoking cessation counseling may be more interested and hence more engaged in counseling activities than the overall population of physicians. Nevertheless, self-report measures make it possible to measure many participants and are therefore an appropriate research tool for this population [61]. While other methods such as video-based observation can be used to conduct research in primary care, these methods complicate the research process due to technical requirements and confidentiality and privacy aspects [62].

Moreover, differences in the items used to assess counseling behavior limited the comparability of study results. A systematic review on behavioral counseling for cardiovascular disease found that physician-reported smoking cessation counseling differed, depending on the phrasing of survey questions [13]. Moreover, the number of items and type of response option (dichotomous or rating scale) may influence reports of counseling behavior [43]. Further, it should be noted that the 5A’s strategy used to structure smoking cessation counseling was initially presented by the US public health service and may be less familiar outside of the US [5]. Although the strategy is mentioned in the guidelines of other countries, such as Canada [63], and Germany [64], specific recommendations may differ between countries. We still chose the 5A’s strategy because it distinguishes between 5 counseling steps and is therefore more comprehensive than other frameworks such as the ABC model [4, 5, 11]. Also, only articles in English and German language were included in the review, which means that relevant studies published in other languages may have been missed.

Implications

While this review summarizes physicians’ perspective of smoking cessation counseling in practice, it does not provide information on the reasons why physicians do or do not offer counseling. Changes in health care policy and clinical guidelines affect provider behaviour and may influence the frequency and type of smoking cessation counseling. According to previous studies, self-efficacy beliefs, prior training and patient characteristics determine whether physicians offer counseling [13, 65]. For example, physicians may not approach patients who appear unmotivated or do not intend to quit smoking due to fear of harming the physician-patient relationship [66]. A systematic literature on the barriers to discussing smoking cessation with patients exists [66] and future studies could explore a possible association between attitudes towards counseling and actual counseling behavior [13]. This would help to further understand and address common barriers. Also, future studies could include patient-reported or more objective data, in order to gain further insights into the implementation of smoking cessation counseling in practice.

In concluding, more research is needed in order to monitor changes and draw firm conclusions about provider behavior. The present results suggest that there is need for a standardized instrument to assess counseling behavior that differentiates between the possible forms of advice and assistance (e.g. NRT, referral to specialist) because this would help to identify current gaps in practice. While instruments to assess smoking cessation counseling have been developed in relation to the 5A’s strategy, these instruments require additional evaluation. Most instruments remain unpublished and data on reliability and validity are often missing [57].

Acknowledgments

We thank Dr. Florian Vogt for his overall advice and support during the initial research phase. Furthermore, we thank Benjamin Strothmann for help as a student assistant and Klaus-Dieter Papke for advice on the systematic database search.

Author Contributions

  1. Conceptualization: AB AL. Bartsch AL. Brütt JN MH.
  2. Data curation: AL. Bartsch JN.
  3. Formal analysis: AL. Bartsch JN.
  4. Funding acquisition: AB AL. Brütt MH.
  5. Investigation: AL. Bartsch JN.
  6. Methodology: AB AL. Bartsch AL. Brütt JN MH.
  7. Project administration: AB AL. Brütt MH.
  8. Supervision: AB AL. Brütt MH.
  9. Writing – original draft: AL. Bartsch.
  10. Writing – review & editing: AB AL. Bartsch AL. Brütt JN MH.

References

  1. 1. WHO. WHO report on the global tobacco epidemic, 2015: Raising taxes on tobacco 2015. Available from: http://www.who.int/tobacco/global_report/2015/report/en/.
  2. 2. WHO. WHO Framework Convention on Tobacco Control Geneva2003. Available from: http://www.who.int/fctc/text_download/en/.
  3. 3. AWMF. S3-Leitlinie Screening, Diagnostik und Behandlung des schädlichen und abhängigen Tabakkonsums [S3-Guideline Screening, diagnosis and treatment of harmful and addictive tobacco consumption]. 2015.
  4. 4. McRobbie H, Bullen C, Glover M, Whittaker R, Wallace-Bell M, Fraser T, et al. New Zealand smoking cessation guidelines. N Z Med J. 2008;121(1276):57–70. pmid:18574510
  5. 5. Fiore MC. US public health service clinical practice guideline: treating tobacco use and dependence. Respiratory Care. 2000;45(10):1200–62. pmid:11054899
  6. 6. Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2013;5.
  7. 7. Schneider S, Diehl K, Bock C, Herr RM, Mayer M, Lindinger P, et al. Terra incognita Hausarztpraxis–Smoking cessation counseling support in Germany's primary care. Sucht. 2014;60(3):175–87.
  8. 8. T.G. Grobe AK, S. Steinmann, J. Szecsenyi. Barmer GEK Arztreport 2015 Siegburg: Asgard-Verlagsservice GmbH; 2015. Available from: http://presse.barmer-gek.de/barmer/web/Portale/Presseportal/Subportal/Presseinformationen/Archiv/2015/150219-Arztreport-2015/PDF-Arztreport-2015,property=Data.pdf.
  9. 9. Ulbricht S, Meyer C, Schumann A, Rumpf H, Hapke U, John U. Provision of smoking cessation counseling by general practitioners assisted by training and screening procedure. Patient Education & Counseling. 2006;63(1–2):232–8.
  10. 10. Hoch E, Muehlig S, Höfler M, Lieb R, Wittchen H. How prevalent is smoking and nicotine dependence in primary care in Germany? Addiction. 2004;99(12):1586–98. pmid:15585050
  11. 11. AAFP. Clinical Preventive Service Recommendation American Academy of Family Physicians; 2016 [cited 2016 26.10.2016]. Available from: http://www.aafp.org/patient-care/clinical-recommendations/all/tobacco-use.html.
  12. 12. van Rossem C, Spigt MG, Kleijsen JR, Hendricx M, van Schayck CP, Kotz D. Smoking cessation in primary care: Exploration of barriers and solutions in current daily practice from the perspective of smokers and healthcare professionals. Eur J Gen Pract. 2015;21(2):111–7. pmid:25649048
  13. 13. Bock C, Diehl K, Schneider S, Diehm C, Litaker D. Behavioral counseling for cardiovascular disease prevention in primary care settings: a systematic review of practice and associated factors. Med Care Res Rev. 2012;69(5):495–518. pmid:22457269
  14. 14. Grant AM, Niyonsenga T, Dion I, Delisle E, Xhignesse M, Bernier R. Cardiovascular disease. Physician attitudes toward prevention and treatment. Can Fam Physician. 1998;44:780. pmid:9585851
  15. 15. Lennox AS, Taylor R. Smoking cessation activity within primary health care in Scotland: present constraints and their implications. Health Educ J. 1995;54(1):48–60.
  16. 16. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of internal medicine. 2009;151(4):264–9. pmid:19622511
  17. 17. Curd P, Pearce K, Schumacher K. Physician roles in improving cardiovascular health: counseling patients and involvement in the community. J Ky Med Assoc. 2004;102(9):433–42. pmid:15481905
  18. 18. Easton A, Husten C, Malarcher A, Elon L, Caraballo R, Ahluwalia I, et al. Smoking cessation counseling by primary care women physicians: Women Physicians' Health Study. Women & Health. 2001;32(4):77–91.
  19. 19. Goldberg RJ, Ockene IS, Ockene JK, Merriam P, Kristeixer J. Physicians’ attitudes and reported practices toward smoking intervention. Journal of cancer education. 1993;8(2):133–9. pmid:8363940
  20. 20. Pluye P, Robert E, Cargo M, Bartlett G, O’Cathain A, Griffiths F, et al. Proposal: A mixed methods appraisal tool for systematic mixed studies reviews. Montréal: McGill University. 2011:1–8.
  21. 21. Pace R, Pluye P, Bartlett G, Macaulay AC, Salsberg J, Jagosh J, et al. Testing the reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic mixed studies review. International journal of nursing studies. 2012;49(1):47–53. pmid:21835406
  22. 22. O’Cathain A. Assessing the quality of mixed methods research: Toward a comprehensive framework. Handbook of mixed methods in social and behavioral research. 2010:531–55.
  23. 23. Alomari MA, Khader YS, Dauod AS, Abu-Hammour KA, Khassawneh AH, Jibril NI. Smoking cessation counselling practices of family physicians in Jordan. Journal of Smoking Cessation. 2013;8(02):85–90.
  24. 24. Barengo NC, Sandstrom HP, Jormanainen VJ, Myllykangas MT. Attitudes and behaviours in smoking cessation among general practitioners in Finland 2001. Soz Praventiv Med. 2005;50(6):355–60.
  25. 25. Boldemann C, Gilljam H, Lund KE, Helgason AR. Smoking cessation in general practice: the effects of a quitline. Nicotine Tob Res. 2006;8(6):785–90. pmid:17132526
  26. 26. Crawford MA, Woodby LL, Russell TV, Turner TJ, Hardin JM, Harrington TM. Tobacco use assessment and counselling practices among Alabama primary care physicians. Quality in Primary Care. 2005;13(3):163–70.
  27. 27. Ganry O, Boche T. Prevention practices and cancer screening among general practitioners in Picardy (France). [French]. Bulletin du Cancer. 2004;91(10):785–91. pmid:15556879
  28. 28. Gokirmak M, Ozturk O, Bircan A, Akkaya A. The attitude toward tobacco dependence and barriers to discussing smoking cessation: a survey among Turkish general practitioners. Int J Public Health. 2010;55(3):177–83. pmid:20013142
  29. 29. Gottlieb NH, Guo JL, Blozis SA, Huang PP. Individual and contextual factors related to family practice residents' assessment and counseling for tobacco cessation. J Am Board Fam Pract. 2001;14(5):343–51. pmid:11572539
  30. 30. Helgason AR, Lund KE. General practitioners' perceived barriers to smoking cessation-results from four Nordic countries. Scand J Public Health. 2002;30(2):141–7. pmid:12028863
  31. 31. Hu S, McAlister AL, Meshack AF, Margolis JA. Physicians' views and practice of smoking cessation. Tex Med. 2003;99(11):57–63. pmid:14650722
  32. 32. Hung DY, Leidig R, Shelley DR. What's in a setting?: Influence of organizational culture on provider adherence to clinical guidelines for treating tobacco use. Health Care Manage Rev. 2014;39(2):154–63. pmid:23636103
  33. 33. Invernizzi G, Bettoncelli G, D'Ambrosio G, Zappa M, Calzolari M, Paredi P, et al. Carbon monoxide, cigarettes and family doctors. Tumori. 2001;87(3):117–9. pmid:11504362
  34. 34. Josseran L, King G, Velter A, Dressen C, Grizeau D. Smoking behavior and opinions of French general practitioners. J Natl Med Assoc. 2000;92(8):382–90. pmid:10992683
  35. 35. Katz A, Lambert-Lanning A, Miller A, Kaminsky B, Enns J. Delivery of preventive care: the national Canadian Family Physician Cancer and Chronic Disease Prevention Survey. Can Fam Physician. 2012;58(1):e62–9. pmid:22267643
  36. 36. Kim JS, Song MS, Oh HE. Predictors of tobacco-control activities of community health practitioners: report from a national survey. Taehan Kanho Hakhoe Chi. 2004;34(8):1443–50. pmid:15687786
  37. 37. Kossler W, Lanzenberger M, Zwick H. Smoking habits of office-based general practitioners and internists in Austria and their smoking cessation efforts. Wiener Klinische Wochenschrift. 2002;114(17–18):762–5. pmid:12416280
  38. 38. Kruger J, O'Halloran A, Rosenthal A. Assessment of compliance with U.S. Public Health Service clinical practice guideline for tobacco by primary care physicians. Harm Reduct J. 2015;12:7. pmid:25889679
  39. 39. Longo DR, Stone TT, Phillips RL, Everett KD, Kruse RL, Jaen CR, et al. Characteristics of smoking cessation guideline use by primary care physicians. Mo Med. 2006;103(2):180–4. pmid:16703721
  40. 40. McEwen A, West R. Smoking cessation activities by general practitioners and practice nurses. Tob Control. 2001;10(1):27–32. pmid:11226357
  41. 41. McEwen A, West R, Owen L, Raw M. General practitioners' views on and referral to NHS smoking cessation services. Public Health. 2005;119(4):262–8. pmid:15733685
  42. 42. McLeod D, Somasundaram R, Howden-Chapman P, Dowell AC. Promotion of smoking cessation by New Zealand general practitioners: a description of current practice. N Z Med J. 2000;113(1122):480–5. pmid:11198538
  43. 43. Meshefedjian GA, Gervais A, Tremblay M, Villeneuve D, O'Loughlin J. Physician smoking status may influence cessation counseling practices. Can J Public Health. 2010;101(4):290–3. pmid:21033533
  44. 44. Ng N, Prabandari YS, Padmawati RS, Okah F, Haddock CK, Nichter M, et al. Physician assessment of patient smoking in Indonesia: a public health priority. Tob Control. 2007;16(3):190–6. pmid:17565139
  45. 45. Nobile CG, Bianco A, Biafore AD, Manuti B, Pileggi C, Pavia M. Are primary care physicians prepared to assist patients for smoking cessation? Results of a national Italian cross-sectional web survey. Prev Med. 2014;66:107–12. pmid:24945695
  46. 46. O'Loughlin J, Makni H, Tremblay M, Lacroix C, Gervais A, Dery V, et al. Smoking cessation counseling practices of general practitioners in Montreal. Prev Med. 2001;33(6):627–38. pmid:11716660
  47. 47. Pipe A, Sorensen M, Reid R. Physician smoking status, attitudes toward smoking, and cessation advice to patients: an international survey. Patient Educ Couns. 2009;74(1):118–23. pmid:18774670
  48. 48. Schneider S, Diehl K, Bock C, Herr RM, Mayer M, Gorig T. Modifying health behavior to prevent cardiovascular diseases: a nationwide survey among German primary care physicians. Int J Environ Res Public Health. 2014;11(4):4218–32. pmid:24739770
  49. 49. Schnoll RA, Rukstalis M, Wileyto EP, Shields AE. Smoking cessation treatment by primary care physicians: An update and call for training. Am J Prev Med. 2006;31(3):233–9. pmid:16905034
  50. 50. Skoeries BA, Ulbricht S, Koepsell S, Rumpf HJ, John U, Meyer C. Readiness to provide smoking cessation counselling—results of a survey among general practitioners in Brandenburg [German]. Gesundheitswesen. 2010;72(4):228–32. pmid:19533584
  51. 51. Soto Mas FG, Papenfuss RL, Jacobson HE, Hsu CE, Urrutia-Rojas X, Kane WM. Hispanic physicians' tobacco intervention practices: a cross-sectional survey study. BMC Public Health. 2005;5:120. pmid:16287500
  52. 52. Squier C, Hesli V, Lowe J, Ponamorenko V, Medvedovskaya N. Tobacco use, cessation advice to patients and attitudes to tobacco control among physicians in Ukraine. European Journal of Cancer Prevention. 2006;15(5):458–63. pmid:16912576
  53. 53. Tanriover O, Hidiroglu S, Save D, Akan H, Ay P, Karavus M, et al. Knowledge of oral cancer, preventive attitudes, and behaviors of primary care physicians in Turkey. Eur J Cancer Prev. 2014;23(5):464–8. pmid:24584196
  54. 54. Varona P, Bonet M, Fernandez N, Canizares M, Roche RG, Ibarra AM, et al. Use of medical counseling for the prevention and control of smoking in the municipality of old Havana. J Urban Health. 2005;82(1):71–5. pmid:15738334
  55. 55. Young JM, Ward JE. Implementing guidelines for smoking cessation advice in Australian general practice: opinions, current practices, readiness to change and perceived barriers. Fam Pract. 2001;18(1):14–20. pmid:11145622
  56. 56. WHO. Global Health Professionals Survey 2005 [cited 2008 3 Sep]. Available from: http://www.who.int/tobacco/global_report/2015/report/en/.
  57. 57. Glasgow RE, Emont S, Miller DC. Assessing delivery of the five ‘As’ for patient-centered counseling. Health Promot Int. 2006;21(3):245–55. pmid:16751630
  58. 58. Podsakoff PM, MacKenzie SB, Lee J-Y, Podsakoff NP. Common method biases in behavioral research: a critical review of the literature and recommended remedies. Journal of applied psychology. 2003;88(5):879. pmid:14516251
  59. 59. Lawson PJ, Flocke SA, Casucci B. Development of an instrument to document the 5A's for smoking cessation. Am J Prev Med. 2009;37(3):248–54. pmid:19666161
  60. 60. Pbert L, Adams A, Quirk M, Hebert JR, Ockene JK, Luippold RS. The patient exit interview as an assessment of physician-delivered smoking intervention: a validation study. Health Psychol. 1999;18(2):183. pmid:10194054
  61. 61. Hummers-Pradier E, Scheidt-Nave C, Martin H, Heinemann S, Kochen MM, Himmel W. Simply no time? Barriers to GPs' participation in primary health care research. Family Practice. 2008;25(2):105–12. pmid:18417465
  62. 62. Asan O, Montague E. Using video-based observation research methods in primary care health encounters to evaluate complex interactions. Informatics in primary care. 2014;21(4):161. pmid:25479346
  63. 63. CAN-ADAPTT. Canadian Smoking Cessation Clinical Practice Guideline. Toronto, Canada: Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health.; 2011. Available from: https://www.nicotinedependenceclinic.com/English/CANADAPTT/Documents/CAN-ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf.
  64. 64. AWMF. S3-Guideline Screening, diagnosis and treatment of harmful and addictive tobacco consumption 2015. Available from: http://www.dg-sucht.de/fileadmin/user_upload/pdf/leitlilnien/AWMF_76-006_S3-Leitlinie_Tabak.pdf.
  65. 65. Coleman T, Wilson A. Anti-smoking advice in general practice consultations: general practitioners' attitudes, reported practice and perceived problems. Br J Gen Pract. 1996;46(403):87–91. pmid:8855014
  66. 66. Vogt F, Hall S, Marteau TM. General practitioners' and family physicians' negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction. 2005;100(10):1423–31. pmid:16185204