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Archived at the Flinders Academic Commons: http://dspace.flinders.edu.au/dspace/ This is the publisher's copyrighted version of this article. The original can be found at: http://www.publish.csiro.au/?act=view_file&file_id=PY06054.pdf 2006 Australian Journal of Primary Health Care Published version of the paper reproduced here in accordance with the copyright policy of the publisher. Personal use of this material is permitted. However, permission to reprint/republish this material for advertising or promotional purposes or for creating new collective works for resale or redistribution to servers or lists, or to reuse any copyrighted component of this work in other works must be obtained from Australian Journal of Primary Health Care. GPs' Confidence in and Barriers to Implementing Smoking Cessation
Activities: Compared to Dentists, Dental Hygienists and Pharmacists
David Edwards,1 Toby Freeman,2 John Litt3 and Ann M Roche4
Quality Use of Medicines and Pharmacy research Centre, University of South
Australia, and Quit SA, Cancer Council South Australia1
National Centre for Education and Training on Addiction and School of Psychology
Flinders University,2 department of General Practice, Flinders University3
National Centre for Education and Training on Addiction and School of Medicine,
GP smoking cessation interventions have been found to be highly efficacious. However, reported uptake is low, and little is known about barriers or comparisons with other health professionals. The objectives of this study were to examine GPs' provision of smoking cessation activities, confidence and perceived barriers, and compare the results to other health professions (dentists, dental hygienists and pharmacists). A random sample of South Australian GPs (n = 69) were surveyed. Comparisons were made with dentists, dental hygienists and pharmacists for whom similar data had been obtained. Participants were surveyed on their confidence, perceived barriers, level of smoking cessation activity and practice and demographic factors. GPs reported greater provision of and greater confidence in a range of brief smoking cessation interventions than other professions and perceived fewer barriers to the provision of smoking cessation activities. Confidence and system barriers were reported as the most common factors that impeded greater provision of smoking cessation activities. It was concluded that confidence and system barriers need to be addressed to increase rates of smoking cessation interventions provided by these professional groups. Skills-based training that develops confidence would be beneficial for all health professional groups and would increase the number of smokers receiving advice and assistance to quit smoking. Key words: Smoking, Tobacco, Prevention, Physicians
Tobacco is a leading cause of disease and death concerning smoking from GPs (Richmond, Kehoe, worldwide (Esson & Leeder, 2004). There is wide Heather, Wodak, & Webster, 1996) and perceive scope for the prevention of tobacco-related harm, higher quality of care when the GP does address and developing strategies to reduce harm is one of smoking (Kottke, Solberg, Brekke, Cabrera, & the most important goals for public health. Greater Marquez, 1997).
provision of consistent advice about smoking International clinical practice recommendations cessation across all health care providers would provide an evidence-based framework for smoking considerably reduce tobacco-related harm.
cessation in health care settings. The framework consists of the "5 As"; Asking about smoking, Smoking cessation interventions in the
Assessing dependence and readiness to change, health care setting
Advising, Assisting in quitting, and Arranging The efficacy of health professional interventions for referral or follow-up (Zwar et al., 2004).
smoking cessation is well established (Lancaster & However, uptake of smoking cessation activities Stead, 2004). Spending less than three minutes with among GPs in Australia has been poor, and has not a smoker can double the chance of a successful improved over the last decade (Humair & Ward, attempt to quit (Zwar et al., 2004). 1998; Litt, 2002). Humair and Ward videotaped GP Efforts to implement interventions in health consultations and observed that GPs identified and care settings have most often targeted GPs intervened with less than a third of smokers, and (Roche & Freeman, 2004). GPs are influential and spent less than one minute, on average, discussing credible (Pieterse, Seydel, DeVries, Mudde, & Kok, smoking. In a survey of 1000 smokers attending 2001), patients are comfortable receiving advice GPs, only 18% of smokers had ever been handed Australian Journal of Primary Health — Vol. 12, No. 3, December 2006 David Edwards, Toby Freeman, John Litt and Ann M Roche a Quit book by their GP and only 10% had been and lack of skills. Smoking cessation activities referred to the Quitline (Litt, Pilotto et al., 2003).
were compared among physicians, dentists, Research has indicated that several barriers dental hygienists, mental health counsellors and have hindered the uptake of smoking cessation counsellors on a specific program (Secker-Walker, interventions in general practice. System-level Chir, Solomon, Flynn, & Dana, 1994). Physicians barriers include lack of time (Gottlieb, Guo, Blozis, reported considerably higher rates of intervening, & Huang, 2001; Wiggers, Sanson-Fisher, & Ring, advising and assisting patients than the other 1997), difficulty identifying smokers (Gottlieb et al.; professions. In a survey of smokers in the general Wiggers et al.), lack of support (Litt, Ling, & McAvoy, population, Tomar, Husten and Manley (1996) 2003; Young & Ward, 2001) and lack of incentives found that smokers reported receiving advice to (Pieterse et al., 2001; Young & Ward). Practitioner quit smoking from physicians twice as often as barriers include lack of interest (McAvoy, Kaner, compared to dentists.
Lock, Heather, & Gilvarry, 1999; Young & Ward), lack of skills and training (McIlvain, Backer, The current study
Crabtree, & Lacy, 2002), and negative attitudes Very little is known about current comparative towards smoking cessation interventions (McIlvain rates of advice and assistance between health et al.; Wigger et al.). Patient barriers include the professions and differences in perceived barriers patient not being interested in quitting (Coleman and confidence. This study was designed to & Wilson, 1999), and infrequently requesting help address that gap. Smoking cessation activities (Borland, Pigott, Rintoul, Shore, & Young, 2002).
amongst GPs—their level of confidence, readiness After several decades of concerted effort to to change smoking cessation activities and engage GPs in smoking cessation interventions, perceived barriers—were examined. The impact discouraging levels of involvement have prompted of confidence and barriers on smoking cessation examination of possible additional intervention activity was also examined. These results were agents. All health professions could potentially play compared to three other professional groups a role in addressing smoking amongst their patients (dentists, dental hygienists and pharmacists) for through offering advice and support to quit smoking whom similar data had also been obtained. (Ministerial Council on Drug Strategy, 2004). Upskilling other health professionals in smoking cessation in addition to GPs has several benefits. Participants and procedures
Firstly, the more professions that routinely deliver The questionnaire was mailed to all 590 general smoking cessation interventions, the wider the practitioners registered in South Australia with the population of smokers who will receive assistance Royal Australian College of General Practitioners from at least one health professional. Secondly, (SA Branch). Only participants working at least other professionals may not experience as many two sessions per week were included to ensure barriers to implementation as GPs, and hence may responses reflected current general practice be able to achieve greater rates of uptake (Roche & Freeman, 2004). Thirdly, if multiple delivery agents After three weeks a reminder postcard was are employed, smokers may receive consistent sent to non-respondents. A second copy of the quit smoking messages from more than one health questionnaire and letter of endorsement was professional, which may increase the motivating sent a further two weeks later. Three weeks after effects of the advice.
the second mail-out a random sample of non- Few studies have undertaken cross-disciplinary respondents were telephoned (n = 153). examinations of smoking cessation activities. The little data available comparing uptake or barriers between professions come mainly from The activity, barriers and readiness to change scales the United States. Perez-Stable et al.(2001) found were adapted from measures developed for the that physicians were more likely to intervene with GASP program (Litt et al., 2005). The following smoking parents than paediatricians, who were measures were included: more likely to perceive barriers to smoking cessation Background variables – variables measured activities, including poor patient receptiveness included personal characteristics (age, gender, Australian Journal of Primary Health — Vol. 12, No. 3, December 2006 GPs' Confidence in and Barriers to Implementing Smoking Cessation Activities: Compared to Dentists, Dental Hygienists and Pharmacists smoking status, smoking cessation education or Five items measured practitioner barriers training) and practice characteristics (solo or group addressing personal factors such as "Lack practice, consulting hours per week, number of of necessary skills to assist patients to quit" patients seen in the last week, average consultation (Cronbach's alpha .72).
length, display of Quit materials).
Four items measured patient barriers addressing Confidence – confidence was defined as the management of patients or patients' attitudes health professionals' self-efficacy beliefs regarding (Cronbach's alpha .81). An example item is smoking cessation activity. Eight items assessed "Patients don't want to discuss quitting".
confidence in undertaking different aspects of The same questionnaire (modified slightly to suit smoking cessation interventions (see Table 5, specific health professional groups) was distributed response scale: 1 "Not confident" to 5 "Extremely simultaneously to all dentists (N = 621), dental confident"). Internal consistency was high hygienists (N = 70) and pharmacists (N = 691) (Cronbach's alpha: .80).
registered in South Australia during the same time Readiness to change – Participants were asked to period. The administration of the questionnaire was select one of three options: that they didn't see a need identical and all measures were comparable across to change the way they provided smoking cessation professional groups. Measures of confidence, services, that they were seriously thinking about readiness to change, and system, practitioner changing in the next six months or that they had and patient barriers, and most items measuring already initiated changes in the last six months.
activity were the same across professional groups, Smoking cessation activity – six scales addressed with the exception of minor wording changes to smoking cessation activity based on the 5As and reflect the setting. Some activity items concerning an additional measure of follow-up activity. A nicotine replacement therapies, Zyban, linking the 5-point Likert scale was used (1 "Never" to 5 advice to the presenting problem and referring "Always"). Recording smoking status was measured to the Quitline were modified slightly for some with one item, "Record smoking status on file". professions to reflect issues such as ability to Recording smoking status was chosen rather than prescribe and other professional factors.
asking about smoking as it is a more concrete behaviour. Advising was measured by three items: giving brief advice to quit, linking advice to the Demographic factors were compared between presenting problem, and discussing the effects of GPs, dentists, dental hygienists and pharmacists, smoking on other family members (Cronbach's and between the current sample of GPs and alpha .70). Assessing was measured using two national labour force estimates (Britt et al., 2004) items, "Assess interest in quitting" and "Assess the using chi-squared and t-tests. Confidence, barriers level of nicotine dependence" (Cronbach's alpha and smoking cessation activities were compared .53). Assisting the patient to quit smoking was between professions using t-tests. Relationships measured by six items addressing strategies such between these variables were examined using as setting a quit date, developing a cessation plan standard multiple regression analyses on a and providing Quit materials (Cronbach's alpha combined measure of activity (calculated from .68). Arranging was measured using four items the mean of all activity items, Cronbach's alpha addressing referrals to the Quitline or a Quitline 0.87 for GPs). To include readiness to change as program and recommending nicotine replacement a dichotomous variable in the regression analysis, therapy or Zyban (Cronbach's alpha .54). Follow- the responses "seriously thinking" and "already up was measured with one item, "Follow-up on initiated" were combined.
progress in giving up smoking". Barriers to providing smoking cessation activities – 17 items assessed system, practitioner and patient barriers to service provision. The The total number of respondents was 269 general perceived importance of each barrier was assessed practitioners. In 18 cases the questionnaire was not on a 5-point Likert scale (1 "Not a barrier at all" to completed; two had retired, seven were no longer 5 "A major barrier"). Eight items measured system practising and nine questionnaires were returned barriers (see Table 5, Cronbach's alpha .87).
"not completed" or "not at this address", resulting Australian Journal of Primary Health — Vol. 12, No. 3, December 2006 David Edwards, Toby Freeman, John Litt and Ann M Roche in a final response rate of 47%. in a solo practice, equivalent to the national labour Response rates for the comparator groups were: force estimate (Britt et al., 2004) (11%) (c2(1, n = dentists 54% (N = 334), dental hygienists 83% (N 1,252) = 0.47, p = 0.49) and 238 (89%) worked in = 58) and pharmacists 48% (N = 331). Dentists a team with more than one general practitioner. and dental hygienists were representative of the Five respondents were locums. national population in terms of gender and public Just over half of general practitioners employed or private sector. Dentists were younger than the a practice nurse (n = 156, 59%), equivalent to the national sample and worked fewer hours per national labour force estimate (Britt et al., 2004) week. Dental hygienists were representative of the (58%) (c2(1, N = 1,262) = 0.01, p = 0.92).
national sample on age, but also worked fewer GPs in the current sample were younger than hours per week. Pharmacists were representative the national (Britt et al., 2004) average (c2(3, n = of the national population in hours worked 1,265) = 71.49, p < .001), 57% were aged 44 years or per week, but were younger than the national less. GPs in the current sample worked fewer hours per week compared to the national labour force population; female pharmacists were slightly estimate (Britt et al.) (c2(3, n = 1,234) = 35.65, p < .001), 71% worked 40 hours or less per week. Means and standard deviations for demographic variables by profession are shown in Table 1. GPs Of the 269 general practitioners, 159 (59%) were saw two to four times as many patients per week male and 109 (41%) were female, significantly than either dentists or dental hygienists. This was different to the national labour force estimate (Britt not measurable for pharmacists. Conversely, GPs et al., 2004) (c2(1, N = 1,268) = 5.95, p = .015), had the shortest consultation time, less than half which comprises 67% males (46).
that of dentists, and less than a third of the time The majority of general practitioners had hygienists spent with each patient.
never smoked (77%, n = 207). Only six (2%) were current smokers—well below the national Smoking cessation activities and barriers
prevalence rate of 17% (Australian Institute of Means and standard deviations for confidence, Health and Welfare, 2005).
barriers and smoking cessation activities by Twenty-four general practitioners (9%) worked profession are shown in Table 1. GPs reported Table 1: Means (and standard deviations) for demographic variables, confidence, activities and barriers by profession
Variable (Number of items) GPs (N = 269) Dentists (N = 334) Hygienists (N = 58) Pharmacists (N = 265) F Years in practice Patients per week Hours worked /week Consult length (mins) System barriers (8) Prof. barriers (5) Patient barriers (4) Note: N/A = Not applicable (not asked in the questionnaire). Means with the same alphabetical subscript were not significantly different using Tukey's HSD test. All ANOVA results remained significant after Bonferroni adjustment for multiple testing.
***
p < .001 Australian Journal of Primary Health — Vol. 12, No. 3, December 2006 GPs' Confidence in and Barriers to Implementing Smoking Cessation Activities: Compared to Dentists, Dental Hygienists and Pharmacists Table 2: Education or training in smoking cessation and levels of readiness to change by profession
GPs (N = 269) Dentists (N = 334) Hygienists (N = 58) Pharmacists (N = 265) c2(df=3) Smoking cessation education/training No need to change practice Seriously thinking about change Already initiated change Note: Means with the same alphabetical subscript were not significantly different using post hoc Bonferroni adjusted pairwise comparisons.
***
p < .001 the highest level of confidence and lowest level on the activity scale. None of the factors was of barriers relative to the other three health significant; hence, they were excluded from the professional groups. main analysis.
GPs had the highest overall activity followed The standardised (b) and unstandardised (B) by pharmacists and dental hygienists, with dentists regression coefficients for the main regression reporting the least activity. GPs and dental hygienists analysis are presented in Table 3. Confidence were the most active recorders of smoking status, emerged as the most important predictor of GPs and pharmacists were the most active health smoking cessation activities, followed by system professionals in assessing nicotine dependence barriers. Overall, the variables accounted for 33% and readiness to quit, and GPs were most active of variance in the smoking cessation activities.
in advising and following up on patient progress The standardised (b) and unstandardised (B) with quitting. Pharmacists were the most active regression coefficients for the most important group in regard to arranging referrals.
predictors of smoking cessation activity across the GPs indicated high levels of readiness to change four professional groups are presented in Table their smoking cessation activities (see Table 2 4. Confidence emerged as the most important below). Fewer GPs saw no need to change their predictor of smoking cessation activity across all current practice compared to dentists, and more Table 3: Multiple regression analysis for the smoking
GPs had already initiated changes to their provision cessation activities of GPs
of smoking cessation activities compared to dentists and pharmacists.
More GPs had received smoking cessation education or training (32%) compared to the other professions. Dentists reported the least education Education or training and training and the least interest in changing their Readiness to change provision of smoking cessation activities.
Standard multiple regression analyses were run on the combined activity measure. Practice Practitioner barriers factors, including whether it was a solo or group practice, consulting hours per week, patients Note: B are unstandardised coefficients, b are standardised per week, consultation length and whether the practice employed a practice nurse, were regressed * p < .05, ** p < .01, *** p < .001 Table 4: Comparison of multiple regression analysis results for the smoking cessation activities of GPs, dentists,
dental hygienists and pharmacists

GPs (N =269) Dentists (N = 334) Hygienists (N = 58) Pharmacists (N = 265) a approached significance (p=.056) b approached significance (p=.09)Note: B are unstandardised coefficients, b are standardised coefficients. Australian Journal of Primary Health — Vol. 12, No. 3, December 2006 David Edwards, Toby Freeman, John Litt and Ann M Roche Table 5: Mean ratings of importance (and standard deviations) of confidence and system barriers for GPs
Confidence (5 = extremely confident) Raise smoking issues when they are related to the visit Discuss patient readiness to change smoking behaviour Use brief advice to help people quit Assess nicotine dependence and recommend therapies Raise smoking issues when not related to the visit Spend additional time assisting patients who are having difficulties with the quitting process Increase patient motivation to quit using specific counselling strategies Engage all staff members in a process to develop systems for smoking cessation. System barriers (5 = a major barrier ) Insufficient financial incentives for time spent No coordinated plan to implement protocols/guidelines Lack of feedback on patient progress Lack of smoking cessation protocols/guidelines Lack of knowledge of other support services Lack of printed resources Lack of reminders of patient smoking status Note: All items were measured using a 5-point Likert scale ranging from 1 ("Not confident"/"Not a barrier") to 5 ("Extremely confident"/"A major barrier"). groups. Practitioner factors were significant for improve confidence levels. Education and training dentists and dental hygienists, and approached alone is not sufficient; Richmond, Mendelsohn significance for pharmacists, while system barriers and Kehoe (1998) found that lack of confidence were significant for dentists and general practitioners was still quite low following training in effective and approached significance for dental hygienists.
behavioural techniques to assist smokers. GPs' confidence and system barriers were GPs are ahead of other health professional analysed to identify the specific issues perceived groups in terms of uptake of smoking cessation to be of highest importance (see Table 5). General activities. There may be several reasons for this, practitioners were least confident about engaging including GPs' higher rate of smoking cessation staff members in a process to develop systems education and training compared to the other for smoking cessation and increasing patient professions surveyed, and arguably having greater motivation using specific counselling strategies. resources to draw upon (such as being able The practitioner barriers perceived to be most to prescribe Zyban) and greater knowledge of important were lack of time and lack of financial potential co-morbidities and health effects. GPs incentives for spending time on smoking. also reported fewer barriers to activity. However, many smokers are still not receiving smoking cessation advice and assistance from their GP (Humair & Ward, 1998; Litt, Pilotto et al., 2003). This study is the first Australian research to (1) There is still room to improve uptake of smoking compare GPs' self-reported smoking cessation cessation interventions. In particular, the more activities to other professional groups, namely proactive strategies of assisting patients to quit and dentists, dental hygienists and pharmacists, and arranging referrals to services such as a quitline (2) compare confidence in and barriers to smoking are under-utilised. Given the effectiveness of quit cessation activities among these professions. lines for smokers (Stead, Lancaster, & Perera, 2004), Confidence emerged as the major predictor of interventions with GPs should focus attention on provision of smoking cessation activities to patients these strategies in order to maximise the impact across all professions. If confidence is a pivotal GPs could have on smoking cessation rates among factor, then questions arise regarding how to their patients.
Australian Journal of Primary Health — Vol. 12, No. 3, December 2006 GPs' Confidence in and Barriers to Implementing Smoking Cessation Activities: Compared to Dentists, Dental Hygienists and Pharmacists The system barrier rated as most important Limitations of the study
by GPs was lack of time to discuss smoking. While the GP sample in the present study matched Strategies that address or acknowledge the limited national labour force estimates on variables opportunistic time available to GPs (Jaen et al., such as solo or group practice, and employing a 2001) and reflect the current time they devote to practice nurse, the current sample were younger, smoking cessation (Humair & Ward, 1998) are worked fewer hours per week and had a higher more likely to be acceptable and adopted (Jaen proportion of females than the national estimate et al., 2001; Litt, 2002).
(Britt et al., 2004). These differences, in addition GP implementation of effective smoking to the low response rate for GPs, suggest that the cessation activities could be improved by: current sample may represent those GPs most likely to intervene with their smoking patients. • improved smoking cessation training and Consequently, findings from this sample should education (Lancaster, Silagy, & Fowler, 2004) best be viewed as "as good as it gets" for GPs' • clinical systems that provide a supportive practice smoking cessation activities.
infrastructure (McIlvain et al., 2002) While the current findings are applicable to South Australia and may be applicable to other • developing and implementing organisational Australian states and territories, similar research policies that are conducive to smoking cessation is needed internationally to examine global activity (Litt, Ling, & McAvoy, 2003).
similarities and differences. Although Pieterse et al. (2001) suggest that barriers to uptake of smoking cessation interventions among GPs may The majority of GPs, dental professionals and be universal, there is not a strong evidence base pharmacists reported willingness to engage in to support this, and it is likely that variation in smoking cessation activities. Hence, there is systemic barriers exists between countries.
opportunity to increase levels of smoking cessation The general criticism of self-reported measures activity. Increasing the range of health professionals of behaviour applies—that participants' reported skilled and prepared to respond to smoking would levels of behaviour may not equate to real increase the chances of every smoker receiving behaviour. Previous evidence suggests that GPs advice and assistance to quit smoking from a health tend to over-report their prevention activities (Wilson & McDonald, 1994). However, this can In order to achieve increased participation of only be addressed through the observation of health professionals in smoking cessation activities, participants' behaviour, which presents many challenges and is beyond the scope of this research. the key barriers identified in this study need to be The self-report measures used in this study are not addressed—in particular levels of confidence. established scales, but rather were adapted from A key strategy to increase confidence and the GASP program (Litt, Pilotto et al., 2005). Hence, skills among health workers is the provision of internal consistencies were the only psychometrics education and training. Less than one-third of the available, and these are not necessarily appropriate South Australian GPs indicated they had received for judging reliability. Since the activity measures education and training in smoking cessation, are indexes of different behaviours, rather than and rates were even lower among the other scales, participant responses are not expected to professions. This is a serious deficit that must be be homogenous across items (Streiner, 2003). What Cronbach's alphas may be indicating in this case This study demonstrates that many of the issues is that GPs use different assessing and arranging which affect health workers' smoking cessation strategies to different degrees (moderate alphas), activities are common across professional groups. where their use of advising and assisting strategies Hence, there may be benefits in adopting a are more uniform (high alphas). Future research systematic and coordinated approach that addresses may be able to build on the current findings by common issues across professional boundaries, as developing validated instruments and examining in the Clinical Tobacco Intervention Program based possible methods of ascertaining estimates of actual in Ontario, Canada (www.ctica.org).
Australian Journal of Primary Health — Vol. 12, No. 3, December 2006 David Edwards, Toby Freeman, John Litt and Ann M Roche prevention strategy. If the deficits identified by this study were addressed, the contribution GPs Increasing the consistency of provision of smoking and other health professionals could make to the cessation advice across health providers would prevention of smoking-related harm would be maximise the public health benefits of this essential references
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David Edwards Quit SACancer Council South AustraliaPO Box 929Unley South Australia 5061 AUSTRALIAEmail: dedwards@quitsa.org.au Toby Freeman National Centre for Education and Training on AddictionSchool of PsychologyFlinders University GPO Box 2100Adelaide South Australia 5001AUSTRALIA John Litt Department of General PracticeFlinders UniversityGPO Box 2100Adelaide South Australia 5001AUSTRALIA Ann M Roche National Centre for Education and Training on AddictionFlinders University GPO Box 2100Adelaide South Australia 5001AUSTRALIA Correspondence to David Edwards Australian Journal of Primary Health — Vol. 12, No. 3, December 2006
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    The Brain and Fatigue : New Opportunities for Nutritional Romain Meeusen1, Phil Watson2 , Jiri Dvorak3 1. Dept Human Physiology & Sportsmedicine - Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels , Belgium 2. School of Sport and Exercise Sciences, Loughborough University, Leicestershire, LE11 3TU, 3. Dept Neurology and F-MARC (FIFA Medical Assesment and Research Center) Schulthess