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Abstract

Medications for smoking cessation can double quit rates but are underused in primary care. This qualitative study aimed to explore: (1) patients’ perspectives regarding having their general practitioner (GP) use a proactive approach to smoking cessation treatment using an encounter decision aid (DA), and (2) their expectations regarding their GP’s role. We conducted qualitative semi-structured interviews with participants of the FIRST randomized trial (adults who smoke daily with any level of motivation for tobacco quitting). In the FIRST study, the intervention was a half-day course teaching GPs to use a proactive approach using a DA. Control GPs received a 1-h refresher training. Phone interviews were run 5-16 weeks after a routine visit with their GP. A thematic data analysis was performed with 20% double independent coding. We conducted 20 semi-structured interviews (mean age 49 years, 55% female). In the intervention group (n = 12), 7 participants appreciated the DA, saw it as useful, usable, and valuable. Two participants did not find it helpful and 3 did not recall having used it. Participants felt their GP provided moral support, more than from a specialist (cardiologist or pulmonologist) because their GP knows them better and has more time during the visit. They felt that the most important factor influencing smoking cessation was their own motivation, not treatment. Most participants appreciated the DA. Most participants did not perceive medications as part of quitting. They thought quitting was a matter of motivation. A DA could be an acceptable way to encourage use of treatments to aid with tobacco cessation. An early presentation of treatment options to all persons who smokes may encourage them to request a treatment when ready to quit smoking. Patient perceptions of the role of GPs and treatments for smoking cessation may be a barrier to seeking help to quit.

Keywords

primary care smoking cessation decision aid

Introduction

Tobacco use is the leading cause of preventable morbidity and mortality in industrial countries. In Switzerland (8.7 million inhabitants), around 2 million people have smoked in the last 30 days and tobacco use causes 9500 premature deaths every year, mostly due to cardiovascular disease (34%) and lung cancer (29%).¹

The U.S. Preventive Services Task Force (USPSTF) recommends that doctors ask all adults about tobacco use, advise them to stop using tobacco and provide behavioral interventions and approved pharmacotherapy for cessation. This is a strong recommendation with high certainty that the net benefit is substantial (Grade A).² The Swiss clinical prevention program “EviPrev” makes the same strong recommendation.³ General practitioners (GPs) play an important role in tobacco cessation. Evidence shows a graded effect, with increasing benefit from brief advice, more intensive individual counseling, and counseling plus medications.⁴ When compared with placebo, medications for smoking cessation, especially combination therapy (short and long-acting nicotine replacement together) and varenicline can double or triple quit rates.⁵

Despite these strong recommendations, previous studies in Switzerland showed that only 13% to 19% of patients who smoke surveyed had been offered a cessation aid, most often nicotine replacement therapy.^6,7 In the US, patients are less likely to receive treatments (including behavioral counseling) for smoking cessation than for other cardiovascular risk factors such as hypertension, diabetes or hypercholesterolemia.⁸ The situation seems to be similar in Switzerland.

GPs in Switzerland assess patients’ readiness to quit smoking (precontemplation, contemplation, preparation and action stages) and use the technique of motivational interviewing. Generally, only patients who have expressed a clear desire to quit smoking will receive information about different existing methods to help them. This reflects the 5A’s approach used during decades of teaching.^9-11 However, motivation to quit before a routine consultation only partially predicts tobacco abstinence or the desire to discuss quitting.^12-14 It means that we should proactively invite every person who smokes to speak about tobacco cessation and offer them assistance to quit smoking with behavioral interventions or medication even if they don’t have plans to quit soon.

We conducted a cluster randomized controlled trial, the FIRST study (Combining Default Choices and an Encounter Decision Aid to Improve Tobacco Cessation in Primary Care Patients: A Pragmatic, Cluster-Randomized Trial), which aimed to increase smoking cessation rate.¹⁵ In the intervention group, GPs received a half-day training course. The first part of the course consisted of a general reminder of the proven methods to help people stop smoking. The second part encouraged GPs to discuss smoking cessation treatments with every person who smokes and not only with those motivated and ready to stop. It is the concept of “default choice” or “opt-out care.”^16,17 To help the discussion with the patient and promote shared decision making (SDM), we developed a decision aid (DA) showing the different recognized methods to help to quit smoking: nicotine replacement therapies, varenicline, bupropion and electronic cigarettes. Treatment efficacy, adverse effect profiles and prices can be compared. This DA exists in French in an online¹⁸ and paper format. In the control group, GPs received only the first part of the training course (a general reminder of proven methods to help people stop smoking). They did not receive the DA and we did not teach them to be more proactive to speak about treatment options.

The FIRST study’s hypothesis was that more participants will quit smoking at 6 months after attending their routine visit with GPs in the intervention group (proactive discussion of treatments and use of our DA) than among patients of GPs of the control group.

This qualitative study, nested in the FIRST randomized trial, aimed to explore the reactions of a purposive sample of patients to the discussion they had with their GPs about smoking cessation during routine consultations. In the intervention group, we asked patients about the acceptability of a more proactive offering of treatment and the helpfulness of a decision aid to understand the different treatment options. In both intervention and control groups, we explored patients’ expectations regarding the role of their GP in tobacco counselling and whether patients liked to be prescribed a medication to help them to quit.

Methods

Design and setting

As part of the FIRST cluster randomized controlled trial,¹⁵ we conducted cross-sectional qualitative semi-structured interviews with study participants in both arms to explore the acceptability of the intervention and patients’ expectations regarding the role of their GP in tobacco cessation counselling (Figure 1).

Figure 1.

Description of the communication approach used by GPs in the control and intervention groups of the FIRST study.

Our protocol was approved by the ethics committee of the canton of Vaud in February 2021 (Project ID 2020-02898). We followed the COnsolidated criteria for REporting Qualitative research (COREQ) standards (Appendix 1).

Participants

Inclusion criteria were identical to those of patients involved in the FIRST study. They were to be ≥18 years of age, to use tobacco daily (cigarettes, cigars, smokeless tobacco) and to consider the GP randomized to be their primary care physician. Participants therefore had a previous therapeutic relationship with their GP, ranging from months to years (exact duration not recorded). Exclusion criteria were those consulting for an urgent complaint that prevented even a brief discussion about smoking cessation, the inability to follow the procedures of the study (eg, unable to read French-language consent materials, severe psychiatric disorders, dementia), previous enrolment in a smoking cessation trial during the last year or current daily use of a pharmacologic smoking cessation aid.

Participants in the FIRST study were recruited by their GP during routine primary care visits. All participants signed a consent form for their participation in the study. 3 weeks after this visit, they were contacted by the study team and asked about features of this visit, whether they had attempted to quit smoking since, and whether they would be willing to participate in an option interview for this qualitative study, which 54% of trial participants accepted. Participants knew that we were evaluating the effectiveness of the training given to their GP on smoking cessation but did not know the nature of the training program.

For this optional interview, patients received a compensation of 50 Swiss francs. We didn’t repeat any interviews.

We selected a purposive sample of patients in the intervention and control groups, of different gender and age, and among patients who had quit smoking and patients who had not. As the interview was optional, motivation of patient to participate was essential. We conducted interviews until thematic data saturation was reached.¹⁹

Data collection

We conducted the interviews between November 2021 and October 2022. The semi-structured interview guide was written by the FIRST study authors and was adapted during the study according to the interest of the themes highlighted (Appendix 2).

Interviews were recorded over the telephone. Audio recordings were transcribed by a person external to the study. Transcripts were not returned to participants for comment. Participants did not provide feedback on the findings. No interviews were repeated.

The interviews were conducted by a female physician (AB), member of the FIRST research team, who has previously been trained for semi-structured interviewing. AB is the first author of this article.

Data analysis

We analyzed the interviews using thematic data analysis assisted by MAXQDA 2022 software. Themes were identified in advance depending on the research questions. We did 20% double independent coding. The 2 data coders were physicians from the research team FIRST and one of those conducted the interviews. A research fellow external to the FIRST project performed an investigator triangulation, meaning that a third, independent researcher, reviewed the title of the assigned codes to ensure they represented the text in quotes.

Results

Participant characteristics

Among the 20 participants, 8 were in the control and 12 in the intervention group. We selected more participants in the intervention group to explore the acceptability of our DA. Participant characteristics are described in Table 1. Mean age was 49 years, 55% were female, most participants were strongly dependent on nicotine (at baseline), reflected in the number of cigarettes smoked per day or the time to first cigarette in the morning.²⁰

Table 1.

Characteristics of patients who are current smokers who participated in the study.

Number of participants	n = 20
Control group, n (%)	8 (40%)
Intervention group, n (%)	12 (60%)
Gender, n (%)
• Female	11 (55%)
• Male	9 (45%)
Age range (years), n (%)
• 20 to 40	6 (30%)
• 41 to 60	10 (50%)
• ≥61	4 (20%)
Nationality, n (%)
• Swiss	14 (70%)
• Other European countries	5 (25%)
• North Africa	2 (10%)
Education, n (%)
• Never attended high school	2 (10%)
• Apprenticeship	7 (35%)
• High school	3 (15%)
• University	8 (40%)
Number of cigarettes smoked per day, n (%)
• ≤10	6 (30%)
• 11 to 20	4 (20%)
• 21 to 30	7 (35%)
• ≥31	3 (15%)
Time to first cigarette in the morning, n (%)
• ≤5 min	3 (15%)
• 6 to 30 min	9 (45%)
• 31 to 60 min	4 (20%)
• ≥61 min	2 (10%)
Ever used a smoking cessation treatment (medications (nicotine replacement, etc.), electronic cigarettes, and other treatments), n (%)
• Yes	8 (40%)
• No	11 (55%)
• No answer	1 (5%)
Quit smoking during study follow up, n (%)
• Yes	6 (30%)
• No	14 (70%)

Setting and interview characteristics

The average delay between the inclusion in the FIRST study after the patient’s routine visit with his GP and the semi-structured interview was 8.5 weeks (min. 5 and max. 16 weeks and 60% between 5 and 8 weeks). The average interview length was 15.5 min (min. 4.8 and max. 26.1 min).

Themes

The themes and sub-themes explored during the semi-structured interview are described in Table 2.

Table 2.

Themes and sub-themes raised in semi-directed interviews (n=20, of whom 12 were in the intervention group of the FIRST study).

Themes	Sub-themes
Acceptability of the decision aid used in the intervention group (n = 12)	• Decision aid was useful, usable and valuable (n = 7/12)
	• Decision aid was not useful (n = 2/12)
	• Do not recal using the decision aid (n = 3/12)
Characteristics of the consultations (n = 20)	• Most patients discussed tobacco cessation (n = 15: 5 in control group and 10 in intervention group)
	• Half specifically discussed quit aids for tobacco cessation (n = 9: 2 in control group and 7 in intervention group)
	• Discussions in the intervention group were more treatment-oriented
Patients’ expectations regarding the role of clinicians in tobacco counselling (n = 20)	• The influence of the general practitioner (n = 7 in control group and n = 12 in intervention group)
	• The influence of the specialists (pneumologist, cardiologist) (n = 5 in control group and n = 7 in intervention group)
	• General willingness to receive a medication:
	• Yes (n = 2 in control group and n = 5 in intervention group)
	• No (n = 4 in control group and n = 7 in intervention group)
Barriers and facilitators of quitting smoking (n = 20)	• Facilitators due to the health benefits of quitting (n = 11) and social motivation (n = 9)
	• Barriers linked to psychological dependence (n = 12), to fear of physical (n = 6) or psychological (n = 4) changes and to costs (n = 2)
	• Advantages (n = 6) and disadvantages (n = 15) of the electronic cigarette

Acceptability of the decision aid used in the intervention group

Among the 12 patients in the intervention group (I), 7 participants appreciated the DA, saw it as useful, usable and valuable.

I found [the DA] very useful because on one screen we had [] an impressive quantity of alternatives. All of them well classified. There are for example the patches, I said: “no thank you” []. I’ve already used a lot of methods, but I found the presentation very good. (PT05 (I), pos. 35)

It was on an A4 sheet, there were all the substitutes listed with the prices []. It was well detailed, there were between 10 and 15 alternatives. (PT116 (I), pos. 21)

[My GP] explained to me the whole combination, everything that exists and it’s true that I may have had some preconceived ideas []. I realized that I wasn’t at all up to date and that I didn’t know what treatments are available today and what could be good. (PT66 (I), pos. 19)

Two participants did not find the DA helpful: because they thought they already had all the knowledge on the subject or found the information very generic. Three did not recall using the DA during the visit.

I didn’t really get it because it was nothing new to me. I didn’t discover anything. (PT19 (I), pos. 25)

Discussion about tobacco

In the intervention group (I) and the control group (C), most participants discussed smoking cessation during their consultation. In the intervention group, this discussion was mostly treatment-oriented. This was judged as open and non-judgmental.

I didn’t feel ready to stop, so we didn’t go into too much detail [about smoking cessation]. (PT18 (C), pos. 9)

[My GP] proposed that I consider all of the solutions, she showed me on her computer: the patches, the chewing gums, the tablets and also the electronic cigarette (PT14 (I), pos. 23)

I found that [my GP] approached it with a perspective that was [] more relaxed than usual, far from the perspective that we usually have on these subjects: “Ah it’s not very good” which is moralistic. He had a rather open perspective. (PT66 (I), pos. 11)

It was open, it was well discussed, it was non-judgmental on his part that I was smoking. So it’s been a pretty convivial discussion. (PT69 (I), pos. 17)

As I was a smoker of 3-4 cigarettes maximum per day, [my GP] felt willpower was more important [to help me to stop]. (PT22 (C), pos. 25)

Patients’ expectations regarding the role of clinicians in tobacco counselling

Participants in both groups felt their GP was an important support to help them stop smoking. However, they expected their GP to give moral support rather than specific treatments. Quitting smoking, to them, was an individual, personal process that they had to overcome.

[My GP] is a very good listener and that’s very important to me. We can really talk [], he’ll guide me to what suits me best. (PT18 (C), pos. 61)

[My GP] helps me in theory, but in practice I must make the effort []. He is an excellent moral support. (PT17 (C), pos. 65)

The influence [of my GP] isn’t huge, because he’s more an influence on the way to stop, but in terms of choice, he’s not. (PT69 (I), pos. 67)

Participants expected more help from their GP than from a specialist (cardiologist or pulmonologist) because their GP knows them better and has more time to talk during visits. Four participants discussed the benefits of hypnosis to help them to stop smoking. They perceived hypnosis to be a good psychological support against addiction.

I only see a cardiologist [] occasionally, whereas my GP [] I have known him for years and have great confidence in him. (PT22 (C), pos. 47)

It’s psychological, which is why I’ve tried hypnosis and laser treatments. (PT50 (I), pos. 37)

Seven participants wanted to receive a medication to stop smoking. But most of them felt that the most important factor influencing smoking cessation was their own motivation. At the time of conducting the interviews, one participant had received a prescription in the control group and four in the intervention group.

I’m already annoyed with the treatments I have. (PT39 (C), Pos. 60)

When I was pregnant with my first daughter, I stopped overnight, so I said the day I really want to quit I’ll do it the same way. I don’t want a patch, I don’t want gum. (PT14 (I), pos. 30)

I can rely on something [] that can help. Without anything, we can’t really do it, we’re a bit lost. (PT27 (I), pos. 73)

Quit attempts

Smoking cessation motivators for participants were the health benefits of quitting, as lungs or cardiovascular diseases or during pregnancy, and social factors.

I’m starting to cough. I’m 56 years old now [] it’s time to stop because my joker has already been played. (PT20 (I), pos. 65)

Whether it’s the health side or the financial side, we know that [smoking] costs in every way. (PT69 (I), pos. 75)

At home, being the only one who smokes, I have spies [my children] that make me pause. (PT39 (C), pos. 42)

Barriers to quit smoking were linked to psychological dependence, the fear of physical or psychological changes and the cost of smoking cessation treatments.

The right way to stop, without gaining too much weight and without getting depressed, that’s what scares me. (PT18 (C), pos. 69)

I have a situation that’s not easy either, so that’s all I have left: smoking. (PT17 (C), pos. 19)

[Treatments are] too expensive and it’s not covered by insurance. (PT117 (I), pos. 39)

Many participants (n = 15) were not interested in electronic cigarettes to help them to stop. Most of them had already tried one and didn’t like the taste/sensations, described a concern they might increase their exposure to nicotine, or had difficulties handling the liquid. Some participants didn’t want to replace one addiction with another.

I don’t like the sensation in my mouth, it’s not the same thing. And then we smoke a lot more because we’re always with this thing. (PT14 (I), Pos. 49)

My goal is [] to stop smoking, it is not to vape []. Because it’s also an addiction, the electronic cigarette. (PT17 (C), Pos. 49)

Discussion

Main findings

We performed semi-structured interviews in the context of a cluster-randomized controlled trial encouraging GPs in the intervention group to have proactive, treatment-focused quit discussions with people who have smoked in the last 30 days using a decision aid. Participants were not surprised or shocked to have their GPs discuss treatment options to help them stop smoking without asking about their readiness to quit. Most of them appreciated the decision aid showing all available treatments and encouraging shared decision-making. Participants felt that the primary determinant of quitting smoking was their personal choice and having sufficient willpower. They perceived medical professionals as an important support but weren’t expecting a medication. Interestingly, patients didn’t necessarily want a prescription to help them quit.

Implications

Several studies have described low rates of medication prescription for smoking cessation.^6,7 Most have focused on the lack of time and resources from physicians and their belief that an intervention has only limited effectiveness.²¹ Barriers for people who smoke are many: the cost (especially in Switzerland where nicotine replacement therapies are not reimbursed), lack of awareness regarding smoking cessation treatments, misperceptions about their effectiveness or safety and the impression that existing approaches encouraging smoking cessation are unattractive.^22-24 They emphasize the importance of intrinsic motivation to quit smoking and the belief quitting is their personal responsibility.^23,24

Our study confirmed that most patients did not perceive medications as part of quitting. They think quitting is a question of individual motivation. They may underappreciate the importance of nicotine addiction. This is also a group that is typically reluctant to take medications. They may be more receptive to hypnosis and laser treatments, despite a lack of evidence about the effectiveness of those approaches. Further efforts should be made to normalize medications as part of the smoking cessation treatment.

However, our findings confirm that physicians and other health care providers should not hesitate to talk to every person who smokes about stop-smoking treatments. This approach is well received by patients and should be done in a way that is non-judgmental.

Providing information about treatments to quit smoking as often as possible could be an effective means of increasing quit attempts. Improving patients’ knowledge of smoking cessation aids allows them to be more involved in shared decision-making. The use of a DA is a good way for identifying patient preferences. Further, better characterization of patients’ expectations for smoking cessation could help GPs better meet the needs of their patients.

Strengths and limitations

The strength of this study is a robust thematic analysis with 20% double independent coding and an investigator triangulation. Participants were of different ages, genders and education levels. They smoked a little and a lot. Further, we were able to interview people who have smoked in the last 30 days from the control, ‘enhanced usual care’ group who were not exposed to the default choice intervention for comparison.

One limitation is that we recruited participants from a randomized trial and only recontacted those who volunteered to do an interview. We needed to select people with different socio-demographic characteristics and open to discussion. It is a risk of research bias. All participants were selected by their own GP and interviewed by a GP. There is a possible desirability bias as there is a strong therapeutic relation between a GP and his patient. During the interviews, we repeated to the participants that we were not judging their GP but our training. The delay between the visit and the semi-structured interview was up to 16 weeks (average 8.5 weeks). We might consider that this is too long to remember the intervention in detail and might have introduced a recall bias.

Conclusion

Most participants in the intervention group appreciated the decision aid. Participants across both groups expected their GP to provide support but not necessarily treatment to quit smoking. In daily practice, the use of the DA could be helpful for GPs to discuss medications for smoking cessation more easily. Furthermore, an early explanation of treatment options for every person who smokes seen in primary care may encourage them to ask for help when they are ready to quit smoking.

Supplemental Material

Supplemental Material - Patient reactions to proactive tobacco cessation counseling using a decision aid in primary care: A qualitative study

Supplemental Material for Patient reactions to proactive tobacco cessation counseling using a decision aid in primary care: A qualitative study by Anne Boesch, Marie-Anne Durand, Ines Habfast-Robertson, Isabelle Jacot-Sadowski, Ivan Berlin and Kevin Selby in Journal of Tobacco Use Insights.

Supplemental Material

Supplemental Material - Patient reactions to proactive tobacco cessation counseling using a decision aid in primary care: A qualitative study

Footnotes

Acknowledgments

The authors would like to thank Ms Océane Pittet and Dr Cristina Hempel-Bruder for their help and feedback during the study.

Declaration of conflicting interests:

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Marie-Anne Durand has contributed to the development of Option Grid patient decision aids (from which Picture Option Grid is derived). EBSCO Information Services sells subscription access to Option Grid patient decision aids. She receives consulting income from EBSCO Health, and royalties. No other competing interests declared.

Funding:

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Fonds de prévention du tabagisme (Tobacco Control Fund) (240.0005–22/5/5437326). Kevin Selby’s salary was in part paid by the Fondation Leenaards.

ORCID iD

Kevin Selby

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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