Smoking cessation treatment in primary and specialized care, a real opportunity

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"Torrecilla García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "M" "apellidos" => "Barrueco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 2 => array:3 [ "Iniciales" => "JA" "apellidos" => "Maderuelo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 3 => array:3 [ "Iniciales" => "C" "apellidos" => "Jiménez Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 4 => array:3 [ "Iniciales" => "MD" "apellidos" => "Plaza Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 5 => array:3 [ "Iniciales" => "MA" "apellidos" => "Hernández Mezquita" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "San Juan Health Center, Salamanca, Spain." "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Pneumology Service, University of Salamanca Hospital, Spain." "etiqueta" => "b" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Family and Community Medicine Teaching Unit, Salamanca, Spain." "etiqueta" => "c" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Anti-Smoking Unit, Hospital de la Princesa, Madrid, Spain." "etiqueta" => "d" "identificador" => "affd" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "El abordaje del tabaquismo en atención primaria y especializada, una oportunidad real y una necesidad de salud pública" ] ] "textoCompleto" => "Introduction<hr></hr>Many patients who consult their doctor, regardless of the level of care involved, are smokers. According to the 1997 National Health Survey in Spain,1 35.7% of all Spaniards older than 16 years smoke. In addition, smoking causes 56 000 deaths yearly in Spain.2 This means that for many patients, the reason for seeking medical help is likely to be related with smoking.The use of primary care by the general population in Spain is increasing, possibly because of its accessibility. (It is estimated that 75% of all Spaniards visit their doctor at least once a year.) The mean number of visits per year per person is 5.5, a number that provides practitioners and the health care system itself with multiple opportunities to help those who wish to quit smoking.3 Many other persons seek help from the second level of care, ie, from specialists. As a result, a very large percentage of persons in Spain seek health care and may thus be reachable through interventions to quit smoking.The favorable cost-benefit ratio of smoking cessation treatments, especially in comparison to other preventive measures often used in primary care, is well known. Programs to quit smoking are possibly the procedures that most efficiently improve the health of the population.4 However, systematic intervention for smoking is not yet a reality in the Spanish health system, and we may still be far from such intervention.Despite the frustrating slowness with which smoking prevention is becoming part of clinical practice, the situation is changing. It is revealing in this connection to reread the medical training texts used in the 1970s, which contained statements such as «Quitting is very difficult if the inveterate smoker does not cooperate or lacks will power...The decision to quit smoking once and for all is of prime importance in getting through the first three days without smoking, and the following may be of help: 3 tablets per day of belladenal or bellergal, taking a walk before bedtime, candies, exercising, and showering in the morning.»5Fortunately the current concept of smoking has changed, and the problem is now considered one of the main public health issues and the most frequent cause of preventable deaths in developed countries.6 However, as noted above, we are still far from the day when anti-smoking therapy forms part of the daily activities of primary care physicians and nurses. At most, patients are asked to provide a history of their smoking habit, and this history is usually incomplete, lacking information on which phase of the quitting process the patient is in, or on the degree of nicotine dependence. Moreover, the health advice given is sometimes not accompanied by printed supporting material or plans for follow-up, which are part of systematic minimal intervention for smoking cessation. Pharmacological treatment has been relegated in most cases to specialized anti-smoking units, which are scarce and hence cover only a small proportion of the population. These units are therefore unlikely to have a substantial influence on the public health problem that smoking creates.Minimal intervention is undoubtedly a measure that ought to be implemented by primary care physicians, but what is to be done about pharmacological treatment? Should it be restricted to specialized units, or could it also succeed if offered at primary care centers? The aim of this study was to compare the efficacy of smoking cessation treatments based on systematic minimal intervention and nicotine replacement therapy (NRT) offered in the setting of primary care (PC) and specialized care (SC).<hr></hr>Material and methods <hr></hr><img src="27v30n04-13036733tab01.gif"></img>This quasi-experimental, longitudinal, prospective study7 formed part of a larger research project.8 Some of the findings for the predictive power of abstinence 2 months after quitting have been reported previously.9SubjectsThe population we studied consisted of all smokers older than 18 years who came for any reason to the family medicine service at the San Juan Health Center in Salamanca (northwestern Spain) or to the pneumology out-patient clinic at the University of Salamanca Hospital. Exclusion criteria for patients on NRT were the same as those for any pharmacological treatment: recent history of myocardial infarction, severe cardiac arrhythmia, unstable angina, pregnancy, breastfeeding, active gastroduodenal ulcer, and severe mental illness. In both treatment groups addiction to other drugs besides tobacco was considered an exclusion criterion.InterventionsFor each smoker we recorded name, age, sex, and phone number. Disease antecedents were noted, and information was obtained about disease antecedents and smoking habits: number of cigarettes smoked/day, nicotine consumption/day, packs/year ratio, phase of the quitting process, degree of nicotine dependence (as measured with the Fagerström test), and carbon monoxide concentration in exhaled breath (measured with a Bedfont Micro Smokerlyzer).The patients were classified on the basis of the phase of the quitting process, and all were offered stage-appropriate oral and printed medical advice. Those in the precontemplation phase were given an information sheet about smoking, and those in the contemplation, preparation and action phase were given in addition a 10-item list of steps for quitting smoking, and a practical guide to quitting. All advice was given at each visit by the same person, and a talk lasting approximately 3 min was given to explain the damage caused by smoking, and the short- and long-term advantages of quitting. The same information was provided in both settings, and was developed in accordance with the recommendations of the Section on Smoking (Área de Tabaquismo) of the Spanish Pneumology and Thoracic Surgery Society (Sociedad Española de Neumología y Cirugía Torácica, SEPAR).10 All physicians in both settings were trained to follow exactly the same procedures.Patients with high (score of 7 or more on the Fagerström test) and moderate nicotine dependence (score of 5 or 6) who also smoked more than 10 cigarettes/day or reported previous attempts to quit which failed because of nicotine withdrawal symptoms, medical advice was accompanied by pharmacological support with nicotine patches as recommended by the SEPAR.10The patients were divided into two groups: Group 1. Patients who smoked ¾20 cigarettes/day, with low nicotine dependence (score <5 on the Fagerström test), those with moderate nicotine dependence (Fagerström score of 5-6) and low cigarette consumption, and those with moderate or high dependence who declined NST with nicotine patches (19 patients). All participants were given printed material and medical advice, psychological support and follow-up during the quitting process. This group consisted of 194 persons: 75 in the precontemplation phase, 65 in the contemplation phase, and 54 in the preparation phase.Group 2. The members of this group were in the preparation phase, and were candidates for NRT either because they smoked more than 20 cigarettes/day or because their nicotine dependence was high. This group consisted of 163 persons: 16 with low dependence, 49 with moderate dependence and 98 with high dependence.Follow-upPatients in both the systematic minimal intervention and NST group were seen on day 15, and 1, 2, 6 and 12 months after starting the program, and abstinence (as the main outcome variable) was evaluated after 2, 6 and 12 months. When the participant missed an appointment he or she was contacted by telephone to determine the reason and to reschedule the appointment.At each follow-up appointment progress in quitting was recorded as self-reported abstinence, which was verified with exhaled carbon monoxide measurements. A value <10 ppm was considered the cutoff value for distinguishing between smokers and nonsmokers, and between nonsmokers and light smokers.11 For patients who were unable to quit we recorded the number of cigarettes/day, nicotine dependence, exhaled carbon monoxide concentration, phase of the quitting process, and whether the phase had changed since the start of the program. Patients in both groups were offered additional information aimed at achieving abstinence.Outcome measuresThe main outcome variables were:  Success rate, measured on the basis of intention to treat, ie, patients who quit smoking 2, 6 or 12 after the intervention started were considered successes. The main outcome variable was abstinence after 6-12 months. Patients who had not given up smoking after 12 months, and those who skipped the appointments, were considered failures. Number of patients who significantly reduced the number of cigarettes consumed during the year of follow-up, or who progressed in the quitting process.Statistical analysesChi-squared tests were used for comparison of the proportions; Fisher´s exact test was used when appropriate. Student-Fisher´s t test was used for comparison of the means.To investigate the changes in the number of cigarettes consumed per day during the follow-up period and the variables related with these changes, we used multifactorial analysis of variance of repeat measures. In the initial model the dependent variable was number of cigarettes smoked per day, the intrasubject factor was the number of follow-up visits, and the intersubject factor was the level of care (primary or specialized) that provided treatment. After possible differences were identified, multiple comparisons were done with the Bonferroni test.<hr></hr>Results <hr></hr>In all, 427 patients were seen during the study period, 221 in SC and 206 in PC. Of these patients, 357 (83.6%) agreed to participate in the study (191 in SC and 166 in PC); 194 received systematic minimal intervention, and 163 received NRT.Thirty-two patients (9%) did not attend scheduled appointments (19 [8.6%] in SC and 13 [6.3%] in PC), and were considered cases in which therapy failed. Of these patients, 17 received systematic minimal intervention (12 [10.5%] in SC, and 5 [4.9%] in PC), and 15 received NRT (7 [6.5%] in SC and 8 [7.6%] in PC). Seventeen patients were men and 15 were women; 10 were younger than 30 years. Of the 32 patients who missed appointments, 23 had moderate or high nicotine dependence.Of the total sample, 200 patients (56%) were men and 157 (44%) were women. The distribution according to level of care differed significantly: men predominated in SC (66% vs 44.7%; P<.0001).Mean age for the entire sample was 39.9 years (95% confidence interval 38.7-41.2 years); mean age was 45.1±12.9 years in SC and 34.2±12 years in PC. In men, mean age was 44.5±13.8 years, and in women the figure was 34.3±10.9 years (P<.0001).Among patients seen in the pneumology service a significantly higher percentage (63.4%) had some underlying disease in comparison to patients seen at the PC center (34.9%; P<.0001). The most common diagnoses were asthma (24.6%), chronic bronchitis (23.5%) and emphysema (9.5%); together these three accounted for more than 57% of all the diseases detected. These diseases were present in 76% of the patients followed at the pneumology service, but in only 20.7% of those followed at the PC center, where they were seen in 48.2% and 7.2% of the patients who kept their appointments. Of the patients with some underlying disease, 67% were men and 31.8% were women (P<.0001).The mean number of cigarettes smoked per day at the beginning of the intervention was 20.8±10.2 in SC and 25.1±12.9 in PC (P<.05). However, the packs/year ratio was significantly higher in SC patients (29.2±20.9) than in PC patients (22.5±20.9; P<.01).The degree of nicotine dependence at the beginning of the study was greater in the PC (mean Fagerström score 6.3) than in the SC group (mean score 5.8; P<.01).Mean concentration of exhaled carbon monoxide was 25.5 ppm in PC and 23.6 ppm in SC (P>.05).The percentage of participants who had quit smoking after 12 months of systematic minimal intervention was 41.8% in SC and 36.5% in PC. This difference was not statistically significant, nor were the differences seen at any of the intermediate follow-up visits (P>.05) (Table 1).<img src="27v30n04-13036733tab02.gif"></img>After one year of NRT the percentage of smokers who had quit was 35.5% in SC and 37.1% in PC (P>.05) (Table 2). Although abstinence after treatment with systematic minimal intervention showed no large changes during the follow-up period (P>.05), abstinence in patients who received NRT decreased steadily with time, although the differences from one follow-up visit to the next were not statistically significant.<img src="27v30n04-13036733tab03.gif"></img>The percentage of patients in the systematic minimal intervention group who were able to quit at the beginning of the intervention and who remained abstinent throughout the 12-month follow-up period (sustained abstinence) was 29.6% in SC and 27.1% in PC. In patients who received NRT the figures were 33.3% in SC and 31.4% in PC (P>.05).Throughout the follow-up period, mean daily cigarette consumption (Table 3) was always lower in SC patients (10.6; 95% CI, 8.3-10.2) than in PC patients (14.3; 95% CI, 12.7-15.9; P=.008).<img src="27v30n04-13036733tab04.gif"></img>Multivariate analysis was used to determine the effectiveness of the intervention in reducing the number of cigarettes smoked per day. After 2 months the number had decreased significantly in comparison to the number at the start of the study. This reduction was maintained with little change in subsequent follow-ups, and there were no significant differences in the number of cigarettes smoked per day after 2, 6 and 12 months (Table 4).<img src="27v30n04-13036733tab05.gif"></img>Multivariate analysis showed that there was no interaction between duration of follow-up and level of care: the changes during follow-up in the numbers of cigarettes smoked per day were similar in SC and PC patients.The decrease in the number of cigarettes was reflected in mean values of exhaled carbon monoxide concentration at the beginning of the study and during follow-up. Statistically significant differences between the results at each follow-up visit were found for the sample as a whole when participants who were able to quit and those who were unable to quit were considered together. Mean carbon monoxide concentration at the start of the study was 24.3±10.5 ppm, as compared to 12.1±10.2 ppm at the end of the study. In participants who were unable to quit smoking by the end of the 12-month study period, the final concentration was 19.9±8.9 ppm. When we compared the results for the two levels of care we found similar differences between participants who quit and those who did not. In the SC group the initial and final concentrations were 23.9±11.2 ppm and 11.7±10.9 ppm respectively, and the final concentration for those who were unable to quit was 20.6±10.1 ppm. In the PC group the figures were 24.7±9.7 ppm and 12.3±9.5 ppm, respectively, and the final concentration in those who were unable to quit was 19.3±7.8 ppm.<hr></hr>Discussion<hr></hr><img src="27v30n04-13036733tab06.gif"></img>The differences in the results between the primary care and specialized center resulted from the particular characteristics of the patients managed at each level of care. The population followed by the pneumology clinic was older on the average, and the main reason for consulting was chronic respiratory disease related with smoking. These problems take longer to appear than do the acute processes normally seen in primary care.The predominance of men in the specialized clinic was related not with an actual difference in the prevalence of smoking between men and women, but with the fact that women have begun smoking relatively recently, and hence the manifestations of the resulting damage have not yet appeared. However, this situation is changing in accordance with the classical epidemiological curve of smoking.12Patients followed at the specialized center had more severe respiratory disease and may therefore have smoked fewer cigarettes per day. However, the packs/year ratio was higher in these patients. A logical finding was that the degree of nicotine dependence and carbon monoxide concentration, which are linked to current smoking habits, were lower in patients followed at the pneumology clinic.A number of studies have shown minimal intervention to be effective13-22 in both PC and SC settings, and have found NRT to be effective in SC,23-28 but there are no studies that used the same method to compare the efficacy of these two interventions for smoking cessation at both levels of care.We found no significant differences in the results between groups at any time during follow-up, in terms of change of phase, abstinence or smoking reduction. This leads us to note that despite the limitations related to the different populations treated at the two levels of care we compared, and foregoing any attempt to undertake a rigorous comparison of the two centers, smoking cessation can and should be undertaken in primary care, a setting with the added advantages of greater accessibility and coverage, and thus greater benefits in terms of public health as shown in the classic study by Russell et al.13The percentage abstinence rates in the present study contrast with earlier results reported by other authors.13-29 The better results obtained in the present study are probably due to the fact that our patients sought medical help for health problems, and smoking cessation treatment was offered to them within the wider context of treatment for their underlying illness. This made more prolonged, systematic interventions possible (with periodic follow-up examinations scheduled regularly and also taking place during visits to the center for any other health problem). The results, as shown in other studies,30-32 were thus better than if the interventions had been attempted in isolation. Another possible factor is the greater need in the general population to quit smoking, as also reported in a recent study by Torrel et al.33, in which a high percentage of participants ceased smoking. This factor has been noted and discussed in a previous article in Atención Primaria.34It should be recalled that our participants were assigned to receive minimal intervention or NRT on the basis of their degree of nicotine dependence and cigarette consumption. This might explain, in part, the high percentages of abstinence in the group that received systematic minimal intervention, as it might be assumed that it would not be difficult for these patients to quit.An important task for health care professionals is to develop activities aimed at fomenting healthy attitudes in patients, and smoking cessation treatment is one way to favor such attitudes. The appearance of new drugs35 along with personal factors that might give some indication of the patient´s course in the quitting process,36,37 as well as more reliable predictive factors--such as the results of cessation intervention after 2 months,9 can help enhance the efficacy and efficiency of measures to help the patient quit.On the basis of the results of the present study, we believe that systematic minimal intervention and NRT should be used by health professionals and included in all medical contacts regardless of the level of care.In conclusion, NRT is effective, with success rates ranging, according to a meta-analysis by Silagy et al.,38 from 15% to 24% depending on the mode of treatment. This therapy should be used at all levels of health care and not be limited to specialized centers. Because it is recommended for patients with higher levels of dependence, it has been found effective in primary care, as the patients seen at this level of care smoke more cigarettes and have higher levels of dependence than patients seen by specialists.It may be useful to identify the limitations of these interventions in primary and specialized care, especially now that the appearance on the Spanish market of bupropion means that there are more options for pharmacological treatment, and now that the future holds expectations for gene therapy.39,40 The limitations of available treatments will probably be determined by specific situations that require more specialized interventions such as those offered by anti-smoking units. One aim should thus be to define the criteria for referral to such units,41 having accepted that systematic minimal intervention and pharmacological treatment can and should be used at all levels of care within the health system. Correspondence: Miguel Torrecilla García. Centro de Salud San Juan. C/ Valencia 32. 37005 Salamanca. España. E-mail: mtorrecillag@papps.org  Manuscript accepted for publication 4 February 2002." "pdfFichero" => "27v30n04a13036733pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec692972" "palabras" => array:4 [ 0 => "Tabaco" 1 => "Atención primaria" 2 => "Atención especializada" 3 => "Cesación tabáquica" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec692971" "palabras" => array:4 [ 0 => "Tobacco" 1 => "Primary care" 2 => "Specialized care" 3 => "Smoking cessation" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Aim. To determine whether primary care provides a suitable framework for integrated treatment aimed at smoking cessation with systematic minimal intervention or pharmacological treatment with nicotine replacement therapy (NRT). To compare the results with those obtained in a specialized pneumology unit. Design. Prospective, quasi-experimental study. Setting. Primary and specialized care services. Participants. 357 smokers who were followed at a health center (166) or a specialized clinic (191) during a 6-month period. Interventions. Two types of intervention were used depending on the patients' degree of nicotine dependence: systematic minimal intervention for those with low dependence or who were still in the contemplation or precontemplation phase, and NRT for those with high dependence, in the preparation phase. Main outcome measures. Twelve months after the start of the study, abstinence among participants who received systematic minimal intervention was 36.5% in primary care patients and 41.8% in specialized care patients ( P>.05). Among participants who received NRT abstinence was 37.1% in the former group and 35.5% in the latter ( P>.05). The percentage of patients lost to follow-up was 8.6% in specialized care and 6.3% in primary care. Conclusions. The results lead us to recommend smoking cessation treatment integrated in the primary care setting, either with systematic minimal intervention or NRT." ] "es" => array:1 [ "resumen" => "Objetivo. Valorar si atención primaria ofrece un marco adecuado para el abordaje del tabaquismo de forma global, tanto con la intervención mínima sistematizada en tabaquismo como con tratamiento farmacológico mediante terapia sustitutiva con nicotina (TSN), comparando los resultados obtenidos con los de una unidad especializada de neumología. Diseño. Estudio prospectivo cuasi experimental. Emplazamiento. Atención primaria y especializada. Participantes. Un total de 357 fumadores que acudieron a una consulta de atención primaria (n = 166) o especializada (n = 191) durante un período de 6 meses. Intervenciones. Se realizaron dos tipos de intervención en función de la dependencia nicotínica de los pacientes: intervención mínima sistematizada en los que presentaban baja dependencia o que aún se encontraban en fases de precontemplación y contemplación, y TSN en los fumadores con alta dependencia y en fase de preparación. Mediciones y resultados principales. La abstinencia observada a los 12 meses del inicio del estudio fue, en el grupo de la intervención mínima sistematizada, del 36,5% en atención primaria y del 41,8% en especializada (p > 0,05), y en el grupo de la TSN, del 37,1 y el 35,5%, respectivamente (p > 0,05). El porcentaje de pérdidas de seguimiento fue del 8,6% en especializada y del 6,3% en primaria. Conclusiones. Los resultados observados en el presente estudio nos permiten aconsejar el tratamiento del tabaquismo de forma global en el marco de la atención primaria, bien sea mediante la denominada intervención mínima sistematizada o la TSN." ] ] "multimedia" => array:12 [ 0 => array:6 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n04-13036733tab01.gif" "imagenAlto" => 508 "imagenAncho" => 333 "imagenTamanyo" => 12919 ] ] ] ] ] ] 1 => array:6 [ "identificador" => "tbl2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n04-13036733tab02.gif" "imagenAlto" => 275 "imagenAncho" => 347 "imagenTamanyo" => 12318 ] ] ] ] ] ] 2 => array:6 [ "identificador" => "tbl3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n04-13036733tab03.gif" "imagenAlto" => 310 "imagenAncho" => 344 "imagenTamanyo" => 13879 ] ] ] ] ] ] 3 => array:6 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n04-13036733tab04.gif" "imagenAlto" => 610 "imagenAncho" => 700 "imagenTamanyo" => 17246 ] ] ] ] ] ] 4 => array:6 [ "identificador" => "tbl5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n04-13036733tab05.gif" "imagenAlto" => 625 "imagenAncho" => 702 "imagenTamanyo" => 19079 ] ] ] ] ] ] 5 => array:6 [ "identificador" => "tbl6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v30n04-13036733tab06.gif" "imagenAlto" => 403 "imagenAncho" => 337 "imagenTamanyo" => 15215 ] ] ] ] ] ] 6 => array:5 [ "identificador" => "tbl7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 7 => array:5 [ "identificador" => "tbl8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 8 => array:5 [ "identificador" => "tbl9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 9 => array:5 [ "identificador" => "tbl10" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 10 => array:5 [ "identificador" => "tbl11" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 11 => array:5 [ "identificador" => "tbl12" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:41 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "Madrid: Ministerio de Sanidad y Consumo, 1999." 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Smoking cessation treatment in primary and specialized care, a real opportunity

El abordaje del tabaquismo en atención primaria y especializada, una oportunidad real y una necesidad de salud pública

M. Torrecilla Garcíaa, M. Barruecob, JA. Maderueloc, C. Jiménez Ruizd, MD. Plaza Martína, MA. Hernández Mezquitaa

a San Juan Health Center, Salamanca, Spain.

b Pneumology Service, University of Salamanca Hospital, Spain.

c Family and Community Medicine Teaching Unit, Salamanca, Spain.

d Anti-Smoking Unit, Hospital de la Princesa, Madrid, Spain.

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    "textoCompleto" => "<p class="elsevierStylePara">Introduction</p><hr></hr><p class="elsevierStylePara">Many patients who consult their doctor&#44; regardless of the level of care involved&#44; are smokers&#46; According to the 1997 National Health Survey in Spain&#44;<span class="elsevierStyleSup">1</span> 35&#46;7&#37; of all Spaniards older than 16 years smoke&#46; In addition&#44; smoking causes 56 000 deaths yearly in Spain&#46;<span class="elsevierStyleSup">2</span> This means that for many patients&#44; the reason for seeking medical help is likely to be related with smoking&#46;</p><p class="elsevierStylePara">The use of primary care by the general population in Spain is increasing&#44; possibly because of its accessibility&#46; &#40;It is estimated that 75&#37; of all Spaniards visit their doctor at least once a year&#46;&#41; The mean number of visits per year per person is 5&#46;5&#44; a number that provides practitioners and the health care system itself with multiple opportunities to help those who wish to quit smoking&#46;<span class="elsevierStyleSup">3</span> Many other persons seek help from the second level of care&#44; ie&#44; from specialists&#46; As a result&#44; a very large percentage of persons in Spain seek health care and may thus be reachable through interventions to quit smoking&#46;</p><p class="elsevierStylePara">The favorable cost-benefit ratio of smoking cessation treatments&#44; especially in comparison to other preventive measures often used in primary care&#44; is well known&#46; Programs to quit smoking are possibly the procedures that most efficiently improve the health of the population&#46;<span class="elsevierStyleSup">4</span> However&#44; systematic intervention for smoking is not yet a reality in the Spanish health system&#44; and we may still be far from such intervention&#46;</p><p class="elsevierStylePara">Despite the frustrating slowness with which smoking prevention is becoming part of clinical practice&#44; the situation is changing&#46; It is revealing in this connection to reread the medical training texts used in the 1970s&#44; which contained statements such as &#171;Quitting is very difficult if the inveterate smoker does not cooperate or lacks will power&#46;&#46;&#46;The decision to quit smoking once and for all is of prime importance in getting through the first three days without smoking&#44; and the following may be of help&#58; 3 tablets per day of belladenal or bellergal&#44; taking a walk before bedtime&#44; candies&#44; exercising&#44; and showering in the morning&#46;&#187;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Fortunately the current concept of smoking has changed&#44; and the problem is now considered one of the main public health issues and the most frequent cause of preventable deaths in developed countries&#46;<span class="elsevierStyleSup">6</span> However&#44;<br></br> as noted above&#44; we are still far from the day when anti-smoking therapy forms part of the daily activities of primary care physicians and nurses&#46; At most&#44; patients are asked to provide a history of their smoking habit&#44; and this history is usually incomplete&#44; lacking information on which phase of the quitting process the patient is in&#44; or on the degree of nicotine dependence&#46; Moreover&#44; the health advice given is sometimes not accompanied by printed supporting material or plans for follow-up&#44; which are part of systematic minimal intervention for smoking cessation&#46; Pharmacological treatment has been relegated in most cases to specialized anti-smoking units&#44; which are scarce and hence cover only a small proportion of the population&#46; These units are therefore unlikely to have a substantial influence on the public health problem that smoking creates&#46;</p><p class="elsevierStylePara">Minimal intervention is undoubtedly a measure that ought to be implemented by primary care physicians&#44; but what is to be done about pharmacological treatment&#63; Should it be restricted to specialized units&#44; or could it also succeed if offered at primary care centers&#63; The aim of this study was to compare the efficacy of smoking cessation treatments based on systematic minimal intervention and nicotine replacement therapy &#40;NRT&#41; offered in the setting of primary care &#40;PC&#41; and specialized care &#40;SC&#41;&#46;</p><hr></hr><p class="elsevierStylePara">Material and methods </p><hr></hr><p class="elsevierStylePara"><img src="27v30n04-13036733tab01.gif"></img></p><p class="elsevierStylePara">This quasi-experimental&#44; longitudinal&#44; prospective study<span class="elsevierStyleSup">7</span> formed part of a larger research project&#46;<span class="elsevierStyleSup">8</span> Some of the findings for the predictive power of abstinence 2 months after quitting have been reported previously&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara">Subjects</p><p class="elsevierStylePara">The population we studied consisted of all smokers older than 18 years who came for any reason to the family medicine service at the San Juan Health Center in Salamanca &#40;northwestern Spain&#41; or to the pneumology out-patient clinic at the University of Salamanca Hospital&#46; Exclusion criteria for patients on NRT were the same as those for any pharmacological treatment&#58; recent history of myocardial infarction&#44; severe cardiac arrhythmia&#44; unstable angina&#44; pregnancy&#44; breastfeeding&#44; active gastroduodenal ulcer&#44; and severe mental illness&#46; In both treatment groups addiction to other drugs besides tobacco was considered an exclusion criterion&#46;</p><p class="elsevierStylePara">Interventions</p><p class="elsevierStylePara">For each smoker we recorded name&#44; age&#44; sex&#44; and phone number&#46; Disease antecedents were noted&#44; and information was obtained about disease antecedents and smoking habits&#58; number of cigarettes smoked&#47;day&#44; nicotine consumption&#47;day&#44; packs&#47;year ratio&#44; phase of the quitting process&#44; degree of nicotine dependence &#40;as measured with the Fagerstr&#246;m test&#41;&#44; and carbon monoxide concentration in exhaled breath &#40;measured with a Bedfont Micro Smokerlyzer&#41;&#46;</p><p class="elsevierStylePara">The patients were classified on the basis of the phase of the quitting process&#44; and all were offered stage-appropriate oral and printed <span class="elsevierStyleItalic">medical advice</span>&#46; Those in the precontemplation phase were given an information sheet about smoking&#44; and those in the contemplation&#44; preparation and action phase were given in addition a 10-item list of steps for quitting smoking&#44; and a practical guide to quitting&#46; All advice was given at each visit by the same person&#44; and a talk lasting approximately 3 min was given to explain the damage caused by smoking&#44; and the short- and long-term advantages of quitting&#46; The same information was provided in both settings&#44; and was developed in accordance with the recommendations of the Section on Smoking &#40;&#193;rea de Tabaquismo&#41; of the Spanish Pneumology and Thoracic Surgery Society &#40;Sociedad Espa&#241;ola de Neumolog&#237;a y Cirug&#237;a Tor&#225;cica&#44; SEPAR&#41;&#46;<span class="elsevierStyleSup">10</span> All physicians in both settings were trained to follow exactly the same procedures&#46;</p><p class="elsevierStylePara">Patients with high &#40;score of 7 or more on the Fagerstr&#246;m test&#41; and moderate nicotine dependence &#40;score of 5 or 6&#41; who also smoked more than 10 cigarettes&#47;day or reported previous attempts to quit which failed because of nicotine withdrawal symptoms&#44; medical advice was accompanied by pharmacological support with nicotine patches as recommended by the SEPAR&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">The patients were divided into two groups&#58;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Group 1&#46;</span> Patients who smoked &#190;20 cigarettes&#47;day&#44; with low nicotine dependence &#40;score &#60;5 on the Fagerstr&#246;m test&#41;&#44; those with moderate nicotine dependence &#40;Fagerstr&#246;m score of 5-6&#41; and low cigarette consumption&#44; and those with moderate or high dependence who declined NST with nicotine patches &#40;19 patients&#41;&#46; All participants were given printed material and medical advice&#44; psychological support and follow-up during the quitting process&#46; This group consisted of 194 persons&#58; 75 in the precontemplation phase&#44; 65 in the contemplation phase&#44; and 54 in the preparation phase&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Group 2</span>&#46; The members of this group were in the preparation phase&#44; and were candidates for NRT either because they smoked more than 20 cigarettes&#47;day or because their nicotine dependence was high&#46; This group consisted of 163 persons&#58; 16 with low dependence&#44; 49 with moderate dependence and 98 with high dependence&#46;</p><p class="elsevierStylePara">Follow-up</p><p class="elsevierStylePara">Patients in both the systematic minimal intervention and NST group were seen on day 15&#44; and 1&#44; 2&#44; 6 and 12 months after starting the program&#44; and abstinence &#40;as the main outcome variable&#41; was evaluated after 2&#44; 6 and 12 months&#46; When the participant missed an appointment he or she was contacted by telephone to determine the reason and to reschedule the appointment&#46;</p><p class="elsevierStylePara">At each follow-up appointment progress in quitting was recorded as self-reported abstinence&#44; which was verified with exhaled carbon monoxide measurements&#46; A value &#60;10 ppm was considered the cutoff value for distinguishing between smokers and nonsmokers&#44; and between nonsmokers and light smokers&#46;<span class="elsevierStyleSup">11</span> For patients who were unable to quit we recorded the number of cigarettes&#47;day&#44; nicotine dependence&#44; exhaled carbon monoxide concentration&#44; phase of the quitting process&#44; and whether the phase had changed since the start of the program&#46; Patients in both groups were offered additional information aimed at achieving abstinence&#46;</p><p class="elsevierStylePara">Outcome measures</p><p class="elsevierStylePara">The main outcome variables were&#58;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">&#173; Success rate&#44; measured on the basis of intention to treat&#44; ie&#44; patients who quit smoking 2&#44; 6 or 12 after the intervention started were considered successes&#46; The main outcome variable was abstinence after 6-12 months&#46; Patients who had not given up smoking after 12 months&#44; and those who skipped the appointments&#44; were considered failures&#46;</p><p class="elsevierStylePara">&#173; Number of patients who significantly reduced the number of cigarettes consumed during the year of follow-up&#44; or who progressed in the quitting process&#46;</p><p class="elsevierStylePara">Statistical analyses</p><p class="elsevierStylePara">Chi-squared tests were used for comparison of the proportions&#59; Fisher&#180;s exact test was used when appropriate&#46; Student-Fisher&#180;s <span class="elsevierStyleItalic">t</span> test was used for comparison of the means&#46;</p><p class="elsevierStylePara">To investigate the changes in the number of cigarettes consumed per day during the follow-up period and the variables related with these changes&#44; we used multifactorial analysis of variance of repeat measures&#46; In the initial model the dependent variable was number of cigarettes smoked per day&#44; the intrasubject factor was the number of follow-up visits&#44; and the intersubject factor was the level of care &#40;primary or specialized&#41; that provided treatment&#46; After possible differences were identified&#44; multiple comparisons were done with the Bonferroni test&#46;</p><hr></hr><p class="elsevierStylePara">Results  </p><hr></hr><p class="elsevierStylePara">In all&#44; 427 patients were seen during the study period&#44; 221 in SC and 206 in PC&#46; Of these patients&#44; 357 &#40;83&#46;6&#37;&#41; agreed to participate in the study &#40;191 in SC and 166 in PC&#41;&#59; 194 received systematic minimal intervention&#44; and 163 received NRT&#46;</p><p class="elsevierStylePara">Thirty-two patients &#40;9&#37;&#41; did not attend scheduled appointments &#40;19 &#91;8&#46;6&#37;&#93; in SC and 13 &#91;6&#46;3&#37;&#93; in PC&#41;&#44; and were considered cases in which therapy failed&#46; Of these patients&#44; 17 received systematic minimal intervention &#40;12 &#91;10&#46;5&#37;&#93; in SC&#44; and 5 &#91;4&#46;9&#37;&#93; in PC&#41;&#44; and 15 received NRT &#40;7 &#91;6&#46;5&#37;&#93; in SC and 8 &#91;7&#46;6&#37;&#93; in PC&#41;&#46; Seventeen patients were men and 15 were women&#59; 10 were younger than 30 years&#46; Of the 32 patients who missed appointments&#44; 23 had moderate or high nicotine dependence&#46;</p><p class="elsevierStylePara">Of the total sample&#44; 200 patients &#40;56&#37;&#41; were men and 157 &#40;44&#37;&#41; were women&#46; The distribution according to level of care differed significantly&#58; men predominated in SC &#40;66&#37; vs 44&#46;7&#37;&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;0001&#41;&#46;</p><p class="elsevierStylePara">Mean age for the entire sample was 39&#46;9 years &#40;95&#37; confidence interval 38&#46;7-41&#46;2 years&#41;&#59; mean age was 45&#46;1&#177;12&#46;9 years in SC and 34&#46;2&#177;12 years in PC&#46; In men&#44; mean age was 44&#46;5&#177;13&#46;8 years&#44; and in women the figure was 34&#46;3&#177;10&#46;9 years &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;0001&#41;&#46;</p><p class="elsevierStylePara">Among patients seen in the pneumology service a significantly higher percentage &#40;63&#46;4&#37;&#41; had some underlying disease in comparison to patients seen at the PC center &#40;34&#46;9&#37;&#59; <span class="elsevierStyleItalic"> P</span>&#60;&#46;0001&#41;&#46; The most common diagnoses were asthma &#40;24&#46;6&#37;&#41;&#44; chronic bronchitis &#40;23&#46;5&#37;&#41; and emphysema &#40;9&#46;5&#37;&#41;&#59; together these three accounted for more than 57&#37; of all the diseases detected&#46; These diseases were present in 76&#37; of the patients followed at the pneumology service&#44; but in only 20&#46;7&#37; of those followed at the PC center&#44; where they were seen in 48&#46;2&#37; and 7&#46;2&#37; of the patients who kept their appointments&#46; Of the patients with some underlying disease&#44; 67&#37; were men and 31&#46;8&#37; were women &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;0001&#41;&#46;</p><p class="elsevierStylePara">The mean number of cigarettes smoked per day at the beginning of the intervention was 20&#46;8&#177;10&#46;2 in SC and 25&#46;1&#177;12&#46;9 in PC &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;05&#41;&#46; However&#44; the packs&#47;year ratio was significantly higher in SC patients &#40;29&#46;2&#177;20&#46;9&#41; than in PC patients &#40;22&#46;5&#177;20&#46;9&#59; <span class="elsevierStyleItalic">P</span>&#60;&#46;01&#41;&#46;</p><p class="elsevierStylePara">The degree of nicotine dependence at the beginning of the study was greater in the PC &#40;mean Fagerstr&#246;m score 6&#46;3&#41; than in the SC group &#40;mean score 5&#46;8&#59; <span class="elsevierStyleItalic"> P</span>&#60;&#46;01&#41;&#46;</p><p class="elsevierStylePara">Mean concentration of exhaled carbon monoxide was 25&#46;5 ppm in PC and 23&#46;6 ppm in SC &#40;<span class="elsevierStyleItalic">P</span>&#62;&#46;05&#41;&#46;</p><p class="elsevierStylePara">The percentage of participants who had quit smoking after 12 months of systematic minimal intervention was 41&#46;8&#37; in SC and 36&#46;5&#37; in PC&#46; This difference was not statistically significant&#44; nor were the differences seen at any of the intermediate follow-up visits &#40;<span class="elsevierStyleItalic">P</span>&#62;&#46;05&#41; &#40;Table 1&#41;&#46;</p><p class="elsevierStylePara"><img src="27v30n04-13036733tab02.gif"></img></p><p class="elsevierStylePara">After one year of NRT the percentage of smokers who had quit was 35&#46;5&#37; in SC and 37&#46;1&#37; in PC &#40;<span class="elsevierStyleItalic">P</span>&#62;&#46;05&#41; &#40;Table 2&#41;&#46; Although abstinence after treatment with systematic minimal intervention showed no large changes during the follow-up period &#40;<span class="elsevierStyleItalic">P</span>&#62;&#46;05&#41;&#44; abstinence in patients who received NRT decreased steadily with time&#44; although the differences from one follow-up visit to the next were not statistically significant&#46;</p><p class="elsevierStylePara"><img src="27v30n04-13036733tab03.gif"></img></p><p class="elsevierStylePara">The percentage of patients in the systematic minimal intervention group who were able to quit at the beginning of the intervention and who remained abstinent throughout the 12-month follow-up period &#40;sustained abstinence&#41; was 29&#46;6&#37; in SC and 27&#46;1&#37; in PC&#46; In patients who received NRT the figures were 33&#46;3&#37; in SC and 31&#46;4&#37; in PC &#40;<span class="elsevierStyleItalic">P</span>&#62;&#46;05&#41;&#46;</p><p class="elsevierStylePara">Throughout the follow-up period&#44; mean daily cigarette consumption &#40;Table 3&#41; was always lower in SC patients &#40;10&#46;6&#59; 95&#37; CI&#44; 8&#46;3-10&#46;2&#41; than in PC patients &#40;14&#46;3&#59; 95&#37; CI&#44; 12&#46;7-15&#46;9&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;008&#41;&#46;</p><p class="elsevierStylePara"><img src="27v30n04-13036733tab04.gif"></img></p><p class="elsevierStylePara">Multivariate analysis was used to determine the effectiveness of the intervention in reducing the number of cigarettes smoked per day&#46; After 2 months the number had decreased significantly in comparison to the number at the start of the study&#46; This reduction was maintained with little change in subsequent follow-ups&#44; and there were no significant differences in the number of cigarettes smoked per day after 2&#44; 6 and 12 months &#40;Table 4&#41;&#46;</p><p class="elsevierStylePara"><img src="27v30n04-13036733tab05.gif"></img></p><p class="elsevierStylePara">Multivariate analysis showed that there was no interaction between duration of follow-up and level of care&#58; the changes during follow-up in the numbers of cigarettes smoked per day were similar in SC and PC patients&#46;</p><p class="elsevierStylePara">The decrease in the number of cigarettes was reflected in mean values of exhaled carbon monoxide concentration at the beginning of the study and during follow-up&#46; Statistically significant differences between the results at each follow-up visit were found for the sample as a whole when participants who were able to quit and those who were unable to quit were considered together&#46; Mean carbon monoxide concentration at the start of the study was 24&#46;3&#177;10&#46;5 ppm&#44; as compared to 12&#46;1&#177;10&#46;2 ppm at the end of the study&#46; In participants who were unable to quit smoking by the end of the 12-month study period&#44; the final concentration was 19&#46;9&#177;8&#46;9 ppm&#46; When we compared the results for the two levels of care we found similar differences between participants who quit and those who did not&#46; In the SC group the initial and final concentrations were 23&#46;9&#177;11&#46;2 ppm and 11&#46;7&#177;10&#46;9 ppm respectively&#44; and the final concentration for those who were unable to quit was 20&#46;6&#177;10&#46;1 ppm&#46; In the PC group the figures were 24&#46;7&#177;9&#46;7 ppm and 12&#46;3&#177;9&#46;5 ppm&#44; respectively&#44; and the final concentration in those who were unable to quit was 19&#46;3&#177;7&#46;8 ppm&#46;</p><hr></hr><p class="elsevierStylePara">Discussion</p><hr></hr><p class="elsevierStylePara"><img src="27v30n04-13036733tab06.gif"></img></p><p class="elsevierStylePara">The differences in the results between the primary care and specialized center resulted from the particular characteristics of the patients managed at each level of care&#46; The population followed by the pneumology clinic was older on the average&#44; and the main reason for consulting was chronic respiratory disease related with smoking&#46; These problems take longer to appear than do the acute processes normally seen in primary care&#46;</p><p class="elsevierStylePara">The predominance of men in the specialized clinic was related not with an actual difference in the prevalence of smoking between men and women&#44; but with the fact that women have begun smoking relatively recently&#44; and hence the manifestations of the resulting damage have not yet appeared&#46; However&#44; this situation is changing in accordance with the classical epidemiological curve of smoking&#46;<span class="elsevierStyleSup">12</span></p><p class="elsevierStylePara">Patients followed at the specialized center had more severe respiratory disease and may therefore have smoked fewer cigarettes per day&#46; However&#44; the packs&#47;year ratio was higher in these patients&#46; A logical finding was that the degree of nicotine dependence and carbon monoxide concentration&#44; which are linked to current smoking habits&#44; were lower in patients followed at the pneumology clinic&#46;</p><p class="elsevierStylePara">A number of studies have shown minimal intervention to be effective<span class="elsevierStyleSup">13-22</span> in both PC and SC settings&#44; and have found NRT to be effective in SC&#44;<span class="elsevierStyleSup">23-28</span> but there are no studies that used the same method to compare the efficacy of these two interventions for smoking cessation at both levels of care&#46;</p><p class="elsevierStylePara">We found no significant differences in the results between groups at any time during follow-up&#44; in terms of change of phase&#44; abstinence or smoking reduction&#46; This leads us to note that despite the limitations related to the different populations treated at the two levels of care we compared&#44; and foregoing any attempt to undertake a rigorous comparison of the two centers&#44; smoking cessation can and should be undertaken in primary care&#44; a setting with the added advantages of greater accessibility and coverage&#44; and thus greater benefits in terms of public health as shown in the classic study by Russell et al&#46;<span class="elsevierStyleSup">13</span></p><p class="elsevierStylePara">The percentage abstinence rates in the present study contrast with earlier results reported by other authors&#46;<span class="elsevierStyleSup">13-29</span> The better results obtained in the present study are probably due to the fact that our patients sought medical help for health problems&#44; and smoking cessation treatment was offered to them within the wider context of treatment for their underlying illness&#46; This made more prolonged&#44; systematic interventions possible &#40;with periodic follow-up examinations scheduled regularly and also taking place during visits to the center for any other health problem&#41;&#46; The results&#44; as shown in other studies&#44;<span class="elsevierStyleSup">30-32</span> were thus better than if the interventions had been attempted in isolation&#46; Another possible factor is the greater need in the general population to quit smoking&#44; as also reported in a recent study by Torrel et al&#46;<span class="elsevierStyleSup">33</span>&#44; in which a high percentage of participants ceased smoking&#46; This factor has been noted and discussed in a previous article in Atenci&#243;n Primaria&#46;<span class="elsevierStyleSup">34</span></p><p class="elsevierStylePara">It should be recalled that our participants were assigned to receive minimal intervention or NRT on the basis of their degree of nicotine dependence and cigarette consumption&#46; This might explain&#44; in part&#44; the high percentages of abstinence in the group that received systematic minimal intervention&#44; as it might be assumed that it would not be difficult for these patients to quit&#46;</p><p class="elsevierStylePara">An important task for health care professionals is to develop activities aimed at fomenting healthy attitudes in patients&#44; and smoking cessation treatment is one way to favor such attitudes&#46; The appearance of new drugs<span class="elsevierStyleSup">35</span> along with personal factors that might give some indication of the patient&#180;s course in the quitting process&#44;<span class="elsevierStyleSup">36&#44;37</span> as well as more reliable predictive factors--such as the results of cessation intervention after 2 months&#44;<span class="elsevierStyleSup">9</span> can help enhance the efficacy and efficiency of measures to help the patient quit&#46;</p><p class="elsevierStylePara">On the basis of the results of the present study&#44; we believe that systematic minimal intervention and NRT should be used by health professionals and included in all medical contacts regardless of the level of care&#46;</p><p class="elsevierStylePara">In conclusion&#44; NRT is effective&#44; with success rates ranging&#44; according to a meta-analysis by Silagy et al&#46;&#44;<span class="elsevierStyleSup">38</span> from 15&#37; to 24&#37; depending on the mode of treatment&#46; This therapy should be used at all levels of health care and not be limited to specialized centers&#46; Because it is recommended for patients with higher levels of dependence&#44; it has been found effective in primary care&#44; as the patients seen at this level of care smoke more cigarettes and have higher levels of dependence than patients seen by specialists&#46;</p><p class="elsevierStylePara">It may be useful to identify the limitations of these interventions in primary and specialized care&#44; especially now that the appearance on the Spanish market of bupropion means that there are more options for pharmacological treatment&#44; and now that the future holds expectations for gene therapy&#46;<span class="elsevierStyleSup">39&#44;40</span> The limitations of available treatments will probably be determined by specific situations that require more specialized interventions such as those offered by anti-smoking units&#46; One aim should thus be to define the criteria for referral to such units&#44;<span class="elsevierStyleSup">41</span> having accepted that systematic minimal intervention and pharmacological treatment can and should be used at all levels of care within the health system&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Correspondence&#58; Miguel Torrecilla Garc&#237;a&#46; Centro de Salud San Juan&#46; C&#47; Valencia 32&#46;  37005 Salamanca&#46; Espa&#241;a&#46; E-mail&#58; mtorrecillag&#64;papps&#46;org</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"> Manuscript accepted for publication 4 February 2002&#46;</p>"
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        "resumen" => "Aim&#46; To determine whether primary care provides a suitable framework for integrated treatment aimed at smoking cessation with systematic minimal intervention or pharmacological treatment with nicotine replacement therapy &#40;NRT&#41;&#46; To compare the results with those obtained in a specialized pneumology unit&#46; Design&#46; Prospective&#44; quasi-experimental study&#46; Setting&#46; Primary and specialized care services&#46; Participants&#46; 357 smokers who were followed at a health center &#40;166&#41; or a specialized clinic &#40;191&#41; during a 6-month period&#46; Interventions&#46; Two types of intervention were used depending on the patients&#39; degree of nicotine dependence&#58; systematic minimal intervention for those with low dependence or who were still in the contemplation or precontemplation phase&#44; and NRT for those with high dependence&#44; in the preparation phase&#46; Main outcome measures&#46; Twelve months after the start of the study&#44; abstinence among participants who received systematic minimal intervention was 36&#46;5&#37; in primary care patients and 41&#46;8&#37; in specialized care patients &#40; <span class="elsevierStyleItalic">P</span>&#62;&#46;05&#41;&#46; Among participants who received NRT abstinence was 37&#46;1&#37; in the former group and 35&#46;5&#37; in the latter &#40; <span class="elsevierStyleItalic">P</span>&#62;&#46;05&#41;&#46; The percentage of patients lost to follow-up was 8&#46;6&#37; in specialized care and 6&#46;3&#37; in primary care&#46; Conclusions&#46; The results lead us to recommend smoking cessation treatment integrated in the primary care setting&#44; either with systematic minimal intervention or NRT&#46;"
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        "resumen" => "Objetivo&#46; Valorar si atenci&#243;n primaria ofrece un marco adecuado para el abordaje del tabaquismo de forma global&#44; tanto con la intervenci&#243;n m&#237;nima sistematizada en tabaquismo como con tratamiento farmacol&#243;gico mediante terapia sustitutiva con nicotina &#40;TSN&#41;&#44; comparando los resultados obtenidos con los de una unidad especializada de neumolog&#237;a&#46; Dise&#241;o&#46; Estudio prospectivo cuasi experimental&#46; Emplazamiento&#46; Atenci&#243;n primaria y especializada&#46; Participantes&#46; Un total de 357 fumadores que acudieron a una consulta de atenci&#243;n primaria &#40;n &#61; 166&#41; o especializada &#40;n &#61; 191&#41; durante un per&#237;odo de 6 meses&#46; Intervenciones&#46; Se realizaron dos tipos de intervenci&#243;n en funci&#243;n de la dependencia nicot&#237;nica de los pacientes&#58; intervenci&#243;n m&#237;nima sistematizada en los que presentaban baja dependencia o que a&#250;n se encontraban en fases de precontemplaci&#243;n y contemplaci&#243;n&#44; y TSN en los fumadores con alta dependencia y en fase de preparaci&#243;n&#46; Mediciones y resultados principales&#46; La abstinencia observada a los 12 meses del inicio del estudio fue&#44; en el grupo de la intervenci&#243;n m&#237;nima sistematizada&#44; del 36&#44;5&#37; en atenci&#243;n primaria y del 41&#44;8&#37; en especializada &#40;p &#62; 0&#44;05&#41;&#44; y en el grupo de la TSN&#44; del 37&#44;1 y el 35&#44;5&#37;&#44; respectivamente &#40;p &#62; 0&#44;05&#41;&#46; El porcentaje de p&#233;rdidas de seguimiento fue del 8&#44;6&#37; en especializada y del 6&#44;3&#37; en primaria&#46; Conclusiones&#46; Los resultados observados en el presente estudio nos permiten aconsejar el tratamiento del tabaquismo de forma global en el marco de la atenci&#243;n primaria&#44; bien sea mediante la denominada intervenci&#243;n m&#237;nima sistematizada o la TSN&#46;"
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                0 => array:2 [
                  "referenciaCompleta" => "Nicotine replacement therapy for smoking cessation. En: Lancaster T, Silagy C, Fullerton D, editors. Tobacco addiction. Module of the Cochrane Database of Systematic Reviews (updated 01 December 1997). The Cochrane Collaboration; Issues 1. Oxford: Update Software, 1998."
                  "contribucion" => array:1 [
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                  ]
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            ]
            38 => array:3 [
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                0 => array:3 [
                  "referenciaCompleta" => "Altered disposition of repeated nicotine doses in rats immunized against nicotine. Nicotine&Tobacco Res 1999;1:241-9."
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Altered disposition of repeated nicotine doses in rats immunized against nicotine&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
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                          "autores" => array:4 [
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                    0 => array:2 [
                      "doi" => "10.4137/TUI.S39873"
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                        "tituloSerie" => "Nicotine&Tobacco Res"
                        "fecha" => "1999"
                        "volumen" => "1"
                        "paginaInicial" => "241"
                        "paginaFinal" => "9"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27398028"
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                  "referenciaCompleta" => "Evidence suggesting the role of specific genetic factors in cigarette smoking. Healt Psychology 1999;1:14-20."
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                    0 => array:3 [
                      "titulo" => "Evidence suggesting the role of specific genetic factors in cigarette smoking&#46;"
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Article information

ISSN: 02126567
Original language: English

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	2	0	2
2024 October	36	2	38
2024 September	29	3	32
2024 August	34	4	38
2024 July	24	2	26
2024 June	20	5	25
2024 May	11	1	12
2024 April	19	3	22
2024 March	30	5	35
2024 February	24	8	32
2024 January	41	10	51
2023 December	25	9	34
2023 November	35	11	46
2023 October	60	7	67
2023 September	35	6	41
2023 August	27	8	35
2023 July	52	2	54
2023 June	40	2	42
2023 May	38	7	45
2023 April	47	5	52
2023 March	49	4	53
2023 February	28	2	30
2023 January	25	6	31
2022 December	26	5	31
2022 November	45	7	52
2022 October	31	8	39
2022 September	35	10	45
2022 August	33	10	43
2022 July	23	8	31
2022 June	23	8	31
2022 May	33	14	47
2022 April	32	13	45
2022 March	33	14	47
2022 February	19	8	27
2022 January	23	8	31
2021 December	37	11	48
2021 November	21	9	30
2021 October	32	10	42
2021 September	18	14	32
2021 August	24	10	34
2021 July	19	9	28
2021 June	30	5	35
2021 May	28	6	34
2021 April	80	17	97
2021 March	31	5	36
2021 February	21	6	27
2021 January	17	8	25
2020 December	26	9	35
2020 November	27	9	36
2020 October	23	7	30
2020 September	24	9	33
2020 August	22	8	30
2020 July	20	6	26
2020 June	10	11	21
2020 May	26	5	31
2020 April	11	4	15
2020 March	16	4	20
2020 February	20	3	23
2020 January	26	6	32
2019 December	25	10	35
2019 November	18	11	29
2019 October	16	6	22
2019 September	28	2	30
2019 August	12	4	16
2019 July	21	13	34
2019 June	57	20	77
2019 May	184	65	249
2019 April	68	5	73
2019 March	10	9	19
2019 February	9	7	16
2019 January	5	3	8
2018 December	13	6	19
2018 November	15	7	22
2018 October	12	11	23
2018 September	21	11	32
2018 August	5	11	16
2018 July	12	2	14
2018 June	4	1	5
2018 May	3	6	9
2018 April	8	3	11
2018 March	5	1	6
2018 February	3	0	3
2018 January	4	1	5
2017 December	6	0	6
2017 November	6	1	7
2017 October	15	3	18
2017 September	7	2	9
2017 August	10	0	10
2017 July	12	1	13
2017 June	15	0	15
2017 May	20	3	23
2017 April	13	6	19
2017 March	19	0	19
2017 February	13	0	13
2017 January	7	0	7
2016 December	13	3	16
2016 November	12	3	15
2016 October	43	4	47
2016 September	16	2	18
2016 August	12	1	13
2016 July	14	6	20
2016 June	33	12	45
2016 May	13	4	17
2016 April	13	2	15
2016 March	18	4	22
2016 February	12	2	14
2016 January	9	6	15
2015 December	18	9	27
2015 November	20	1	21
2015 October	18	4	22
2015 September	20	1	21
2015 August	8	2	10
2015 July	10	4	14
2015 June	10	1	11
2015 May	8	2	10
2015 April	8	1	9
2015 March	9	5	14
2015 February	13	0	13
2015 January	19	1	20
2014 December	34	4	38
2014 November	15	0	15
2014 October	28	1	29
2014 September	16	0	16
2014 August	16	0	16
2014 July	20	0	20
2014 June	17	3	20
2014 May	13	2	15
2014 April	12	2	14
2014 March	7	0	7
2014 February	11	4	15
2014 January	14	1	15
2013 December	18	2	20
2013 November	19	3	22
2013 October	20	1	21
2013 September	15	4	19
2013 August	26	2	28
2013 July	15	0	15
2002 September	799	0	799

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