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Discussion
We conducted a comprehensive, qualitative exploration of the patient perspective on smoking cessation among 33 primary care patients from 3 primary care clinics in North Carolina. Participants offered poignant examples of unhelpful experiences and provided a smoker's perspective on interventions and outcomes metrics. The most noteworthy suggestions were using positive messaging, making sure patients have ample time to review tobacco-related information before provider encounters, enhancing confidence in the use of NRT by starting it during office visits, embedding assistance in an addiction model, having more frequent verbal communications with clinical staff, incorporating carbon monoxide monitoring as a tool, and connecting smokers with additional resources. The effectiveness of most of these suggestions is supported in the literature, but others merit further study and inclusion in new or enhanced strategies for engaging patients.
Directly engaging patients in the design of office-based smoking cessation interventions has received little attention in the past decade. However, a few studies, focused on subgroups, support similar patient experiences and suggestions. One study used a series of focus groups and an expert panel to help design a smoking cessation program for a Veterans Affairs women's clinic. These patients sought choice through various quit options, with a particular preference for medications, telephone follow-up, and women-only group sessions. Another study surveyed 375 tobacco users that visited emergency departments in 10 urban medical centers across the United States about intervention preferences. The study found that tobacco users preferred a range of services to support quit attempts, especially medications, followed by telephone-based counseling and one-on-one counseling. Another study assessed the social, cultural, and educational barriers to smoking cessation services in HIV-positive individuals. Here patients wanted more targeted information on the effects of smoking, the difficulty of quitting, and the interactions of cessation and HIV medications.
Our participants made practical, patient-centered recommendations that are consistent with evidenced-based guidelines on behavioral and pharmacologic therapies and that can be implemented with minimal burden on a practice. These include ensuring that providers 1) show more awareness of the increasing isolation that smokers' experience, 2) provide attractive and positively framed materials while patients are waiting to be seen, 3) address smoking at every visit, and 4) acknowledge and help patients deal with issues of addiction in written and spoken communications. Some patient-generated recommendations and outcome measures could be tested in future effectiveness studies or quality-improvement initiatives, such as combining carbon monoxide monitoring with the placement of NRT patches at the point of care in conjunction with more authentic outreach to patients between visits.
This research has several limitations. Although participants were recruited from general primary care clinics, all participants had insurance and the regional smoking rate was lower than the national rate. Our sample was 70% women; men may prefer different approaches. A study of emergency department patients found that male sex and less education were positively related to greater receptivity to smoking cessation counseling. When we asked if different resources were necessary according to sex, age, or other subgroups, we heard repeatedly that such differences were irrelevant because all smokers are united in being smokers — the critical factor when considering needs and challenges.
Participants in our study may also have been particularly motivated (21% had recently quit, 67% had made a serious attempt to quit, and 79% reported receiving provider guidance to quit). People less interested in quitting may need approaches other than those identified by our sample. However, in a study published in 2012, 68.8% of US adult smokers reported that they want to quit completely, and 42.7% went at least 1 day in the previous year without a cigarette in an attempt to quit. These data suggest that the level of motivation in our sample may approach the norm.
True patient-centered research exists when the patient voice is sought early in the planning process. In this study, we obtained insight into various issues centering on the experience of being a smoker, quitting, and interacting with health care systems and providers. Because of the high prevalence of smoking in their patient populations and the commitment of the primary care workforce to prevent the development and progression of chronic diseases, practice-based research networks, such as those supported by the Agency for Healthcare Research and Quality, are particularly well suited to further develop ideas expressed by our participants to augment smoking cessation interventions. We hope our work encourages others to engage in testing new patient-centered interventions, outcomes, and dissemination strategies to help smokers achieve tobacco-free lives.
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