Factors associated with rates of tobacco treatment delivery by General Practitioners in Greece: Missed opportunities for prevention?
More details
Hide details
Clinic of Social and Family Medicine, Department of Medicine, University of Crete, Heraklion, Greece
Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
Faculty of Medicine, University of Ottawa, Ottawa, Canada
School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
Sophia Papadakis   

Clinic of Social and Family Medicine, Department of Medicine, University of Crete, Heraklion, Crete, Greece
Publish date: 2018-05-21
Tob. Induc. Dis. 2018;16(May):21
This study investigates the clinic-, provider- and patient-level factors associated with delivery of 4 (Ask, Advise, Assist, Arrange) elements of the 5As approach to smoking cessation in general practice in Greece.

We conducted a secondary analysis of data derived from a quasiexperimental study (The TiTAN Crete study) among general practitioners (GPs) in Crete, Greece in 2015–2016. Twenty-four GPs and a cross-sectional sample of 1301 smokers from their practices were surveyed. This paper reports on the results of the multi-level modelling conducted to examine predictors of 4As delivery.

Our analysis found clinic characteristics, including the presence of an electronic medical record, being located in a rural setting, and being in private practice were significantly associated with increased rates of tobacco treatment delivery. Female GPs were more likely than males to arrange follow-up (AOR 3.38, 95%CI 1.11, 10.35). Our analysis found a variety of patient-level factors were positively associated with tobacco treatment delivery, including: longer smoking history; presence of a smoking related illness; readiness to quit smoking; and symptoms or a diagnosis of anxiety, depression or other mental health illness. Other patient-level factors were negatively associated with tobacco treatment delivery, including level of education and reason for visit. Patients seen in clinic for episodic care were less likely to be ‘asked’ (AOR 0.22, 95%CI 0.12, 0.39), ‘advised’ (AOR 0.22, 95%CI 0.13, 0.38), and receive ‘assistance’ (AOR 0.36, 95%CI 0.19, 0.66) compared to patients seen in clinic for a medical examination.

Providers are significantly more frequently delivering tobacco treatment to a sub-group of high-risk patients compared to other tobacco users in their clinical practice. This results in missed opportunities for early intervention and disease prevention.

World Health Organization. WHO Global Report: Mortality Attributable To Tobacco. Published, 2012. Accessed February 13, 2018.
World Health Organization. WHO Report on the Global Tobacco Epidemic 2008. Published, 2008. Accessed January 14, 2018.
Behrakis P, Bilir N, Clancy L et al. 2017 Guidelines for Treating Tobacco Dependence. 4th ed. Brussels, Belgium: European Publishing; 2017.
European Commission. Special Eurobarometer 458. Attitudes of Europeans towards Tobacco and Electronic Cigarettes. file:///C:/Users/user/Downloads/ebs_458_sum_en%20(3).pdf. Published May, 2017. Accessed February 13, 2018.
Ganry O, Boche T. Prevention practices and cancer screening among general practitioners in Picardy, France. Public Health. 2005;119(11):1023-1030. doi:10.1016/j.puhe.2005.02.004
Cornuz J, Humair J-P, Seematter L, et al. Efficacy of resident training in smoking cessation: a randomized, controlled trial of a program based on application of behavioral theory and practice with standardized patients. Ann Intern Med. 2002;136(6):429-437. doi:10.7326/0003-4819-136-6-200203190-00006
Van Schayck OCP, Williams S, Barchilon V, et al. Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG. NPJ Prim Care Respir Med. 2017;27(1):38. doi:10.1038/s41533-017-0039-5
Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract. 2004;53(12):974-980. Accessed February 9, 2018.
Fiore M, Jaén C, Baker T, et al. Treating Tobacco Use and Dependence: 2008 Update. Published May, 2008. Accessed January 14, 2018.
Vogt F, Hall S, Marteau TM. General practitioners’ and family physicians’ negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction. 2005;100(10):1423-1431. doi:10.1111/j.1360-0443.2005.01221.x
Brotons C, Björkelund C, Bulc M, et al. Prevention and health promotion in clinical practice: the views of general practitioners in Europe. Prev Med. 2005;40(5):595-601. doi:10.1016/j.ypmed.2004.07.020
Girvalaki C, Papadakis S, Vardavas C, et al. Training general practitioners in evidence-based tobacco treatment: an evaluation of the Tobacco Treatment Training Network in Crete (TiTAN-Crete) intervention. Heal Educ Behav. In press.
Papadakis S, McDonald PW, Pipe AL, Letherdale ST, Reid RD, Brown KS. Effectiveness of telephone-based follow-up support delivered in combination with a multi-component smoking cessation intervention in family practice: A cluster-randomized trial. Prev Med. 2013;56(6):390-397. doi:10.1016/j.ypmed.2013.02.018
Papadakis S, McDonald P, Mullen K-A, Reid R, Skulsky K, Pipe A. Strategies to increase the delivery of smoking cessation treatments in primary care settings: A systematic review and meta-analysis. Prev Med. 2010;51(3-4):199-213. doi:10.1016/j.ypmed.2010.06.007
Anderson P, Jane-Llopis E. How can we increase the involvement of primary health care in the treatment of tobacco dependence? A meta-analysis. Addiction. 2004;99:299-312. doi:10.1111/j.1360-0443.2003.00672.x
Girvalaki C, Papadakis S, Vardavas C, Pipe A, Lionis C. Tobacco treatment TrAining Network in Crete (TiTAN-Crete): protocol for a controlled before-after study. Tob Prev Cessat. 2016;2(June). doi:10.18332/tpc/63823
Papadakis S, Cole AG, Reid RD, et al. Increasing Rates of Tobacco Treatment Delivery in Primary Care Practice: Evaluation of the Ottawa Model for Smoking Cessation. Ann Fam Med. 2016;14(3):235-243. doi:10.1370/afm.1909
Karekla M, Pilipenko N, Feldman J. Patient Health Questionnaire: Greek language validation and subscale factor structure. Compr Psychiatry. 2012;53(8):1217-1226. doi:10.1016/j.comppsych.2012.05.008
Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord. 2010;122(1-2):86-95. doi:10.1016/j.jad.2009.06.019
Chaiton MO, Cohen JE, McDonald PW, Bondy SJ. The Heaviness of Smoking Index as a predictor of smoking cessation in Canada. Addict Behav. 2007;32(5):1031-1042. doi:10.1016/j.addbeh.2006.07.008
Pérez-Ríos M, Santiago-Pérez MI, Alonso B, Malvar A, Hervada X, de Leon J. Fagerstrom test for nicotine dependence vs heavy smoking index in a general population survey. BMC Public Health. 2009;9:493. doi:10.1186/1471-2458-9-493
Papadakis S, Gharib M, Hambleton J, Reid RD, Assi R, Pipe AL. Delivering evidence-based smoking cessation treatment in primary care practice: experience of Ontario family health teams. Can Fam Physician. 2014;60(7):e362-371. Accessed February 9, 2018.
Azuri J, Peled S, Kitai E, Vinker S. Smoking prevention and primary physician’s and patient’s characteristics. Am J Health Behav. 2009;33(6):710-717. Accessed February 9, 2018.
Grandes G, Cortada JM, Arrazola A, Laka JP. Predictors of long-term outcome of a smoking cessation programme in primary care. Br J Gen Pract. 2003;53(487):101-107. Accessed February 9, 2018.
Schnoll RA, Rukstalis M, Wileyto EP, Shields AE. Smoking Cessation Treatment by Primary Care Physicians. Am J Prev Med. 2006;31(3):233-239. doi:10.1016/j.amepre.2006.05.001
Boyle R, Solberg L, Fiore M. Use of electronic health records to support smoking cessation. Cochrane Database Syst Rev. 2014;(12):CD008743. doi:10.1002/14651858.CD008743.pub3
Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004;328(7455):1519. doi:10.1136/bmj.38142.554479.AE
Martínez C, Castellano Y, Andrés A, et al. Factors associated with implementation of the 5A’s smoking cessation model. Tobacco Induced Diseases. 2017;15:41. doi:10.1186/s12971-017-0146-7