Background
Smoking is a cause of many health problems, including cancers, heart and lung diseases. Health professionals (e.g. doctors, nurses, pharmacists, dentists, etc.) may be able to reduce this harm by helping smokers to quit during a clinic visit. However, it may be difficult for health care providers to recognize smokers. They may also feel they cannot deliver good support as they do not have enough time, skills, training, budget or resources. A change within health professionals' wider organization may help to improve their involvement in care to help people to stop smoking, and in turn improve the chances of them quitting smoking. These changes may include introducing a system for asking patients if they smoke and recording smoking status on the patient health records; providing health care providers with training, budget or resources to help them deliver more effective quitting support; identifying a dedicated staff member to provide quitting support; introducing new rules to restrict smoking or support quitting activities; introducing advice to quit smoking into routine care; and paying health workers for delivering cessation support. This review aimed to find out whether implementing these organizational changes improves health professionals’ involvement in quit smoking activities, and whether it helps smokers stop smoking. We assessed the following activities by health professionals to evaluate their involvement in quit smoking activities: 1) asking about tobacco use; 2) documenting smoking status on patient health records; 3) advising smokers to quit; 4) counselling to quit; 5) providing medicines to quit smoking; and 6) referring to other centers such as quitlines (a telephone support service for smokers to quit) where smokers can obtain further help.
Study characteristics
We searched for studies published up to February 2016.
Our search identified seven studies which investigated changes made to the way organizations offered stop-smoking support in healthcare settings; six studies were conducted in the USA and one in Spain. Two studies evaluated the changes implemented in primary care clinics and another two studies evaluated changes in dental clinics. One study each evaluated changes in community pharmacy, Veterans Affairs Medical Center and pediatric practice. All included studies were supported or funded by government agencies.
None of the studies implemented all the recommended changes or activities listed above. Five studies implemented four types of changes and two studies implemented three types of changes. Identifying all smokers, training health professionals and advising smokers to quit were part of all included studies.
Key results
Of the seven studies identified, only four evaluated the effect of organizational changes on study participants' quitting status. Of these, two found that organizational changes helped people to quit smoking, but the other two studies reported that they did not, and hence no conclusion could be drawn on this factor. Activities such as counselling to quit, recording smoking status in patient health records, and referring smokers to an outside stop-smoking clinic improved after those changes were made. Of the three studies which evaluated factors such as asking about tobacco use and advising to quit, two reported that organizational changes could improve both of those factors.
Quality of the evidence
The overall quality of the evidence was judged to be low because of the small number of available studies and inadequate study designs. More well-conducted studies are needed to fill this knowledge gap. Some studies are already underway but need to be evaluated in detail to include in the review.
The available evidence suggests that system change interventions for smoking cessation may not be effective in achieving increased cessation rates, but have been shown to improve process outcomes, such as documentation of smoking status, provision of cessation counselling and referral to smoking cessation services. However, as the available research is limited we are not able to draw strong conclusions. There is a need for additional high-quality research to explore the impact of system change interventions on both cessation and system-level outcomes.
System change interventions for smoking cessation are policies and practices designed by organizations to integrate the identification of smokers and the subsequent offering of evidence-based nicotine dependence treatments into usual care. Such strategies have the potential to improve the provision of smoking cessation support in healthcare settings, and cessation outcomes among those who use them.
To assess the effectiveness of system change interventions within healthcare settings, for increasing smoking cessation or the provision of smoking cessation care, or both.
We searched databases including the Cochrane Tobacco Addiction Group Specialized Register, CENTRAL, MEDLINE, Embase, CINAHL, and PsycINFO in February 2016. We also searched clinical trial registries: WHO clinical trial registry, US National Institute of Health (NIH) clinical trial registry. We checked ‘grey' literature, and handsearched bibliographies of relevant papers and publications.
Randomized controlled trials (RCTs), cluster-RCTs, quasi-RCTs and interrupted time series studies that evaluated a system change intervention, which included identification of all smokers and subsequent offering of evidence-based nicotine dependence treatment.
Using a standardized form, we extracted data from eligible studies on study settings, participants, interventions and outcomes of interest (both cessation and system-level outcomes). For cessation outcomes, we used the strictest available criteria to define abstinence. System-level outcomes included assessment and documentation of smoking status, provision of advice to quit or cessation counselling, referral and enrolment in quitline services, and prescribing of cessation medications. We assessed risks of bias according to the Cochrane Handbook and categorized each study as being at high, low or unclear risk of bias. We used a narrative synthesis to describe the effectiveness of the interventions on various outcomes, because of significant heterogeneity among studies.
We included seven cluster-randomized controlled studies in this review. We rated the quality of evidence as very low or low, depending on the outcome, according to the GRADE standard. Evidence of efficacy was equivocal for abstinence from smoking at the longest follow-up (four studies), and for the secondary outcome ‘prescribing of smoking cessation medications' (two studies). Four studies evaluated changes in provision of smoking cessation counselling and three favoured the intervention. There were significant improvements in documentation of smoking status (one study), quitline referral (two studies) and quitline enrolment (two studies). Other secondary endpoints, such as asking about tobacco use (three studies) and advising to quit (three studies), also indicated some positive effects.