An Effective Strategy to Activate Physicians to Promote High Cardiovascular Risk Patients to Quit Smoking

Abstract

Background

Adult patients cared for by cardiologists, neurologists, and diabetologists are highly vulnerable to cardiovascular diseases (CVDs), which are worsened by smoking. In the past, physicians of these three specialties at major hospitals in Taiwan always referred patients to family medicine and chest medicine departments for smoking cessation programs. However, the participation rate in these programs was unsatisfactory.

Objectives

To encourage cardiologists, neurologists, and diabetologists to provide smoking cessation treatment services (SCTSs) to their patients through an annual contest.

Methods

Sequential expert meetings, group training, a contest to reward service quantity and abstinence rate, and an annual awards ceremony were held over the past 3 years.

Results

More than 350 cardiologists, neurologists, and diabetologists were certified to provide SCTSs, and in the second half of 2020, 3716 high CVD risk patients entered smoking cessation treatment programs, with an abstinence rate exceeding 30% at 3 months.

Conclusions

The strategy used in this study was effective in overcoming physician inertia to provide SCTSs and encourage high CVD risk smokers to quit smoking.

INTRODUCTION

Smoking is a strong risk factor for cardiovascular diseases (CVDs), including heart disease and cerebrovascular disease, both of which have been listed among the top 5 leading causes of death in Taiwan for the past 35 years (Taiwan Department of Health and Welfare, https://www.mohw.gov.tw/np-128-2.html). Accumulating data have confirmed the beneficial effects of abstinence from smoking on CVD.^1,2 Although several strategies have been applied in Taiwan to reduce the prevalence of smoking, 13.0% of adults are still smokers [Health Promotion Administration (HPA), https://www.hpa.gov.tw/Pages/List.aspx?nodeid=1719]. The prevalence is even higher in patients with CVD. For example, more than 50% of patients with ST-elevation myocardial infarction have been reported to be current smokers, and more than 75% of those below 35 years of age.^3,4 The HPA of Taiwan launched a second-generation smoking cessation treatment program in 2012, which offers drugs such as varenicline, bupropion, and different preparations of nicotine free of charge, and free education from counselors. In addition, service payments are given to the physicians, counselors, and pharmacists, based on the registration with the HPA Virtual Private Network (VPN) system of smokers who fulfill the enrollment criteria and receive smoking cessation treatment services (SCTSs). In the past, the service was mainly provided by family medicine physicians or chest specialists at clinics or during hospitalization. Although other physicians including cardiologists, neurologists, diabetologists, and nephrologists referred patients for SCTSs, they were generally not certificated for SCTSs and not familiar with the treatment program, nor did they monitor referral outcomes. Therefore, it was estimated that only a small percentage of smokers with CVD really entered treatment programs.

In early 2018, the presidents or representatives of 7 medical societies closely related to CVD met and reached a consensus to promote smoking cessation to reduce the cardiovascular (CV) risk of smokers (see Supplementary Data). In addition, they agreed that physician members of the 7 societies should be encouraged and trained to provide SCTSs to their patients who smoked. Furthermore, to encourage participation, a contest to reward SCTS goals was proposed by the corresponding author. Thereafter, group training of physicians to get certified for SCTSs followed by a contest were planned and executed. Here, we report the outcomes of the past 3 years.

METHODS

This study was approved by the Institutional Review Board (Approval No: 21MMHIS186e) of MacKay Memorial Hospital, Taipei, Taiwan.

Group training

Following the meeting, support was sought from the HPA for the training course, and a virtual online course and physical course were designed (Table 1). In order to promote the training course and contest to physicians, expert meetings were arranged for directors of departments in medical centers and major regional hospitals, and SCTSs conducted by family medicine physicians were demonstrated.

Table 1. Evolution of the HPA training course time length for physicians and counselors to get certificated for smoking cessation treatment program.

	2017	2018	2019 and after
Physician
Online course	0	5 hrs before physical course	6 hrs before physical course
Physical course	7 hrs in 1 day	3 hrs in 1 day	2 hrs in 1 day
Total	7 hrs	8 hrs	8 hrs
Counselor
Online course	0	0	19 hrs before physical course
Physical course	34 hrs in 5 days	34 hrs in 5 days	14 hrs in 3 days
Extracurricular practical training	15 hrs within half a year	15 hrs within half a year	10 hrs within half a year
Total	49 hrs	49 hrs	43 hrs

HPA, Health Promotion Administration; hrs, hours.

Physicians’ training course time lengths with online course 5 hrs and physical course 3 hrs were only for the service contest in 2018.

Contest

The HPA also supported the contest and recommended awards for: 1) "service king" (a physician who personally recruited the most smokers into the HPA treatment program), 2) "referral king" (a hospital department which referred the most smokers to other departments of the same hospital, and the referred smokers were successfully enrolled into the HPA treatment program), and 3) "success king" (best 3-month abstinence rate of the patients treated by a department of a hospital; data were based on phone calls by the counselors of the hospitals). All data were provide and audited by the HPA using the VPN system. The prizes included gold, silver, and bronze medals, and the winners were awarded money equivalent to the prices of various carbon monoxide detectors for smokers. The contest was planned for cardiologists in the first year, cardiologists and neurologists in the second year, and cardiologists, neurologists and diabetologists in the third year.

All of the data used for the contest were provided by the HPA, including the name and affiliation of participating physicians, number of patients treated by each physician, number of patients referred by the participating physicians to other departments for smoking cessation, and the number of patients who had not smoked at 3 months post entry to the smoking cessation treatment program for each participating physician.

Statistics

Comparisons of the 3-month abstinence rates in each of the past 3 years were conducted using the chi-squared test. Data were analyzed using SPSS version 21.0 (IBM, Armonk, New York). A p value < 0.05 was considered statistically significant.

RESULTS

Between April and June 2018, the Taiwan Society of Lipids and Atherosclerosis arranged 3 cardiology expert meetings in northern, central, and southern Taiwan to promote the contest. Subsequently, the physical course (Table 1) also took place in northern, central, and southern Taiwan. The first-year contest started in July and ended in November 2018, followed by an awards ceremony. The number of hospitals and physicians joining the contest and the achievements are respectively summarized in Tables 2 and 3.

Table 2. Hospitals and physicians participating in the smoking cessation service contest.

	2018	2019	2020
Hospitals
Medical centers (n)	12	13	17
Regional hospitals (n)	9	18	26
Total	21	31	43
Physicians
Cardiologists (n)	308	215	274
Neurologists (n)	-	138	80
Endocrinologists (n)	-	-	105
Total	308	353	459

Table 3. Patients registered in the HPA VPN system for smoking cessation service in the contests and the 3-month abstinence rate.

	2018	2019	2020
The whole contest
Enrollment period	7/1-11/15	7/1-11/30	7/1-12/15
Direct service (n)	538	1785	1828
Referral (n)	449	481	1888
Total	987	2266	3716
3-month point abstinence analysis
Enrollment period	7/1-8/15	7/1-8/31	7/1-9/15
Registered patients (n)	166	676	1088
Abstinent (n)	34	191	378
Abstinence rate*	20.4%	28.3%	34.7%

* Chi-squared test for trend, p = 0.004.

HPA, Health Promotion Administration; VPN, Virtual Private Network.

Since this model of promotion, including group training, service contest, and awards ceremony was shown to be workable, it was repeated in 2019 and 2020. Data showed that the numbers of hospitals and their physicians joining the contest increased over the 3 years (Table 2), as did the number of patients entering the smoking cessation treatment program (Table 3). In addition, the 3-month abstinence rate continued to significantly increase (Table 3).

DISCUSSION

The advantages of having specialists providing SCTSs to their own patients with CVD or at high risk of CVD are as follows. First, the physicians would be familiar with their patients’ condition, and would have a greater influence on getting their patients to quit smoking compared to physicians of other departments, who would need time to review the charts to understand the referred patients. Second, specialists can easily monitor the patients’ smoking status during outpatient department follow-up visits and reinforce the harms of smoking. Third, when specialists start SCTSs, they would pass the knowledge and skills to resident physicians and medical students during hospital activities such as ward rounds and case discussions, and this would help to create a culture for young physicians to join the service. Finally, although smoking cessation services should be provided by any physician to their patients who smoke, healthcare expenses are also a consideration, and the costs saved after smoking cessation in smokers with CVD or at high risk of CVD would exceed those of low risk smokers. This is important when resources for smoking cessation treatment programs are limited as in Taiwan and in many other countries.

Tobacco smoking is the leading cause of preventable death in the world. The barriers to providing smoking cessation services by physicians include a lack of knowledge, lack of awareness, and ineffectiveness to overcome the inertia of daily routine practice.^5-7 Many physicians in Taiwan advise smokers in their clinics to stop smoking. However, a lack of adequate knowledge and, most importantly, a regular monitoring system for the effectiveness of cessation programs are major reasons for failure in this regard. Few studies have described group training or programs promoting smoking cessation among physicians,⁸ and most of them have involved only family physicians.^9,10 In the present study, for the first time in Taiwan, we report a group training system for physicians from different departments, including cardiologists, neurologists and endocrinologists which has been conducted for 3 years. Through sequential expert meetings, organized training courses, contest of service quantity and abstinence rate, and annual awards ceremony, more than 350 physicians have been certified for smoking cessation services and provided SCTSs to their own patients who were smokers with CVD or at high risk of CVD.

Training nurses to become SCTS counselors is also very important. When we started the training course for physicians, we found that the number of certificated counselors in all hospitals was limited. Moreover, for the second-year contest, cardiologists of several hospitals reported that they were unable to continue to join the contest because of a lack of counselors in their own departments. This led to a decrease in the number of participating cardiologists in the second year. We also noted that the training for counselors was time-consuming (Table 1). We advised the HPA to reform the training course, as they had for physicians. In addition, we encouraged all participating hospitals to ask their case managers for patients with coronary artery disease, heart failure, stroke, and diabetes to get certified and join the contest. All of the counselors were connected by social media, and we found that the counselors in each hospital played a key role in the contest.

There were several limitations to the present study. First, we did not have data on the characteristics of the patients, including age, sex, risk factor distribution, and medications used to help stopping smoking. Therefore, we could not analyze the factors affecting the success of abstinence from smoking. In addition, data on smoking status after 3 months of abstinence were not available, and the relapse rate was not clear. Further studies are required to clarify these important issues.

CONCLUSIONS

We report an effective strategy to promote smoking cessation in high CV risk smokers by holding a contest for specialists of CVD, stroke, and diabetes, preceded by expert meetings for directors and an online plus shortened physical training course for physicians and counselors. Currently, the fourth year activities are underway, and involve all 3 specialist plus nephrologists. We think this strategy may help other countries to reduce CVD and the healthcare burden attributed to smoking.

SUPPLEMENTARY DATA

Consensus meeting of 7 medical societies

In early 2018, the corresponding author (the President of Taiwan Society of Lipids and Atherosclerosis then), when conducting a project of HPA, recognized the physician inertia. In March 10, 2018, he invited presidents/representatives of 6 other CVD closely relevant societies (Taiwan Society of Cardiology, Taiwan Society of Cardiovascular Intervention, Taiwan Stroke Society, The Diabetes Association of the Republic of China (Taiwan), Taiwanese Association of Diabetes Educators, and Taiwan Society of Nephrology) to discuss how to promote physicians to provide SCTS for their own patients. All the attendees agreed that the issue was important and the societies should take action to encourage their physician members to join SCTS. A practical way for physicians to update their knowledge and skills of SCTS suggested by some attendees was to urge the physicians to attend the training course provided by the HPA. Barriers for physicians to attend the course and get certificated by the HPA were identified, and the most criticized one was that the training took one whole day of physical course. The consensus of the meeting was a high priority for physicians to promote smoking cessation to reduce CV risk of their patients, and physician members of the 7 societies should be encouraged and trained to provide SCTS to their patients who smoked. In addition, to facilitate the encouragement, a contest to award SCTS was proposed by the corresponding author and accepted. Thereafter, a strategy to organize group training of physicians to get certified for SCTS followed by contest of the service was planned and took actions. Here, we reported the outcome in the past 3 years.

Training

How physicians advise patients to stop smoking and the strategy are essential elements of the training course for physicians to get certified. The details are in the guidelines (https://health99.hpa.gov.tw/storage/pdf/materials/21780.pdf) and consultation skills for physicians (https://quitsmoking.hpa.gov.tw/Download/qu2010ng02/2015%E4%BA%8C%E4%BB%A3%E6%88%92%E8%8F%B8%E6%B2%BB%E7%99%82%E9%86%AB%E5%B8%AB%E8%AB%AE%E5%95%86%E6%8A%80%E5%B7%A7%E6%89%8B%E5%86%8A-%E7%AC%AC3%E7%89%88.pdf) issued by the Health Promotion Administration. The content of training course for the contest is essential the same as those regularly run, except that some physical classes became online video watching (see Table 1).

FUNDING

This project received funding and support from the Taiwan Society of Lipids and Atherosclerosis and Pfizer Taiwan.

DECLARATION OF CONFLICT OF INTEREST

All the authors declare no conflict of interest.