Effects of practitioner education, practitioner payment and reimbursement of patients' drug costs on smoking cessation in primary care: a cluster randomised trial

Objective: To evaluate new strategies to enhance the promotion of smoking cessation in general practice. Design: Cluster randomised trial, 262 factorial design. Setting: 82 medical practices in Germany, including 94 general practitioners. Participants: 577 patients who smoked at least 10 cigarettes per day ( irrespective of their intention to stop smoking) and were aged 36 - 75 years. Interventions: Provision of a 2- h physician group training in smoking cessation methods and direct physician payments for every participant not smoking 12 months after recruitment ( TI, training+ incentive); provision of the same training and direct participant reimbursements for pharmacy costs associated with nicotine replacement therapy or bupropion treatment ( TM, training+ medication). Main outcome measure: Self- reported smoking abstinence obtained at 12 months follow- up and validated by serum cotinine. Results: In intention- to- treat analysis, smoking abstinence at 12 months follow- up was 3% ( 2/ 74), 3% ( 5/ 144), 12% ( 17/ 140) and 15% ( 32/ 219) in the usual care, and interventions TI, TM and TI+ TM, respectively. Applying a mixed logistic regression model, no effect was identified for intervention TI ( odds ratio ( OR) 1.26, 95% confidence interval ( CI) 0.65 to 2.43), but intervention TM strongly increased the odds of cessation ( OR 4.77, 95% CI 2.03 to 11.22). Conclusion: Providing cost- free effective drugs to patients along with improved training opportunities for general practitioners could be an effective measure to achieve successful promotion of smoking cessation in general practice.