OBJECTIVE: To compare tobacco control practices of physicians and their staff in Intervention communities with those in Comparison communities of the Community Intervention Trial for Smoking Cessation (COMMIT). DESIGN: COMMIT was a randomised trial testing community-based intervention for smoking cessation carried out over four years. SETTING: Eleven matched pairs of communities assigned randomly to Intervention and Comparison conditions. PARTICIPANTS AND INTERVENTIONS: Physicians in the Intervention communities participated in continuing medical education (CME). Training for office staff focused on tobacco control and office intervention "systems". OUTCOME MEASURES: Smoking control attitudes and practices reported by primary-care physicians in the 22 communities, smoking policies, and practices of 30 randomly selected medical offices in each community, and patient reports of physician intervention activities. RESULTS: Response rates to the physicians' mail survey were 45% and 42% in Intervention and Comparison communities, respectively. Telephone interviews of office staff had response rates of 84% in both conditions. Physicians in Intervention communities were more likely to attend training than those in Comparison communities (53% and 26%, respectively (PCONCLUSIONS: The COMMIT intervention had a significant effect on some reported physician behaviours, office practices, and policies. However, most physicians still did not use state-of-the-art smoking intervention practices with their patients and there was little, or no, difference between patient reports of intervention activities of physicians in the Intervention and Comparison communities. Better systems and incentives are needed to attract physicians and their staff to CME and to encourage them to follow through on what they learn. The recently released Agency for Health Care Policy and Research clinical practice guideline for smoking cessation and other standards and policies outline these systems and offer suggestions for incentives to facilitate adoption of these practices by physicians.

OBJECTIVE: To measure the characteristics of smokers associated with the use of the nicotine skin patch in the general population and to evaluate whether use of the patch is associated with successful smoking cessation. DESIGN: Data from two surveys conducted in 20 communities in the United States as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT) study. Nicotine patch prevalence was estimated using data from a 1993 cross-sectional survey of 13691 current and former smokers. The effectiveness of the nicotine skin patch as a smoking cessation aid was evaluated adjusting for other covariants using data from a cohort tracking study of 9809 smokers who were followed between 1988 and 1993. As the nicotine patch was not available to consumers until January 1992, analyses were restricted to respondents who reported themselves to be current smokers in 1993 or former smokers who reported quitting after January 1992. OUTCOME MEASURES: Current and former smokers who reported having made a serious effort to stop smoking in the past five years were asked to indicate whether they had used the nicotine skin patch to help them stop smoking. Those answering "Yes", were classified as nicotine patch users. Smoking cessation was based on self-report. A "quitter" was defined as someone who had been a smoker as of January 1992 who reported in 1993 not smoking any cigarettes for the preceding six months or longer. RESULTS: The prevalence of nicotine patch use by smokers averaged across the 20 study communities was 12.8%, making the patch one of the most popular cessation methods used by smokers. Compared with non-users, patch users were more likely to be female, white, have higher annual household incomes, be more motivated to stop smoking, and to smoke more heavily. Among low-income smokers (annual household income below US$10000), nicotine patch use was significantly higher among those who lived in a state where the public insurance programme (Medicaid or Medi-Cal) included the patch as a benefit (12.1% vs 7.7%). Among those who made an attempt to quit smoking, the likelihood of successful quitting was more than twice as high among patch users compared with non-users. Among patch users, the highest quit rates were observed among those who used the patch for between one and three months. CONCLUSIONS: The nicotine skin patch is a popular and effective means of smoking cessation. Use of the nicotine patch, especially by low-income smokers, could be increased by reducing the out-of-pocket expenditure required for smokers to get the product.

OBJECTIVE: To obtain a baseline measure of tobacco control activities carried out by physicians and of tobacco control policies and practices in physician offices. DESIGN: All primary care physicians in 11 communities were asked through a mail survey about their tobacco control practices. Thirty offices in each community were randomly selected and interviewed by telephone to determine office policies and practices. SETTING: Both surveys assessed primary care settings in the 11 intervention communities. RESULTS: The physicians' survey (response rate, 48%) indicated that physicians report intervention with smokers more than 70% of the time, but the interventions rarely include key behavioral elements necessary for smoking modification. Physicians who received formal training in smoking cessation reported that they believed themselves to be more prepared and that they spent more time counseling patients than physicians who were not trained. The office survey (response rate, 83.2%) indicated that smoke-free policies are in place in most clinics and offices and that many offices provide printed materials on smoking cessation. However, few offices had staff to coordinate smoking cessation activities. These surveys will be repeated following the intervention phase of the Community Intervention Trial for Smoking Cessation to assess changes in counseling practices and office policies. CONCLUSION: There is a positive relationship between attending training and intervening with more cessation activities. Physicians perceive themselves as prepared to help smokers, but few are providing more than advice to stop smoking.

BACKGROUND. Data on smoking cessation and relapse for 6 yers of the Multiple Risk Factor Intervention Trial were evaluated in univariate and multivariate analyses to determine the relationship between variables measured at the beginning of the trial and smoking cessation and relapse for special intervention and usual care participants. RESULTS. The variables positively associated with smoking cessation in both the SI and the UC groups included age, education, and past success in quitting; there was a negative association with the number of cigarettes smoked per day. The expectation of quitting was positively associated with cessation in the special intervention group only, while life events, alcohol, and the presence of a wife who smokes were significant predictors of reduced cessation for the usual care group. The special intervention program may have overcome obstacles which interfered with cessation among the usual care participants. Associations with relapse were generally stronger in the usual care group than in the special intervention group. For usual care participants, multivariate analyses showed that education, past success in quitting smoking, alcohol, and life events were associated with relapse rates. For special intervention participants, only alcohol emerged as a significant predictor. CONCLUSION. The data are relevant in terms of factors that govern smoking cessation and relapse for adult smokers who take part in formal intervention programs and for those who are left to modify their behavior on their own.

BACKGROUND. The results of MRFIT smoking intervention program are presented for the 4,103 special intervention and 4,091 usual care men who reported smoking cigarettes at the first screening visit. RESULTS. Among the special intervention men, the reported cessation rate increased from 43.1% at 12 months to 48.9% at 72 months. The reported cessation rate among the usual care men increased from 13.5% at 12 months to 28.8% at 72 months. Among smokers who reported cessation at 72 months, 51.3% of special intervention men and 22.7% of usual care men had quit smoking within the first year and remained abstinent thereafter. Average thiocyanate and expired-air carbon monoxide served as objective measures of smoking and were significantly lower among the special intervention men than among the usual care men over the entire follow-up period. The reported cessation rates at 72 months varied according to initial levels of smoking. Smokers reporting 1-19 cigarettes per day at entry were more likely to quit than heavier smokers. For each category of smoking at entry (1-19, 20-39, and 40 or more cigarettes per day) significantly more special intervention than usual care smokers reported cessation. CONCLUSION. These results indicate that the MRFIT smoking intervention program was successful in promoting early cigarette smoking cessation and maintaining cessation over the entire trial for a large percentage of cigarette smokers.

The Multiple Risk Factor Intervention Trial (MRFIT) is a 6-year clinical trial for the study of the prevention of heart disease. Twelve thousand eight hundred and sixty-six men in the upper 10–15% of heart attack risk were randomly assigned to Special Intervention (SI) or Usual Care (UC). The SI participants received “risk factor” (hypertension, hypercholesterolemia, and cigarette smoking) intervention at the clinical centers; the UC participants were referred to their usual source of medical care for treatment. Forty percent of SI and 21% of UC smokers at entry reported not smoking at year 4, with lighter smokers in both treatment groups reporting significantly more cessation than heavier smokers. The greatest SI-UC difference in cessation rate was achieved during the first year of the program. The use of serum thiocyanate, an objective indicator of cigarette smoking, avoided problems inherent in self-reported data. Misreporting of smoking status was found in both groups with more occurring among the SI smokers. Cohort analysis revealed that of the smokers who stopped during the first year of the trial, 68% of SI and 57% of UC remained abstinent through the 4-year follow-up. Of the smokers who stopped later in the program the UC had better maintenance rates than the SI.

The development, implementation, and results of the smoking cessation program of the Multiple Risk Factor Intervention Trial (MRFIT) are presented. The MRFIT is a 6-year clinical trial designed to investigate the effects of reducing cardiovascular risk factors -- elevated cholesterol, hypertension, and cigarette smoking -- in a group of asymptomatic men at high risk of cardiovascular disease. The men participated in an integrated intervention program that offered both group and individual formats, a structured maintenance program for those who stopped smoking, and an extended intervention program for those unable to quit initially. Results among the original 4,103 smokers included a 47.3% quit rate 4 months after program initiation and a 45.9% quit rate after 4 years. Of those reporting no smoking at 4 months, 56% were abstinent at all visits through 48 months. Most recidivism occurred soon after initial cessation, with 17% of the men who reported quitting at 4 months reporting smoking 4 months later. The quit rates were strongly associated with the initial level of smoking, with light smokers reporting higher quit rates and lower recidivism rates at all visits through 4 years. Results exceed trial goals whether measured by self-reports or by thiocyanate levels, an objective assessment of smoking behavior. Discussion focuses on understanding the variables contributing to smoking cessation and to achieving the goals of reduction of risk of cardiovascular disease.