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Smoking is responsible for 13% of the Dutch morbidity load and is associated with 20.000 deaths/year. The General Practice (GP) setting is important to reach Dutch smokers. Yet, its potential is significantly underused despite existing GP smoking cessation guidelines and protocols. Improving and facilitating the realization of these guidelines and thus reaching and assisting smokers who visit the GP with smoking related complaints is an important objective to increase the public health impact of smoking cessation interventions. This proposal aims to contribute to this objective.



1. To develop a Pro Active Multicomponent Approach (PAMA) using co-creation principles in order to facilitate the realization of the Dutch smoking cessation guidelines in the General Practice by offering smoking patients with smoking related complaints evidence based interventions (EBIs) to quit smoking from four domains: 1. face to face counseling; 2.eHealth; 3. telephonic counseling; 4. group counseling;

2. To use shared decision making principles for goal setting and cessation method selection to tailor smoking cessation treatment for smokers with smoking related complaints in primary care and specific at risk groups (e.g. lower educated smoking patients);

3. To test the (cost) effectiveness, appreciation, feasibility and the likelihood of adoption;

4. To develop an PAMA implementation guideline for future national implementation.



The PAMA approach aims at increasing commitment of patients with smoking related complaints to self-chosen smoking cessation methods. The General Practitioner (GP) and Practice Nurse (PN) serve as case managers and provide available evidence based interventions (EBI) for smoking cessation to the patients. Reaching smokers will be enhanced by involving pharmacies, and by inviting EBI providers to proactively approach smokers when they have chosen one thus fostering collaboration between the primary health care setting organizations.



This proposal entails five studies:


- Study 1: Interview study among GPs, PNs and smoking patients. The goal is to make an inventory of current practice concernign smoking cessation counselingin the primary health care setting in order to assess which strategies are currently used; what characterizes practices that are currently implementing smoking cessation counseling to patients; what the facilitating and hindering factors are for smoking cessation counseling in the GP setting and adequate referral to other EBI and thus which support may be give to optimze smoking cessation counsling in the PHC setting.


- Study 2: Delphi study among Dutch experts (including GPs, PNs, researchers) to generate consensus concerning criteria to define evidence based interventions for smoking cessation; the methods that need to be included in the four domains of approaches (counseling; eHealth; telephonic cousneling; group counseling); the support and training needed for GPs, PNs and pharmacist (assistants) for effective smoking cessation counseling.


The first two studies will provide input for the development of PAMA. We will also construct an advisory board to complete the information of the studies and to create involvement and shared ownership. Furthermore we use two panels of professionals and patients to co-design the PAMA protocol which will a.o. provide us input concerning smokers's needs on methods they prefer to be offered in the GP setting.


- Study 3: Randomized controlled study (RCT) in smoking patients with pre- and posttests at 6 and 12 months with: 1. an experimental condition with the PAMA protocol; 2. an usual care condition. The main outcome measurement is (intention to treat) 7 day point prevalence abstinence. Program appreciation, level of informed decision making and reach are also assessed. In total, 900 patients will be recruited via 50 GPs. Effects in subgroups differing in educational level, smoking motivation, age and gender will also be assessed.


- Study 4: A cost effectiveness study to assess whether the PAMA method will be preferable in terms of costs, effects and utilities (overall and in the abovementioned subgroups). The health care and the societal perspective will be assessed. The (extra) costs and effects (i.e. successful quitters and quality of life) of the PAMA approach will be compared to usual care. Subgroups analyses will also be undertaken.


- Study 5: A study assessing the reactions of GPs, PNs, pharmacy professionals and other stakeholders about PAMA; the determinants of future adoption of PAMA bij the stakeholders. The results of the study will be used to develop an implementation guideline that will be discussed during a final workshop.



The results of the 5 studies will be used to develop in collaboration with the advisory group a PAMA implementation guideline for use in the GP and pharmacy settings.


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