Vol.2, No.11, 1272-1279 (2010)
doi:10.4236/health.2010.211189
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
Supporting smoking cessation in healthcare: obstacles
in scientific understanding and tobacco addiction
management
Dianne de Korte1*, Onno C. P. van Schayck1,2, Paul van Spiegel2,3, Ad A. Kaptein2,4,
Alfred Sachs2,5, Maureen Rutten-van Mölken2,6, Niels Chavannes2,4, Trudi Tromp-Beelen2,7,
Rik Bes2,8, Remi Allard2,9, Gerard Peeters2,10, Leo Kliphuis2,11, Jan Willem Schouten2,
Lies van Gennip2,12, René van Ommen2,13, Javier Asin2,14
1Department of General Practice, Maastricht University Medical Centre, School CAPHRI, Maastricht, the Netherlands;
*Corresponding Author: dianne.dekorte@maastrichtuniversity.nl;
2MIRO Innovation in Smoking Cessation, Core Team, the Netherlands;
3Slotervaart Hospital, Amsterdam, the Netherlands;
4Leiden University Medical Center, Leiden, the Netherlands;
5Julius Center for Health Sciences and Primary Care, Utrecht, the Netherlands;
6Erasmus University Rotterdam, Rotterdam, the Netherlands;
7Jellinek Clinic, Amsterdam, the Netherlands;
8Centre for Motivation and Change, Hilversum, the Netherlands;
9VU University Medical Center, Amsterdam, the Netherlands;
10St. Elisabeth Hospital, Tilburg, the Netherlands;
11Netherlands Association of Organized Primary Healthcare, Utrecht, the Netherlands;
12STIVORO, Den Haag, the Netherlands;
13Pfizer BV, Capelle aan den IJssel, the Netherlands;
14ACSION, Zeist, the Netherlands.
Received 30 August 2010; revised 9 September 2010; accepted 16 September 2010.
ABSTRACT
Despite ongoing efforts to reduce tobacco smo-
king, the smoking prevalence in many countries
has remained stable for years. This may be a
consequence of either lack of knowledge about
effective ways to reduce smoking, or failing
treatment of tobacco addiction in healthcare.
This study explored gaps in the current under-
standing of smoking cessation and the chal-
lenges facing tobacco addiction management in
order to formulate recommendations for future
research and healthcare practice. A narrative
review was written to determine areas in which
more research is needed as well as areas in
which sufficient knowledge is already available.
Recommendations for future research were
prioritised using a Delphi-procedure. Recom-
mendations for healthcare practice were con-
firmed by expert’s assessment. Smoking is not
widely acknowledged as an addiction and a
relatively small number of smokers ask help
from a healthcare professional when trying to
stop smoking. Most healthcare professionals
recognise the importance of advising patients to
stop smoking, but experience certain barriers to
actually do this. Overall, healthcare profession-
als need to be convinced that tobacco smoking
is an addiction and should be treated likewise. If
all healthcare professionals systematically ad-
vise their patients to give up smoking, eventu-
ally more smokers will successfully stop smo-
king.
Keywords: Tobacco Addiction; Smoking Cessation;
Smoking Cessation Interventions; Healthcare
Practice; Tobacco Control
1. INTRODUCTION
Today almost everyone in the world is aware of the
adverse health consequences of smoking, and studies of
ways to reduce smoking are numerous. In addition to the
health consequences and their associated costs, smoking
results in productivity loss by employees that smoke,
which also impacts the economy [1,2]. Moreover, smo-
king threatens to increase the health disparity among
socioeconomic classes since a greater number of smok-
D. de Korte et al. / HEALTH 2 (2010) 1272-1279
Copyright © 2010 SciRes. http://www.scirp.org/journal/HEALTH/Openly accessible at
1273
ers from higher socioeconomic classes stop smoking,
with the consequence that a larger portion of the remain-
ing smokers are from lower socioeconomic classes [3,4].
Despite ongoing efforts to reduce tobacco smoking,
the smoking prevalence in the Netherlands and many
other developed countries has remained stable for years.
This stabilization may be a consequence of either lack of
knowledge about effective ways to reduce smoking, or
failed treatment of tobacco addiction. In order to find
explanations for this stabilization, MIRO began the pre-
sent study in 2008 to investigate gaps in the current un-
derstanding of smoking cessation and the challenges
facing tobacco addiction management in the Netherlands.
MIRO is a care optimization program in which smoking
cessation experts in the Netherlands work together. The
MIRO core team is focused on promoting collaboration
between all parties involved in tackling tobacco addic-
tion in the Netherlands (with the exception of the first
author mentioned, all of the other authors who contrib-
uted to this article are members of the MIRO core team).
This study is based on the view that healthcare profes-
sionals play an essential role in supporting individuals
who are trying to stop smoking. In 2007, 70% of Dutch
smokers did not resort to any form of support (cessation
aids and/or assistance) during their most recent attempt
to stop [5], despite the fact that getting support results in
far greater success. The average success rate of stopping
without any support is 4% [6]. With support, however,
the success rate may rise to 20% [7]. Clearly, receiving
assistance from healthcare professionals can help more
people stop smoking successfully.
This article outlines the study’s principal findings and
provides recommendations for follow-up research and
healthcare practice. Since the focus of MIRO centres on
tobacco addiction management, smoking prevention (pri-
mary prevention) is outside the scope of this study.
2. METHODS
A systematic approach according to systematic review
guidelines would not be the best method to discover
gaps in the scientific understanding of smoking cessation.
The subject is too wide-ranging for a systematic review
and it would not be possible to determine what knowl-
edge is lacking using such a method. This study there-
fore employed a broad narrative review [8] created in the
manner described below.
2.1. Formulating Research Questions
Experts from the core team designed a smoking cessa-
tion process model as illustrated in Figure 1. It is based
on behavioral modification models and the shared view
that healthcare professionals play an important role in
supporting individuals’ attempts to stop smoking.
Research questions were created for each phase in the
cycle and are listed in Table 1.
2.2. Literature Study
The research questions were subsequently used to
identify what determines the success or failure of an
attempt to stop smoking at a specific juncture, what we
already know about this from both Dutch and interna-
tional literature, and what we have yet to learn. Informa-
tion was gathered from the “Tobacco Addiction” topic in
the Cochrane Database of Systematic Reviews, publica-
tions from STIVORO and the Dutch National Institute
for Public Health and the Environment (RIVM), as well
as from the personal archives of the core team members.
In order to ensure that no essential publications were
overlooked, a search was performed using Medline for
every research question encompassing the past 15 years
(1993 - September 1, 2008), using the term “smoking ce-
ssation” in combination with each of these terms: “to-
bacco control”, “parenting”, “peers”, “school-based”,
“worksite”, “primary care”, “hospital setting”, “health-
care professionals”, “genetics”, “public health”, “guide-
line”, “behavioral treatment”, “pharmacological treat-
ment”, “harm reduction” and “relapse”.
The search for literature resulted in 30 relevant arti-
cles and reports [5,7,9-36].
2.3. Expert Assessment
After writing the literature review, each member of
the core team suggested additions and provided critiques
based on his or her own expertise. The core team as a
whole then considered these comments. After complet-
ing this process, a consensus was reached on the narra-
tive review.
2.4. Recommendations for Follow-Up
Research: Delphi Procedure
The realization that certain information was lacking
resulted in recommendations for follow-up research.
These recommendations were prioritized using a Delphi
procedure.
Each member of the core team was given a list with
all of the recommendations for follow-up research ap-
pearing in the review. During the first round of the Del-
phi procedure, each core team member individually
produced his or her own top-10 list of recommendations.
From that, a top-15 list of recommendations was com-
piled. Each of the twelve core team members then
judged these recommendations based on three dimen-
D. de Korte et al. / HEALTH 2 (2010) 1272-1279
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1274
Figure 1. Optimal smoking cessation process according to the MIRO core team [Clockwise, starting at noon].
sions, i.e. speed, importance, and impact, during a sec-
ond round. Speed refers to how quickly the recommen-
dation will lead to relevant results (more successful smo-
king cessation attempts). Importance relates to its overall
importance to society, and impact refers to what effect it
will have on an individual level. The recommendations
were grouped according to speed in short-term (< 2
years), medium-term (2-4 years), and long-term (> 4
years) research. Prioritization was based on the (impor-
tance * impact) score.
Openly accessible at
2.5. Recommendations for Healthcare
Practice: Expert Assessment
Recommendations for healthcare practice were formu-
lated for areas in which adequate knowledge was avail-
able, and the experts in the MIRO core team subse-
quently checked these. The main focus was on recom-
mendations addressed to healthcare professionals that
could result in more people stopping smoking in a short
period of time once implemented.
3. RESULTS
The results of the literature study on healthcare re-
search and healthcare practice are discussed below, re-
stricted to the outlined phases of the cycle in Figure 1
(from Smoker’s choice to Smoker’s persistence).
3.1. Asking Healthcare Professionals for
Help
Smoking is an addictive illness that makes stopping
extremely difficult for many people. However, many peo-
ple, including smokers and healthcare professionals, still
regard it as merely a bad habit. This reinforces the idea
that smokers do not actually need help when trying to
stop.
Remarkably few people in the Netherlands seek ad-
vice and/or support from a healthcare professional when
trying to stop smoking. This is worrying for many rea-
sons including the fact that smokers are dependent on a
physician for many pharmacological resources. In 2006,
only 5% of those trying to stop in the Netherlands sought
assistance, in comparison to the European average of
18%. No less than 41% of individuals attempting to stop
in England sought help. The figure in Belgium was 25%.
There are a number of explanations as to why smokers
do not seek help from healthcare professionals, including:
1) smokers’ ignorance of the support which healthcare
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Table 1. Research questions.
Smoking status of the population
Q1.Why is focusing on and investing in smoking cessation so important?
Environmental influences
Q2. How is a person influenced by his or her environment?
Q3. What are the effects of interventions carried out by people from the smoker’s environment?
Q4. How can the influence of a person’s environment be better utilized?
Consultation with a healthcare professional to stop smoking
Q5. Why is it important for a smoker to see a healthcare professional?
Q6. How many smokers are currently seeing healthcare professionals?
Q7. Why aren’t more smokers seeing healthcare professionals and how can this situation be improved?
Healthcare professional’s treatment strategy
Q8. Why is it important to create a smoker’s profile?
Q9. How effective are the various smoking cessation methods and which one is the best?
Q10. What are healthcare professionals currently doing?
Q11 . Why aren’t healthcare professionals doing more and how can this be improved?
Smoker receives support and follows advice
Q12. Why is support from a healthcare professional important?
Q13. How often are people who have stopped smoking supported by healthcare professionals and why does this not happen more frequently?
Q14. How can we increase the percentage of people who attempt to stop smoking receiving support?
Persistence in smoker’s own environment
Q15. How many people who attempt to stop smoking persist in their own environment?
Q16. What challenges do people who attempt to stop smoking face?
Q17. How can we increase the percentage of people who have stopped smoking managing to persist in their own environments?
Evaluating the success after one year
Q18. Why is it important to evaluate the smoking cessation policy and its results?
Q19. What are healthcare professionals currently doing?
Q20. Why aren’t healthcare professionals evaluating their policies and their results more and how can this situation be improved?
professionals can provide, 2) negative experiences with
healthcare professionals in relation to attempts to stop
smoking, 3) smokers’ denial of their own addiction (and
their desire to stop smoking using their own willpower),
and 4) the cost smokers incur by receiving support from
a healthcare professional.
A study by Kaper et al. showed that having health in-
surance which provides complete financial reimburse-
ment for smoking cessation support (nicotine replace-
ment products, bupropion, and behavioral treatment) is
an effective incentive for smokers to seek help from a
healthcare professional and can eventually lead to an
increased number of people who are able to successfully
stop smoking.
3.2. Available Smoking Cessation Methods
Healthcare professionals can employ a variety of in-
terventions to support smokers who want to stop. Be-
havioral interventions that have proven to be effective in
smoking cessation attempts, when compared to attempts
without any support are: brief advice on stopping smok-
ing, telephone support, individual support, and group the-
rapy.
Effective pharmacological interventions (which work
best when used in combination with behavioral treat-
ment), in comparison to not using any drugs or using a
placebo, are: nicotine replacement therapy (NRT: patches,
gum, microtabs, lozenges), bupropion, varenicline, and
nortriptyline. All of these interventions appear to be
cost-effective; initial investments in smoking cessation
support will in the long term reduce the total costs of
smoking-related illnesses.
It is not possible to simply state what the best smoking
cessation intervention is, since individual factors such as
motivation, self-confidence, degree of addiction, age,
and socioeconomic status all influence attempts to stop
smoking. Theoretically, these specific elements could be
used to create an improved, tailored treatment. For in-
stance, providing intensified support using pharmacol-
ogical resources for smokers who have a lower chance
of success. Increasing knowledge about genetic disposi-
tion to smoking addiction may make it easier to choose
individualized treatment in the future.
3.3. Opportunities for Healthcare
Professionals
If a healthcare professional advises a smoker to stop,
this carries more weight than when such advice comes
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from an individual not working in healthcare. System-
atically giving patients brief advice on stopping is a
small yet effective measure that results in 3-4% more
smokers successfully stopping.
General practitioners and medical assistants, dentists,
cardiologists, pulmonary physicians, general and pul-
monary nurses, and physicians specialized in dealing
with additive behavior, can play a role in supporting pa-
tients attempting to give up smoking. General practitio-
ners and dentists have contact with the largest group of
smokers, including a relatively large number of young
and ‘healthy’ smokers. Pulmonary physicians and cardi-
ologists most often see patients with medical problems
resulting from smoking.
It is largely unclear how structural care for smokers
can be embedded in the Dutch healthcare system. It
would be useful therefore to study which healthcare pro-
fessionals or combination thereof, and at what specific
time, would have the strongest influence on patients who
smoke and be able to provide the best support in helping
them to stop.
3.4. Motivation and Obstacles for
Healthcare Professionals
An attitude study covering various medical disciplines
reveals that Dutch general practitioners, dentists, pul-
monary physicians, and cardiologists all feel that it is
important to provide patients with either solicited or un-
solicited recommendations to stop smoking. The per-
centage of healthcare professionals who actually do this
varies between specialists, from 18% of dentists to 90%
of cardiologists.
General practitioners are the least convinced that smo-
king is an addiction that requires the help of healthcare
professionals, compared to cardiologists, pulmonary phy-
sicians, pulmonary nurses, and medical assistants. Many
cardiologists and pulmonary physicians feel it is impor-
tant to recommend stopping smoking, but consider pro-
viding support for attempts to do so more of a task for
the general practitioner. It is not known to what extent
they actually refer their smoking patients to a general
practitioner.
Healthcare professionals most often cite lack of time
as the main obstacle keeping them from supporting pa-
tients in their attempts to stop smoking. For many, treat-
ing smoking addiction is not a top priority, possibly due
to a lack of adequate funding.
3.5. Relapse
Overcoming a tobacco addiction is typically accom-
panied by physical and psychological withdrawal symp-
toms that increase the likelihood of a relapse. As stated
before, the success rate of attempts to stop smoking var-
ies between 4% and 20%, and it takes most smokers
several attempts before they completely stop smoking.
The available data on methods to prevent relapses from
occurring is limited and inconclusive, and therefore fur-
ther study needs to be done on this topic.
3.6. Recommendations for Follow-Up
Research - Delphi Procedure
Based on the literature study, various recommenda-
tions for follow-up research were formulated. A Delphi
procedure was used to create a top-15 list of recommen-
dations. Using scores for speed, the recommendations
were grouped into short-term (speed score > 3.5), me-
dium-term (speed score 2.5-3.5), and long-term research
(speed score < 2.5). Prioritization was done using the
(importance * impact) score. Table 2 shows the results
of the Delphi procedure.
3.7. Recommendations for Healthcare
Practice - Expert Assessment
The literature study also revealed areas in which suf-
ficient knowledge is available, but not put into practice.
The experts confirmed the following recommendations
for healthcare practice: first, both smokers and health-
care professionals need to fully recognize that smoking
is an addiction, which means that stopping can be very
challenging. Patients attempting to stop smoking should
be well prepared and realize that it is possible they may
have a relapse. Second, each and every healthcare pro-
fessional should be committed to systematically advising
their smoking patients to stop and should point them to
available resources and organizations that can help them
achieve that goal. This takes little time and will eventu-
ally lead to more people stopping smoking.
4. DISCUSSION
The information obtained from the present literature
study has led to a number of recommendations for fol-
low-up research, which were subsequently prioritized
using a Delphi procedure.
In the smoking cessation cycle, presented in figure 1,
three phases seem to be essential in the success of an
attempt to stop. First, it is important that smokers turn to
a healthcare professional to obtain support in stopping
smoking. Since the number of smokers who ask for help
is currently relatively small, it is important to find ways
to have more smokers recognize that they need help
from a healthcare professional in overcoming their ad-
diction, and actually ask for help. Second, care for
smokers should be structurally embedded in the health-
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Table 2. Top 15 recommendations for follow-up research prioritized by (importance * impact) score.
Description Speed Importance Impact I * I
Implementation of the smoking ban in hotels, restaurants and cafés in the Netherlands as of
July 1, 2008 (combined with an increase in excise duty) provides an excellent opportunity to
study the effect that this measure has on passive and active smoking and health.
4.33 4.75 3.67 17.43
In order to encourage more smokers to seek help from a healthcare professional, more study
needs to be done on how this perception can be used to motivate smokers to visit healthcare
professionals.
3.75 4.17 4.17 17.39
Research should indicate whether Motivational Interviewing is an effective smoking cessation
method (by phone and/or face to face) and which healthcare professionals could use this tech-
nique in practice.
3.33 3.92 4.33 16.97
Research should reveal which healthcare professionals or combination thereof reach the larg-
est group of smokers, which are most able to influence smoking patients, and which can pro-
vide the best support for patients attempting to stop smoking.
2.17 4.50 3.67 16.52
Research should reveal whether financial compensation for smoking cessation interventions
results in more involvement from healthcare professionals and how the quality of the care
provided can be guaranteed.
3.42 4.00 4.08 16.32
Randomized controlled trials (RCTs) on the effects of financial compensation for healthcare
professionals who carry out proven effective interventions are needed to identify whether this
leads to more involvement in smoking cessation attempts and increased numbers of people
who successfully stop smoking.
3.42 3.92 4.00 15.68
In order to make optimum use of the influence exerted by healthcare environments, more
study needs to be done on which healthcare professionals have the most opportunities to ef-
fectively support patients in their efforts to stop smoking.
2.25 3.92 3.92 15.37
In regard to relapses, it would be helpful to study what behavioral interventions contribute to
better resisting difficult situations. 2.75 3.42 4.33 14.81
In order to encourage more smokers to seek out help from healthcare professionals, more
study needs to be done on how smokers from various target groups perceive their own smok-
ing behaviour and how a healthcare professional can help them.
2.42 3.27 4.25 13.90
Research should reveal whether financial compensation for smoking cessation interventions
results in more involvement from healthcare professionals in smoking cessation attempts and
more people who successfully stop smoking.
4.08 3.83 3.50 13.41
In order to encourage more smokers to seek help from healthcare professionals, more study
needs to be done on how smokers perceive healthcare professionals and the help they can
provide when it comes to stopping smoking.
3.25 3.42 3.58 12.24
In regard to relapses, it would be helpful to study what role self-identity and the expectation to
succeed play and how this can be used in relation of prevention measures. 2.58 2.75 3.50 9.63
In order to encourage more smokers to seek help from a healthcare professional, more study
needs to be done on which forms of communication should be used to best reach smokers. 3.58 3.25 2.92 9.49
In regard to relapses, it would be helpful to study when follow-up contact is most effective
based on the symptoms table. 3.58 2.50 3.58 8.95
Further research should focus on the effectiveness of physical exercise in relation to smoking
cessation as well as its potential for practical use. 2.33 2.25 2.67 6.01
care system. To achieve this, further research should in-
dicate which healthcare professionals have contact with
the most smokers and are best able to provide support in
smoking cessation. Healthcare professionals who already
are involved in smoking cessation support experience
various obstacles. Future research is needed to find ways
to overcome these obstacles, for instance by investigat-
ing the effect of adequate funding for smoking cessation
support. Third, further research needs to be done into re-
lapse prevention, a research area that is still relatively
poorly explored.
In addition to revealing gaps in the current under-
standing of smoking cessation, our study showed that
although sufficient knowledge is in fact available for a
number of areas, this knowledge is not - or at least not
effectively - being applied in practice. This has resulted
in two recommendations for healthcare practice, each
confirmed by the experts from the MIRO core team. The
fact that smoking is an addictive disease needs to be
recognized by both smokers and healthcare professionals.
Healthcare professionals should also systemically advise
their patients who smoke to stop and offer smoking ces-
D. de Korte et al. / HEALTH 2 (2010) 1272-1279
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1278
Openly accessible at
sation support.
When interpreting the recommendations above, the
reader should take into consideration the limitations of
this study. As outlined earlier, this publication focuses on
the role of healthcare professionals, and therefore other
solutions to reduce smoking were not given a great
amount of attention. The authors feel strongly that the
greatest short-term gains in discouraging tobacco use
can be made through healthcare professionals. After all,
every person who wants to stop smoking has a right to
the most appropriate, customized treatment for his or her
addiction.
5. CONCLUSIONS
Overall, healthcare professionals need to be convinced
that tobacco smoking is an addiction and should be treat-
ed likewise. If all healthcare professionals systematically
advise their smoking patients to give up smoking, even-
tually more smokers will successfully stop.
6. COMPETING INTERESTS
This study and manuscript were funded with an unre-
stricted grant from Pfizer B.V.
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