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, 2×2 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.