Chronic obstructive pulmonary disease (COPD) affects 11.8% of adult Ontarians, remains the
leading cause of hospitalization in Canada, and cost the Canadian economy $770 million in
2010. Smoking cessation reduces mortality and improves quality of life in COPD, and also
reduces the risk of developing stroke, coronary heart disease, and several types of cancer.
Despite this evidence, 45% of patients with COPD continue to smoke.
Previous trials have demonstrated that even brief smoking cessation advice offered by a
physician can increase quit rates, with intensive interventions proving additionally
effective. Despite this, only 37% of US and 54% of Canadian smokers who had a visit with a
physician during the prior year had been advised to quit smoking. Barriers and enablers
underlying this care gap are multi-fold. At the patient level, barriers to quitting include
accessibility of appropriate therapy, low expectations of quit success (self-efficacy) and
low expectations of risk mitigation by quitting (outcome expectancy). Enablers include easily
available therapy, knowledge of ongoing smoking effects, and motivation to quit for personal
gain. For clinicians, barriers to providing smoking cessation advice include perceived lack
of cessation counseling skills (self-efficacy), lack of time, memory (forgetting to do it),
and concerns about harming the doctor-patient relationship. Enablers include reminders to
provide cessation advice and improved outcome expectancy (a belief that their patients have a
reasonable chance of quitting).
Among different lung function metrics, forced expiratory volume in one second (FEV1) is the
best validated metric for quantifying the degree of lung function impairment and is used to
define disease severity. Our group previously developed and validated a prediction tool that
uses individual patient characteristics to predict a personalized rate of future FEV1
decline. Considering the barriers and enablers to effective smoking cessation interventions
noted above, our team then designed a smoking cessation intervention centered on this lung
function decline calculator. Given that smoking is a modifiable variable that affects the
rate of lung function decline, we translated the original calculator into a clinical
infographic which quantitatively demonstrates the consequences of quitting versus continuing
smoking on lung function and its correlated patient-relevant outcomes, for each individual
patient (i.e. a personalized biomedical risk assessment). This approach was informed by
previous studies demonstrating the promise of biomedical risk assessment (the process of
giving smokers feedback on the physical effects of smoking using physiological measurements)
and tailored educational materials for smoking cessation. Such tools can enhance smoking
cessation consultations, particularly when educational material is in a visual format. We
first designed a prototype tool according to best infographic design and content evidence and
then conducted a series of iterative 2-hour moderated focus groups with 4-5 COPD patient
participants per group and semi-structured 1-on-1 interviews with respirologists, until
saturation of themes [4 focus groups (20 participants), 4 interviews]. In a rapid cycle
design process, we made changes to tool content and format after each focus group and
interview, based on qualitative analysis of feedback.
This infographic is designed for clinicians to use as a facilitator for smoking cessation
intervention delivery with their patients. It demonstrates expected FEV1 decline with and
without smoking cessation, and corresponding patient-relevant morbidities (page 1), and
provides clinicians with guidance for smoking cessation pharmacotherapy prescriptions (page
2). With this project, we seek to evaluate this tool in real-world practice to determine
implementation feasibility and preliminary impact. The tool will not only act as a prompt for
clinicians to provide smoking cessation counseling, but also serves to improve their
self-efficacy and to enhance outcome expectancy with respect to smoking cessation advice. In
turn, it provides patients with a personalized analysis of the future impact of their smoking
and the benefit of a quit, with a goal of enhancing motivation to quit.