Perceived feasibility of a primary care intervention for Tobacco Cessation on Prescription targeting disadvantaged groups in Sweden: a qualitative study
© Leppänen et al. 2016
Received: 29 September 2015
Accepted: 22 February 2016
Published: 9 March 2016
There is a lack of scientific evidence on how socioeconomically disadvantaged tobacco users can be reached with tobacco cessation interventions in Swedish primary healthcare (PHC). In this setting other lifestyle interventions are available by prescription, and there is the potential to develop a similar tool for tobacco cessation. The aim of this study was thus to explore the perceived feasibility and optimal design of Tobacco Cessation on Prescription (TCP) in PHC, targeting disadvantaged groups in Sweden.
This qualitative study is based on semi-structured interviews with 32 participants including (1) three experts in lifestyle interventions on prescription, (2) 14 healthcare providers and (3) 15 clients from three PHC centres in socioeconomically disadvantaged areas in Stockholm where tobacco use is high. The interviews were audio-recorded and transcribed verbatim. The manifest content of the transcripts was analysed according to a modified conventional approach to content analysis.
The interviewees proposed that TCP should include a template comprising the client’s information, evidence-based tobacco cessation options and choices for follow-up. They also suggested including information about the benefits of tobacco cessation, as well as empowerment and planning support tools. The participants also commented that other measures for tobacco cessation could be included on the prescription. From the clients’ point of view, the perceived advantages of TCP were often linked to an emotional meaning (e.g. increased motivation to quit tobacco use, sign of support from the healthcare system to seek care for tobacco cessation). For providers, advantages with TCP were frequently related to a practical meaning (e.g. improved documentation and facilitation of tobacco cessation treatment). The disadvantages identified were mainly connected with the future implementation of TCP (e.g. low self-efficacy among clients and providers).
TCP was perceived to be a useful tool for both clients and providers, potentially facilitating a structured and effective approach to tobacco cessation in PHC, and targeting disadvantaged groups. More research is needed to develop the prescription and investigate its effectiveness and cost-effectiveness compared to current strategies for tobacco cessation in a PHC setting.
Tobacco use is the leading preventable cause of death worldwide , estimated to cause approximately 10 % of all premature deaths in Sweden . Furthermore, chronic illnesses caused by tobacco use remain a public health problem in Sweden—particularly in socioeconomically disadvantaged groups, where tobacco use is markedly higher than in the general population . Since tobacco cessation has been found to reduce the risk of tobacco related morbidity and mortality , it is a prioritised target area in Swedish public health policy . How tobacco cessation should be tackled is described in the National Board of Health and Welfare’s guidelines for disease prevention methods . Recommended treatment options include different types of counselling (simple advice, counselling, qualified advice, web- and computer-based counselling and proactive telephone counselling) with or without pharmacotherapy (nicotine replacement therapy, varenicline and bupropion) . However, these types of health-promoting interventions often fail to reach those in greatest need . Difficulties in reaching disadvantaged groups with tobacco cessation interventions could be explained by a lack of motivation, low self-efficacy, reduced social support for quitting and understanding of the harmful effects of tobacco use, a stronger addiction to tobacco, targeted marketing by the tobacco industry and low adherence to treatment . In addition, the costs of pharmacotherapy and counselling present particular barriers for disadvantaged tobacco users to seek and complete treatment for tobacco cessation [8, 9].
Studies conducted in Stockholm on healthcare consumption in different social settings show that individuals with low socioeconomic status and foreign origin often visit primary healthcare (PHC) . PHC may therefore be seen as a potential platform for reaching disadvantaged groups with health-promoting activities. Although the utilisation of PHC is on a par with other groups of the population, the proportion of medical needs not met is higher among disadvantaged groups who frequently feel discriminated against by the healthcare system . Among PHC staff, there is a need for more knowledge and training in how to work with disadvantaged groups for efficient health promotion [11, 12]. There is also a need for healthcare programmes, routines and documentation tools to facilitate such efforts .
Physical activity on prescription (PAP) is a lifestyle intervention on prescription, which has been successfully tested and validated in the general population in Sweden [14, 15]. Methods to prescribe physical activity have also been applied in the healthcare systems in Norway, Denmark, Finland, Great Britain, New Zealand, Australia, USA and Spain [16–22]. In Sweden, PAP is adhered to in a way comparable to medical treatments of chronic diseases and has been found to lead to increased physical activity levels and improved health and quality of life . Previous research suggests that there is a demand among tobacco users in Sweden for receiving tobacco cessation support from healthcare providers , e.g. through referrals . Therefore, Tobacco Cessation on Prescription (TCP) has the potential to become a comprehensive, health-promoting tool in the Swedish PHC setting. TCP may also increase the willingness amongst clients to receive assistance, as tobacco cessation would obtain a status like other medical care . A prescription approach to tobacco cessation treatment could also be relevant in other countries where prescriptions to promote lifestyle changes are already in use. This study aims to explore the perceived feasibility and optimal design of TCP as an innovative and complementary tool for tobacco cessation in PHC, targeting socioeconomically disadvantaged groups in Sweden.
Recruitment and sample selection
Total N (%)
% (n = 15)
% (n = 14)
% (n = 3)
Data was collected between February and May 2014 through semi-structured interviews in conversational form, based on interview guides with open-ended questions, developed specifically for each respondent category (Appendices 1, 2, 3). Clients and providers were asked about their tobacco use, experiences of tobacco cessation and opinions on the concept of, and requested content on, TCP. It was described as a prescription form similar to prescriptions of pharmaceuticals and physical activity, which could be administered by a healthcare provider to a client in the PHC setting to support and facilitate tobacco cessation. The participating experts, providers and clients were all previously familiar with prescriptions of pharmaceuticals. All of the experts and providers, and most of the clients, were also previously familiar with PAP. Clients were asked about their health. Experts were asked about lessons learned from other lifestyle interventions on prescription, the possibilities and barriers associated with these interventions, and how they might impact upon TCP. Examples of interview questions related to the aim of the study were: “If you could prescribe/get a prescription for tobacco cessation, what would you think about that?” and “What are the possible advantages and disadvantages of TCP?”
Twenty-eight of the interviews were conducted face-to-face, while two of the expert interviews and two of the client interviews were conducted via telephone based on participant preference. The face-to-face interviews were conducted in private rooms, located in the PHC centres where the participants were recruited. Due to specific requests from participants, one client interview was conducted in the waiting room and one provider interview was conducted in the interviewer’s office. On average, the interviews lasted for approximately 30 min. All interviews were conducted by an experienced interviewer with degrees in health communication and global health science. All but one of the interviews were conducted in Swedish. The exception was carried out in Arabic in collaboration with a translator. All interviews were audio-recorded and supplemented with field notes. The interviewer transcribed each interview verbatim. A professional agency transcribed and translated the interview from Arabic to Swedish.
Identified codes, sub-categories and categories
Cessation activity, general content, empowerment, contact, medical content, planning support, referral
Mode of administration, layout
Prescription for all smokers, prescription for those with a health problem, prescription for those with high self-efficacy
Prescription whenever, prescription as soon as possible, prescription at a certain point in time
When to receive TCP
No follow-up, when to follow-up, how to follow-up, why follow-up
Shared responsibility, manager responsibility, occupational group responsibility
Guideline characteristics, guideline content
Positive emotional meaning, positive practical meaning, positive characteristics
Negative emotional meaning, negative practical meaning
Providers’ self-efficacy, clients’ self-efficacy
Others indifferent, others positive, others negative, others ambiguous
Perceptions of othersa
Implementation prerequisites, person-centeredness, TCP as a package
Motivation and competence, budget, organisational obstacles, infrastructure, time, capacity building
Ethical approval was obtained from the Regional Ethical Review Board in Stockholm in the autumn of 2013 [no: 2013/2264-32/2]. Written informed consent was obtained from the participants before the start of each face-to-face interview and verbal informed consent was obtained before the start of each telephone interview. The anonymity and confidentiality of the participants was ensured by coding the participants as numbers (1–32) and removing all identifiers but the respondent category in the presentation of the results. Furthermore, best practice guidelines for qualitative research  were applied to ensure quality.
“There should be different aids […] and pharmaceuticals [to choose from] on the prescription itself.” (Provider 18).
“There has to be a pre-printed list of options [for tobacco cessation] that there are to get help from […] so that one can check [a box] and write maybe freely the treatment plan and how one plans to follow it up.” (Provider 7).
“I usually suggest [the client] going on a trip, to have a goal, or that they can go out and enjoy a good meal [as a reward for tobacco cessation].” (Provider 12).
“I think it’s good to have some kind of physical activity [on the prescription] but also to have some kind of relaxation [technique] […] like mindfulness or medical yoga that ensures that you relax […] and explain that ‘You are going to experience abstinence but if you hold out [relax] for a while it will also disappear´.” (Expert 31).
“[TCP should be] like a real [paper] prescription. Anything else would be worthless because then you wouldn’t feel the same dignity as you feel with a doctor.” (Provider 10).
“Nowadays, all prescriptions for medications are electronic […]. But at the same time it would be weird if you had an e-prescription if it was not for medications, if it was an e-prescription for some kind of activity one should do.” (Client 21).
“I don’t think anyone should smoke! But those with diabetes, cardiovascular problems, asthma/COPD are the largest [target] groups [for TCP]. But again, it can be [prescribed] to all [tobacco users].” (Provider 4).
When to receive TCP
Clients frequently responded that they would like to be prescribed TCP “whenever”, “as soon as possible”, or at a certain point in time, e.g. once health status worsens, improves, or once the decision to quit tobacco use has been made.
“I think it [follow-up] is needed. So that they [providers] hear how it went […]. That is always the best. [To] keep track.” (Client 14).
“Maybe in the beginning [the client could be followed-up] each week, if possible […] and later a bit more sporadically.” (Client 20).
It was suggested by two clients and two providers that the follow-up could be carried out via telephone. One provider commented that the follow-up by telephone could be done by a physician while another provider proposed that it could be done by the Swedish quitline. In addition to the cessation progress and how TCP worked, it was suggested by a client that certain body functions could also be tested during the follow-up.
“I think [it should be] like with PAP, that all nurses, all doctors, all [healthcare providers] who have contact with the patient, can offer [TCP], except for pharmaceuticals–that is the doctors responsibility […] I don’t think it [prescription of TCP] should be restricted to a certain [occupational] category. Then the usage would be lower.” (Provider 18).
“There could be some kind of [recommended] chain [of events, like] ´Write a prescription´, ´Inform […] about what happens when you smoke´, ´Inform about the Swedish quitline´ in different steps and if that’s not enough´ Refer to a lifestyle clinic’ as the next step.” (Provider 3).
Moreover, the providers expressed that the guidelines should be easy to use, permissive, generous, structured, and adaptable, without judgement and encouraging the provider to always take up the issue of tobacco use.
“If one gets a’push’, a bit of support, then it would make it easier, at least for me [to quit smoking]. […] I would have made up my mind, after having talked to another person about this [tobacco cessation] and gotten a medication [on prescription]. Then I have to put the work in, make sure that it happens”. (Client 20).
“It [tobacco cessation] becomes clearer with this method [TCP] and then patients can choose themselves which method they want to choose […] – it becomes much easier for healthcare personnel.” (Provider 18).
“And he [the patient] can say ‘Look, I got a prescription because the healthcare system says that I should stop smoking’, then they [the patients] can get motivation from their [family/friends], ‘God, he got a prescription. Now he shouldn’t smoke’ or ‘[…] it is serious, so now we must make sure that he does that [stop his tobacco use]’.” (Provider 8).
“Then [with TCP] I know that I have the right to seek [care for tobacco cessation].” (Client 20).
“The disadvantage would be that I’m not strong enough to accomplish that [tobacco cessation with TCP].” (Client 20).
“He [the client] is allowed to buy Nicotine Replacement Therapies (NRTs) […] without having this paper [TCP] in his hands. That [getting a prescription for tobacco cessation] I can imagine some might think is a little humiliating”. (Provider 5).
“There is the disadvantage of having ‘one additional thing’ [to do].” (Provider 18).
The risk of forgetting, or not following up TCP, was also mentioned as a disadvantage. Some clients were insecure about TCP and some providers found it unnecessary, or perceived it as a way of “labelling smoking as a disease”.
“I think it [the adherence to TCP] would be the same as with all other tobacco cessation [interventions]. I think it is more about motivating them [the clients]. Maybe the prescription could get them more motivated and then the adherence would be higher.” (Provider 11).
Perceptions of others
“I think that there are both, some who will perceive it [TCP] as positive and some that will question it.” (Provider 5).
“If I decide that’Ah, this [cessation option] suits you’, the patient won’t buy it. If you have it [the cessation options] on the prescription, then you can go through [them] with the patient. ‘This is a nicotine patch. Have you tried? Or what do you think, is gum better for you?’ Then you could tick [choose] the [type of] aid together.” (Provider 18).
“The prescription has to be found in Take Care [the electronic medical record] or the data system […] so that I can pick it up easily. It [the form] must be very easily filled in.” (Provider 18).
“As it is now […] we wouldn’t have time [to prescribe TCP] because we [healthcare providers] don’t have enough expertise and it [TCP] requires a lot more. You don’t just give them the note [prescription], so to speak.” (Provider 2).
“‘On prescription’, then it [the treatment] should be included in the reimbursement scheme. Otherwise it [tobacco cessation treatment] is pretty expensive stuff, I have heard.” (Client 22).
Furthermore, a good introduction to TCP for healthcare personnel was found important and expected to have a positive effect on its uptake.
Overall, the concept of TCP was considered a valuable support for both providers and clients, facilitating tobacco cessation treatment among disadvantaged groups in PHC in a new, easy and structured way. The prescription, containing an overview of available cessation options and planning support, could serve as an information source, but also as a basis for discussion between the provider and the client. TCP would allow each client to—together with their caregiver—choose the cessation options that suit them the best, tailoring the prescription to meet their individual preferences and needs. Previous research suggests that personalised and non-judgemental approaches  that combine behavioural support and pharmacotherapy are effective in supporting and engaging disadvantaged tobacco users to quit .
The importance of offering and combining a variety of treatment options in tobacco cessation became clear in the study, since several participants were sceptical towards the use of pharmaceuticals but positive towards some non-traditional measures for tobacco cessation. A recent clinical review suggests that some of the methods mentioned by the participants (e.g. relaxation techniques, drinking water, eating low fat foods like fruit and engaging in physical, fun and health promoting activities) may be used as strategies for stress management or distraction to reduce cravings and withdrawal symptoms . Although these options are unlikely to be pre-printed on the prescription, these could beneficially be discussed in relation to the prescription of TCP. If the client shows interest in a non-evidence based and potentially harmful option in these discussions, such as e-cigarettes, this should not be promoted. Self-efficacy could be improved by involving clients in the choice of treatment and by providing empowerment and planning support on the prescription. The importance of self-efficacy in tobacco cessation has previously been highlighted in the literature [35–37]. It was also considered the most influential determinant of successful cessation among providers and clients in the study.
Although this was not the focus of the study, a need for increased awareness about available cessation alternatives emerged, since few of the participants seemed to know about the services available to help them. Similar findings have been presented in previous research, which also suggests that there are misconceptions in this population about the availability and effectiveness of such services . In order to reach disadvantaged groups with tobacco cessation interventions it is recommended that free or heavily subsidised NRTs should be offered and that targeted marketing strategies using mass media should be applied . Currently, neither of these strategies are used in Sweden. Although the long term effects of these strategies have not been established [33, 39–41], informing the target group about TCP including its potential financial benefits could increase the demand and utilisation of NRTs and other tobacco cessation treatments among disadvantaged tobacco users in PHC in Sweden. The fact that economic incentives influence an individual’s willingness to participate in other life style intervention on prescription programmes support this statement .
Perceived challenges with the implementation of TCP were related to a lack of time, resources and knowledge to prescribe TCP. The same obstacles and the need for education, routines and guidelines have previously been stressed by primary care providers in relation to physical activity counselling  and prescriptions . Development of guidelines and education of PHC staff in how to prescribe TCP should therefore be considered crucial in the implementation process. Since the lack of reimbursement for preventive counselling is also considered a major barrier , financial incentives may be needed to motivate PHC staff to prescribe TCP. Previous research suggests that financial incentives enhance the likelihood that PHC will devote time to health promotion . Without financial support, there is a risk that other activities that are reimbursed will be prioritised . Despite these challenges, the prescription approach has previously been found effective in changing lifestyle behaviour when clear advice was given and prescribed with the same conviction as a drug . Studies have shown that PAP increases self-efficacy  and physical activity, while decreasing the proportion of inactive individuals and reducing costs for inactivity by 22 % . The adherence to PAP has further been found to be similar to that of other treatments for chronic diseases . Although the adherence to prescribed medications is generally lower in disadvantaged groups , the study participants reported that they would become motivated by receiving a prescription on tobacco cessation. Most of the participants also stated that they had high levels of trust in their caregivers and considered TCP to be a demonstration of support from the healthcare system. Since a client’s trust in the provider and the healthcare system has a positive effect on adherence to treatments [49–51], TCP could be an effective approach in achieving tobacco cessation among disadvantaged tobacco users in Sweden.
Introducing TCP as an intervention model for tobacco cessation could be a means for implementing the national guidelines for disease prevention and supporting PHC to integrate health promotion into its daily activities. Better support from PHC staff in tobacco cessation could lead to more successful quit attempts and health improvements in the population. TCP may also help to reduce health inequalities by targeting disadvantaged groups who have a higher prevalence of tobacco use and related health problems compared to the general population. However, before TCP can be implemented, more research is needed to further develop the content and the design of such a prescription. The effectiveness and cost-effectiveness of TCP should also be evaluated in comparison with current tobacco cessation strategies to determine whether or not its implementation would be an efficient allocation of society’s limited resources. Such an intervention study is currently under development.
A possible limitation to the study was that most of the interviews were conducted in Swedish when neither the interviewer, nor some of the participants were native Swedish speakers. A language barrier may thus have been introduced in the communication between the interviewer and the respondents, as well as in the interpretation of data . However, the understanding was enhanced through enquiries, audio-recording of the interviews and validation of the materials by a native Swedish speaker. In addition, social and cultural differences between the interviewer and the participants (e.g. socioeconomic status, nationality, age, gender) may have influenced the data collected . The public health background of the researchers performing the analysis may also have influenced the manner in which the material was coded and categorised. Another limitation of the study was that only the manifest content of the interview transcripts was considered in the analysis. This is a disadvantage of using a conventional approach to content analysis. However, this approach can be useful in concept development or model building  which was closely related to the aim of this study and therefore considered appropriate. Further, it should be noted that the findings from this study are based on the views of 32 participants. Although the credibility of the findings was enhanced by including a diverse sample of participants, representing different ages, sexes and respondent categories, there was only one male healthcare provider in the sample. Overall, fewer male providers were asked whether they wanted to participate, as predominantly female nurses were, or felt like they were, responsible for tobacco cessation at the PHC centres that were involved in the study. A prescription approach to tobacco cessation treatment could be relevant in other countries as well, for example where physical activity or other lifestyle interventions are already being prescribed. However, the approach would have to be modified to the context in which it is intended to be used.
A TCP tool was perceived to be useful for both clients and providers, potentially facilitating a structured and effective approach to tobacco cessation in PHC, targeting disadvantaged groups. More research is needed to develop the prescription and investigate its effectiveness and cost-effectiveness compared to current strategies for tobacco cessation in a PHC setting.
TT was the principal investigator of this study including its design. OB participated in the development of the interview guide with support from TT. OB conducted and transcribed all interviews. The subsequent analysis was performed by OB, supervised by TT. AL reviewed the analysis and results. AL and OB wrote the first draft of this manuscript where then TT and CJS gave their input. All authors read and approved the final manuscript.
We thank the participating experts, PHC providers and clients for their contribution. We also thank Luke Woodham for proof-reading the manuscript. The study was financed by Stockholm County Council [grant no: HUA 13070, HSN 1309-1029].
The authors declare that they have no competing interests.
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