STAGE 5. Defining the action plan

What steps should be completed?

Step 1: Specify intervention actions

MINIMUM/BRIEF HEALTH COUNSELLING INTERVENTION FOR SMOKERS AND HAZARDOUS OR HARMFUL DRINKERS

Minimum/brief health counselling intervention for smoking cessation

Systematic medical counselling for smoking cessation ("minimal intervention") helps stop tobacco use¹ and, although its effectiveness is modest, it is one of the most cost-effective clinical interventions, with individualised counselling by nursing professionals also being effective.² All smokers should receive counselling, and not just those motivated to cease smoking, as the evidence does not support restricting counselling to only those smokers who are highly motivated to change their smoking behaviour.³ The ideal (but not the only) framework for brief interventions is primary health care, because of its accessibility and continuity of care. Counselling effectiveness increases with the duration of the intervention (higher intensity), the inclusion of scheduled follow-up sessions^1,2 and being combined with pharmacological treatment.²

Evidence on brief health counselling to stop smoking makes it possible to formulate a series of conclusions and recommendations⁴:

• Asking all patients if they smoke and documenting their smoking habits in their medical history. Having a clinical system that identifies smokers increases intervention rates.
• Interventions of at least 3 minutes in length increase total tobacco withdrawal rates, so all smokers should be offered at least a minimal intervention, irrespective of whether this leads to an intensive intervention.
• More intensive interventions are more effective than less intensive interventions and should be used whenever possible. There is a dose-response relationship between the duration of the sessions and abstinence rates: higher counselling intensity achieves higher abstinence rates. Both minimal counselling (3 minutes or less), and low-intensity counselling (of 3 to 10 minutes) and high-intensity counselling (more than 10 minutes) significantly increase abstinence rates above those achieved by non-contact interventions.
• The total accumulated contact time with the smoker is directly related to cessation rates, up to a maximum of 90 minutes.

An effective intervention strategy for smoking assistance should combine general medical-health advice with an offer of intensive specialised support for high-risk or highly dependent patients.²

Minimal/brief health counselling intervention for hazardous and harmful alcohol users

Brief health counselling tops the list of effective evidence-based methods to address alcohol abuse.⁵ Brief interventions are effective in primary healthcare settings to reduce alcohol-related problems among people with harmful but non-dependent consumption, and appear to be effective for men and women (slightly more for men), young people and older adults, although they appear to be ineffective during pregnancy.⁶

Positive effects of brief interventions include reducing the use of alcohol beverages, and reducing mortality, morbidity, injuries and social consequences related to alcohol, the use of health care services and laboratory indicators on harm from alcohol consumption.⁷ Evidence suggests that even very brief interventions may be effective in reducing the negative effects of alcohol use, enhanced by motivational interviews.⁸ Therefore, the World Health Organization considers brief interventions to be a simple and cost-effective way to address risk-taking, preventing hazardous drinkers from escalating towards dependence or developing complications arising from consumption, and their application in different health services (primary healthcare, emergencies, traumatology, etc.) has been promoted for decades. However, the strategy is not as widespread as could be expected and it is faced by some obstacles, especially on the part of health professionals.^9,10

Unlike tobacco, conducting longer (higher-intensity) brief interventions on alcohol consumption in primary healthcare does not seem to improve intervention results.¹¹ In fact, evaluating the risk of hazardous or harmful use and limiting intervention to informing the person about the evaluation and providing them with written information (e.g., an information leaflet) can be the most appropriate strategy in the primary health care context to reduce hazardous and harmful alcohol consumption.¹²

Various studies in primary care have also provided evidence of the potential influence of training and support for general practitioners in detection of alcohol consumption and the use of materials for brief interventions on intervention rates and detection of hazardous drinkers.^13,14 Providing training and supporting materials for the consultation may increase the identification rate and percentage of counselling provided by the staff of primary health care centres by almost 50%.⁶

Note: interventions based on brief health counselling straddle the areas of treatment and indicated prevention. Therefore, for more information on this type of intervention, it could be useful to consult the section on brief interventions/health counselling in prevention. See

The World Health Organization provides support for early identification and management of substance use disorders through brief interventions in healthcare systems through the ASSIST project:

More information can also be found in Systems-level implementation of screening, brief intervention, and referral to treatment. SAMHSA: 

 

References:

1 Stead LF, Bergson G & Lancaster T. (2008). Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000165. DOI: 10.1002/14651858.CD000165.pub3.

2 Sancho de JL (coord.). (2003). Evaluación de la eficacia, efectividad y coste-efectividad de los distintos abordajes terapéuticos para dejar de fumar. Informe de evaluación de tecnologías sanitarias. Madrid: Agencia de Evaluación de Tecnologías Sanitarias. Instituto de Salud Carlos III. Ministerio de Sanidad y Consumo. nº 40.

3 Cahill K, Lancaster T & Green N. (2010). Stage-based interventions for smoking cessation. Cochrane Database of Systematic Reviews 2010, Issue 11. Art. No.: CD004492. DOI: 10.1002/14651858.CD004492.pub4.

4 Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

5 Miller WR  et al. (2003). What works? A summary of alcohol treatment outcome research. In: Hester RK & Miller WR (eds.). Handbook of alcoholism treatment approaches: effective alternatives. 3ª ed. Boston, MA: Allyn and Bacon: 13–63.

6 Monteiro MG. (2008). Alcohol y atención primaria de la salud: informaciones clínicas básicas para la identificación y el manejo de riesgos y problemas. Washington, D.C.: Oficina Panamericana de la Salud.

7  Kaner EFS et al. (2007). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007 (2): DC004148.

8 Vasilaki EI, Hosier SG & Cox WM. (2006). The efficacy of motivational interviewing as a brief intervention for excessive drinking: a metaanalytic review. Alcohol and Alcoholism. 41(3): 328–335.

9  WHO (2009). Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol-related harm. Copenhagen: WHO Regional Office for Europe.

10 Aira M et al. (2003). Factors influencing inquiry about patients’ alcohol consumption by primary health care physicians: qualitative semistructured interview study. Family Practic., 20(3): 270-275.

11 Kaner E, Beyer F, Dickinson H, et al. (2007). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2007;(2):CD004148.

12 Kaner E et al. (2013). Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. BMJ;346:e8501 doi:10.1136/bmj.e8501 (Published 9 January 2013) pp.1-14.

13 Nilsen P et al. (2006). Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. Scandinavian Journal of Primary Health Care. 24(1): 5-15.

14 Anderson P et al. (2004). Engaging general practitioners in the management of alcohol problems: Results of a meta-analysis. Journal of Studies on Alcohol and Drugs. 65: 191-199.