Advice as a smoking cessation strategy: a systematic review and implications for physical therapists

BODNER Michael E., DEAN Elizabeth
Journal article citation:
Physiotherapy Theory and Practice, 25(5-6), July 2009, pp.369-407.
Informa Healthcare
Place of publication:

This systematic review examined the effectiveness of advice by a health professional and its components to optimize smoking cessation in the context of physical therapy practice. Thirty source articles were identified. A random-effects model meta-analysis was used to assess the effectiveness of the advice parameters. Risk ratios (RRs) were used to estimate pooled treatment effects. Self-help materials, follow-up, and interventions based on psychological or motivational frameworks were particularly effective components of intermediate and intensive advice interventions. It was found that advice could be readily integrated into physical therapy practice and used to initiate or support ongoing smoking cessation in clients irrespective of reason for referral. Incorporating smoking cessation as a physical therapy goal is consistent with the contemporary definition of the profession and the mandates of physical therapy professional associations to promote health and wellness, including smoking cessation for both primary health benefit and to minimize secondary effects (e.g., delayed healing and recovery, and medical and surgical complications).

Extended abstract:

BODNER Michael E.; DEAN Elizabeth;


Advice as a smoking cessation strategy: a systematic review and implications for physical therapists.

Journal citation/publication details

Physiotherapy Theory and Practice, 25(5-6), July 2009, pp.369-407.


This is a review and meta-analysis of 30 studies on the effectiveness of smoking cessation interventions delivered face-to-face by health professionals, in which the components of the interventions are described in detail. Advice or counselling on smoking cessation at all intervention intensities increased the probability of quitting compared to usual care. Smoking cessation advice is a strategy that should be delivered by physiotherapists. 


Although the importance of smoking cessation as an element of health promotion by physiotherapists has been identified by professional associations, little evidence exists of such a role. 'The purpose of this systematic review was to selectively study the role of advice, as a mode of smoking cessation intervention that could be administered by health professionals, and specifically, by physical therapists in practice.'  


What sources were searched?
The databases searched were: Medline, CINAHL (Cumulated Index to Nursing and Allied Health Literature), EMBASE (Excerpta Medica), PsycINFO, and CENTRAL (Cochrane Central Register of Controlled Trials). Fourteen key journals featuring articles on smoking were hand searched and are listed on p.371. Journals were searched from 1968 or from the year of inception. Reference lists of relevant systematic reviews were also hand searched.


What search terms/strategies were used?
Searches were conducted using 'thesaurus-based' keywords and MeSH terms for 'smoking cessation', 'advice', 'counselling', and 'health personnel'. 

What criteria were used to decide on which studies to include?
In order to be included in the review, studies had to be randomised-controlled or quasi-experimental, published in full, in English, in a peer-reviewed journal. They also had to incorporate advice or counselling as a smoking cessation intervention delivered by a health professional in a clinical context and include quit rates as an outcome measure with at least one follow-up at 5 months post-intervention, or later. Control groups were defined as receiving no advice or usual care.

Studies were excluded if: nicotine replacement therapy (NRT) was included as part of the intervention (unless it was distinct from the advice intervention treatment arm); there was no control group or usual care; subjects had recently quit smoking; the intervention was carried out by professional counsellors; there was no face-to-face contact with the health professional; it specifically targeted youth; other lifestyle advice was included in the intervention.

Who decided on their relevance and quality?
The titles and abstracts of retrieved articles were reviewed against the inclusion and exclusion criteria by the first author (MB), and cross-referenced by the second author. The full-text review of potentially relevant articles was conducted by MB and a random sample was double checked by ED. Discrepancies were resolved by the two authors.

Methodological quality was assessed by the ten point PEDro scale; scores of 0-3, 4-6, and 7-10 were considered to be of poor, fair and high quality, respectively. Responsibility for quality assessment is not attributed.  

How many studies were included and where were they from?
The database searches yielded a total of 1,184 articles; 417 from EMBASE, 389 from Medline, 101 from CINAHL, 51 from PsycINFO, and 226 from CENTRAL. After the removal of duplicates 853 articles remained. The full-text of 62 of these was assessed against the inclusion criteria and subsequently 24 were included in the review. A further six studies were identified by hand searching to produce a total of 30 studies that described 42 interventions.

The majority of the studies were from the UK (11); the others were conducted in the USA (7), the Netherlands (4), Norway (2), Australia (2), Canada (2), Turkey (1), and Denmark (1).

How were the study findings combined?
Studies were categorised as one of three levels of intensity of advice or counselling: brief, intermediate or intensive. Only the most rigorous smoking cessation outcome was extracted from each study and included in the review. Details of each study are reported extensively in tables. They include the demographic details of the populations in Table 1, smoking related characteristics of the study populations in Table 2, the advice presented to participants in each study in Table 3 and details of usual care for the 23 studies in which it was reported in Table 4.

Twenty nine studies reporting 40 interventions were included in the meta-analysis, which was conducted with RevMan v.5.0 and with a random effects model. Risk ratios (RR) with 95% confidence intervals are tabulated for usual care vs. studies using brief advice, intermediate advice, intensive advice, written self-help materials, psychological motivations, and follow-ups. 

Findings of the review

The majority (24) of studies were rated as being of fair methodological quality: only four were rated 'good' and two were of poor quality. The mean methodological quality score was 5.1.

Physicians (16 studies) were the largest group providing smoking cessation advice followed by nurses (8 studies). Other health personnel providing advice were dental staff and midwives. Most of the interventions were of brief (19) or intermediate (17) intensity; only 4 were categorised as being 'intense'. Additional materials in the form of written self-help materials (8), videos (3), and pamphlets (4) were included in some interventions. None of the studies reported cultural adaptation or learning style in relation to the interventions. Seven of the studies based their interventions on behaviour change frameworks.

Risk ratios for each of the three categories of intervention were: brief advice 1.74 (CI 1.37, 2.22); intermediate advice 1.71 (CI 1.39, 2.09); intensive advice 1.60 (CI 1.13, 2.27). The inclusion of self-help materials, follow-up and the use of interventions based on psychological or motivational frameworks were effective components of the longer interventions (RRs 1.59 (CI 1.22, 2.07), 1.70 (CI 1.32, 2.21), 1.55 (CI 1.29, 1.86) respectively).

Authors' conclusions

'The findings of this systematic review show that patients who receive smoking cessation advice/counselling from a health professional at varying levels of intensity… have a greater probability of quitting smoking… than patients in a control group or those receiving usual care.'

Implications for policy or practice

Providing advice on smoking cessation is an intervention that could be exploited in a physiotherapy setting and should be considered as a clinical competency in the field.

Subject terms:
advice services, health professionals, intervention, physiotherapy, smoking;
Content type:
systematic review
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