Proactive referral to behavioral smoking cessation programs by healthcare staff: a systematic review

INTRODUCTION: Behavioral smoking cessation programs are an effective tool for quitting smoking, yet remain underused by smokers. Proactive referral may be a promising strategy for healthcare staff to connect smokers to such programs. The aim of this study was to gain insight into the effectiveness and implementability of proactive referral of smokers to behavioral smoking cessation programs by healthcare staff.

METHODS: A systematic review was conducted using five databases. Effectiveness of proactive referral was defined as the proportion of referred smokers who enrolled in a behavioral smoking cessation program. To determine the implementability of proactive referral, measures of feasibility, acceptability, adoption and referral rates were included as variables of interest. Out of 6,686 screened records, 34 articles were eligible for review. A narrative synthesis approach was used.

RESULTS: The majority of the included studies investigated proactive referral within an e-referral system, combined with one or more intervention components which enhance implementation. Overall, proactive referral resulted in higher enrolment rates, especially among low-income smokers, and was found to be feasible, adoptable, and acceptable to healthcare staff. E-referral systems performed better in terms of implementability compared to fax referral systems. About half of the studies were of good quality. Many studies lacked information which resulted in lower quality scores.

CONCLUSIONS: The literature provides evidence that the proactive referral of smokers to behavioral smoking cessation programs by healthcare staff is effective and implementable across different settings. Based on the results, e-referral systems may be preferable to fax referral systems in terms of implementability.

IMPLICATIONS: This systematic review demonstrated that proactive referral has the potential to increase the reach of smoking cessation programs and reduce inequalities in the access to such programs. In the selection and implementation of behavioral smoking cessation programs with a proactive referral component, stakeholders (e.g., policymakers, healthcare funders, and healthcare professionals) may benefit from taking different aspects of proactive referral systems into account, such as the type of proactive referral system used and additional strategies which can enhance the implementability of the system.