A Web-enabled Integrated Care Pathway (ICP) for Addressing Multiple Modifiable Risk Factors as a Part of Smoking Cessation Treatment in Primary Care Settings.

Tobacco use, in particular, continues to be the leading cause of preventable death, with a recent review identifying strong associations between tobacco and other modifiable risk behaviours. Tobacco users tend to consume more alcohol, eat less fruits and vegetables and report less minutes of leisure physical activity as compared with non-tobacco users. The clustering of these modifiable risk behaviours among tobacco users not only translates a heightened risk for cardiovascular disease but may also negatively influence the likelihood of successful smoking cessation. Alcohol consumed even in small amounts, has been shown to increase cravings for smoking, thus increasing risk of relapse to smoking. Increasing physical activity levels can help to reduce tobacco withdrawal and cravings, as well as minimize the reward anticipation. Individuals also often misattribute the reversal of withdrawal symptoms (i.e. irritability) from smoking as relief from stress. This can also increase the risk of relapse when attempting to quit.

In addition to the more direct relationships between these health behaviours and smoking cessation, successfully changing one or more behaviours may also help to increase self-efficacy and self-confidence to change other health behaviours that individuals may be less motivated to act on. As a result, targeting multiple risk behaviours in smokers may help maximize health promotion efforts by augmenting smoking abstinence rates, improving overall health, and reducing healthcare-related costs. In order to address this, the Smoking Treatment for Ontario Patients (STOP) Program (REB#: 058-2011), a province-wide initiative that uses the existing healthcare infrastructure to provide smoking cessation support to smokers in Ontario, has been developed and is currently testing a web-enabled Integrated Care Pathways (ICP) for some of these behaviours. In 2016, the STOP program started offering specialized clinical pathways through the STOP Portal (a web-based platform and an online data collection/management tool used by the STOP practitioners to complete participant enrollment and record smoking status at each visit) for smokers who drink above Canadian Cancer Society guidelines (REB# 035-2015). In 2018, it added a specialized ICP for those who have mood disorders (REB#: 065-2016). However, there are currently no web-enabled tools in the STOP program that also address some of the other well-known modifiable risk factors such as: physical activity, and diet.

There is substantial high quality evidence that shows the effectiveness of screening for these behaviors, providing a brief intervention, and referral to treatment when needed for helping patients quit smoking as well as change other behaviours. Moreover, a recent systematic review of behaviour change techniques practitioners can use to promote health behaviour change in patients found that, relative to other techniques, 'risk communication' and 'self-monitoring of behaviour' are the most effective techniques.

As a result, we designed the intervention - an integrated care pathway that facilitates practitioners to deliver a brief intervention that includes risk communication, and provides tools for patients to monitor their health behaviours to STOP patients who have at least one of the following other modifiable risk factors at baseline: low levels of physical activity, and low levels of fruits/vegetable consumption. Low levels of physical activity will be defined as being below the Canadian national guidelines: less than 150 min per week of moderate-to-vigorous activity. Low fruits and vegetable is defined as being below the 2007 Canada's Food Guide: less than 7 servings (female) or 8 servings (male) of fruits/vegetable per day.

The specific components of the intervention are outlined below:

1. Systematic screening through the STOP portal for STOP participants with at least one of the following risk factors: low levels of physical activity, and low fruits/vegetable consumption.
2. Have computer prompts that advise the practitioner of patient's risk factors, and to provide a brief intervention that includes how the identified risk factors affect the patient's ability to quit successfully (Risk communication).
3. Provision of self-monitoring tool(s) for monitoring physical activity and/or fruits/vegetable consumption levels.

This study aims to assess whether the addition of an ICP for physical activity and diet into Family Health Teams (FHTs), Community Health Centres (CHCs), and Nurse Practitioner-led Clinics (NPLCs) participating in the STOP program is associated with participants' quit rate at 6 month follow-up. Individuals enrolling into the STOP program through one of these organizations will be randomly allocated (1:1) to control vs intervention group. In addition, we hope to gather insights on how this ICP can be most helpful to organizations, staff and patients, thereby informing implementation processes in other primary care settings across Canada/ Ontario. Our evaluation includes patient, clinician, and organization-level outcomes. To organize this multifaceted evaluation, we use the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework.