Adherence makes perfect: improving practice nurses’ adherence to smoking cessation guidelines

    Ph.D researcher: Dennis de Ruijter

    Supervisor: Dr. Ciska Hoving

    Co-researchers: Dr. Eline Smit & Prof. Dr. Hein de Vries

    Funding: Dutch Cancer Society

    Objective: To develop and test a computer-tailoring program for practice nurses, supporting them to better adhere to evidence-based smoking cessation guidelines


    • A needs assessment (semi-structured individual interviews) among practice nurses regarding their current smoking cessation counseling activities and their needs for adherence support
    • A cross-sectional online questionnaire study to explore determinants of practice nurses’  adherence to evidence-based smoking cessation guidelines, based on theoretical concepts from the I-Change Model
    • Development of a web-based computer-tailoring program aimed to improve practice nurses’ adherence to evidence-based smoking cessation guidelines: program content was based on results of the needs assessment and the cross-sectional study, and development was conducted using the TailorBuilder (online tailoring platform).
    • Usability testing of the web-based program, using heuristic evaluation (by five experts) and think aloud method (by five practice nurses).
    • A randomized controlled trial testing the effects of the computer-tailoring program on practice nurses' level of adherence and patients' smoking abstinence, after six and twelve months: adherence is assessed using self-reported online checklists, online questionnaires filled out by counseled patients and audio-recordings of smoking cessation consultations. Patients’ smoking status is assessed using self-reported online questionnaires.
    • Imbedded trial-based economic evaluation to assess cost-effectiveness of the computer-tailoring program at the level of the practice nurse and patient: data on costs (i.e. patients’ medication costs) and effects (i.e. patients’ smoking abstinence and quality of life, and practice nurses’ adherence) are collected through online questionnaires.
    • Process evaluations among practice nurses (i.e. online questionnaires and several telephone interviews) and counseled smokers (i.e. online questionnaires) concerning their experiences with the web-based program and quality of counseling sessions.


    • Needs assessment: practice nurses had difficulties adhering to all steps of evidence-based smoking cessation guidelines and especially reported their low self-efficacy and perception that quitting is a smoker’s responsibility to be barriers to adherence. They were interested in a web-based program that could provide them with easily accessible and personally relevant information and experiences of colleagues.
    • Cross-sectional study: adherence to individual steps of smoking cessation guidelines ranged from 33-73%. Socio-cognitive determinants (self-efficacy and perceived advantages) and the amount of time spent on counseling were important factors associated with guideline adherence by practice nurses.
    • Program development: a computer-tailored program was developed with several e-learning modules for practice nurses. The program includes three modules with individually tailored advice regarding their behavior and its socio-cognitive determinants; a module with information about smoking cessation (counseling); and an online forum for peer-to-peer contact.
    • Usability testing: similar improving alterations to the program were suggested by practice nurses and experts. Subsequently, more visual elements and return-to-home buttons and clear information on printing and saving content were added; and several answer scales were changed.
    • Randomized controlled trial, economic and process evaluation: data collection is in progress. 


    de Ruijter, D., Smit, E. S., de Vries, H., & Hoving, C. (2016). Web-based computer-tailoring for practice nurses aimed to improve smoking cessation guideline adherence: A study protocol for a randomized controlled effectiveness trial. Contemporary Clinical Trials, 48, 125-132. doi:10.1016/j.cct.2016.04.007

    de Ruijter, D., Smit, E. S., de Vries, H., Goossens, L., & Hoving, C. (2017). Understanding Dutch practice nurses' adherence to evidence-based smoking cessation guidelines and their needs for web-based adherence support: results from semistructured interviews. BMJ Open, 7(3), e014154. doi:10.1136/bmjopen-2016-014154

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