摘要

目的：

基于实施科学理论，对河北省某县级市2023年9月开展的戒烟干预融入基本医疗卫生服务项目进行过程评估，调查影响戒烟干预实施的因素，为项目进一步开展制定改进策略。

方法：

（1）通过问卷调查了解样本城市基线时（2023年8月）15岁及以上常住人群的烟草使用情况和门诊戒烟服务现状。

（2）基于实施科学理念，通过定量和定性调查评估戒烟干预融入基本医疗卫生服务的项目实施情况和影响因素。定量评估包括门诊系统戒烟干预模块数据分析和两次问卷调查，第一次（2024年8月）针对门诊医生与基本公卫医生，采用常态化措施发展工具评估戒烟干预常态化纳入基层医生临床工作的现状。由于该量表尚缺乏过程评估的细化指标，第二次（2025年4月）针对基层医生、高血压和2型糖尿病患者补充调查特异性问题，以评估控烟培训效果、戒烟干预覆盖情况和服务质量等内容。定性评估（2024年7~8月）基于实施性研究综合框架（Consolidated Framework for Implementation Research，CFIR）制定访谈提纲，从戒烟干预涉及的不同利益相关者（卫生政策制定者、卫生机构管理者、卫生服务提供者、卫生服务接受者、门诊系统工程师）角度评估戒烟干预服务在基层实施的促进与阻碍因素。

（3）针对戒烟干预在基层医院的实施障碍，基于实施变革的专家建议（Expert Recommendations for Implementing Change，ERIC）策略库，使用CFIR－ERIC匹配工具，结合实际情况制定戒烟干预融入基本医疗卫生服务的项目改进策略。

结果：

（1）样本城市15岁以上人群烟草使用及戒烟服务的基线情况

2023年样本城市15岁及以上人群现在吸烟率为22.27%（95CI：22.18%~22.36%），男性（44.26%）高于女性（1.18%）。戒烟率为9.60%（95CI：9.48%~9.72%），非吸烟者的二手烟暴露率为38.64%（95CI：36.73%~36.95%）；已戒烟者对于吸烟危害（中风、心脏病、肺癌）和二手烟危害（成人心脏病、儿童肺部疾病、成人肺癌）的总体知晓率（57.52%和53.96%）均高于从未吸烟者（52.30%和50.93%）和现在吸烟者（49.88%和47.37%）。现在吸烟者的戒烟意愿较低，考虑在1个月内戒烟的仅占1.90%（95CI：1.84%~1.96%）。在门诊戒烟服务方面，男性患者（73.16%）被询问吸烟史的比例远高于女性（33.32%）。

（2）戒烟干预融入基本医疗卫生服务的项目实施现状和影响因素

定量调查结果显示，2024年8月戒烟干预模块修改并运行后，系统记录的门诊医生询问吸烟史的比例（30.78%）较修改前（13.83%）升高，卫生院一级提升最明显（从19.95%到55.19%）。目前戒烟干预能够较好地整合到基层医生的日常工作中，但现有控烟培训效果不佳，仅12.85%的卫生院医生和4.35%的村医对戒烟干预知识有一定掌握。有61.62%的市直医生、59.09%的卫生院医生、37.12%的村医自报对每位门诊患者均询问吸烟史，但41.67%的门诊医生仅建议戒烟而未科普戒烟方法。高血压、2型糖尿病患者中仅13.57%的吸烟者自项目启动以来尝试过戒烟，自报戒烟满1个月的现在吸烟者仅有1.74%，自报持续戒烟6个月及以上的仅有0.97%。大部分戒烟者（65.08%）仅依靠毅力戒烟而未尝试过科学的戒烟方法。

定性调查结果显示，虽然戒烟干预项目在基层的实施具备政策环境支持，但是仍存在以下阻碍因素：①门诊量大、诊疗时间紧张等原因导致戒烟干预在三级医院门诊难以实施；②卫生部门领导层的政策执行和项目实施能力不足、基层医务人员缺乏戒烟干预知识和技能导致戒烟干预项目未能落地实施；③吸烟者缺乏戒烟意愿与戒烟服务需求，且农村地区老年人和儿童居多，戒烟App等移动戒烟服务难以推广；④基层依赖数据报表的督导考核机制影响戒烟干预的质量与效果；⑤统一修改门诊系统花费较高且难以协调导致门诊戒烟干预模块修改和运行困难；⑥县级层面难以获得控烟资金支持制约了基层戒烟服务的发展。

（3）戒烟干预融入基本医疗卫生服务的项目改进策略

针对上述障碍因素，改进策略包括：①将二级医院（乡镇卫生院和社区卫生服务中心）作为开展戒烟干预服务的主要机构；②落实对一线医生的控烟培训，加强卫生部门领导层及医务人员的能力建设，同时由项目组带领地方一同开发详细的干预活动方案；③通过加强控烟宣教、开展戒烟活动和行为干预提高吸烟者的戒烟意愿；④完善督导考核机制，加强过程与效果评估；⑤加强顶层设计，借助政府和卫生部门力量实现门诊系统中戒烟干预模块的修改与运行；⑥利用现有资源，借力现有卫生工作及活动开展戒烟干预。

结论：

戒烟干预融入基本医疗卫生服务的项目是可行的，但是在基层地区实施尚需克服领导层政策执行和项目实施能力不足、医务人员戒烟干预技能匮乏、吸烟者戒烟意愿和戒烟服务需求不足、培训与考核制度不完善、门诊系统戒烟干预模块修改困难和基层控烟经费匮乏等阻碍因素。对此，建议未来加强基层人员能力建设，推动相关制度落实与硬件设施完善，同时继续加强控烟宣教，整合现有卫生项目及资源以丰富基层戒烟活动，从而提高戒烟服务在基层地区的可及性。

ABSTRACT

Objective: Based on the theory of implementation science, to conduct a process evaluation of the integration of smoking cessation intervention into the basic medical and health services project launched in September 2023 in a county-level city in Hebei province, investigate the factors affecting the implementation of smoking cessation intervention, and formulate improvement strategies for the project.

Methods: 

(1) A questionnaire survey was conducted to understand tobacco use and cessation services among permanent residents aged 15 years and above at baseline (August 2023) in the sample cities.

(2) Based on the concept of implementation science, a quantitative and qualitative survey was conducted to evaluate the implementation and influencing factors of smoking cessation intervention integrated into primary health care services. The quantitative evaluation included data analysis of the outpatient system smoking cessation intervention module and two questionnaires. The first survey (August 2024) targeted outpatient doctors and primary public health doctors, using the Normalization MeAsure Development Tool to assess the current status of the normalization of smoking cessation interventions into the clinical work of primary doctors. Due to the lack of detailed indicators for process evaluation, the second survey (April 2025) was conducted among primary care doctors and patients with hypertension and type 2 diabetes to evaluate the effectiveness of tobacco control training, intervention coverage and service quality. Qualitative assessments (July-August 2024) developed interview Outlines based on Consolidated Framework for Implementation Research. From the perspective of different stakeholders involved in smoking cessation intervention (health policy makers, health institution managers, health service providers, health service recipients, and outpatient system engineers), the promoting and hindering factors for the implementation of smoking cessation intervention services in primary care were evaluated.

 (3) According to the barriers to smoking cessation intervention in primary hospitals, the CFR-ERIC matching tool was used to develop strategies for integrating smoking cessation intervention into primary health care services.

Results:

(1) Baseline characteristics of tobacco use and cessation services among people aged 15 years and above in the sample cities.

The current smoking rate of people aged 15 years and above in the sample cities in 2023 was 22.27% (95CI: 22.18%-22.36%), which was higher in males (44.26%) than in females (1.18%). The smoking cessation rate was 9.60% (95CI: 9.48%-9.72%), and the passive smoking exposure rate of non-smokers was 38.64% (95CI: 36.73%-36.95%). The overall awareness rates of the risks of smoking (stroke, heart disease and lung cancer) and the risks of second-hand smoke (heart disease in adults, lung disease in children and lung cancer in adults) among former smokers (57.52% and 53.96%) were higher than those of never smokers (52.30% and 50.93%) and current smokers (49.88% and 47.37%). Only 1.90% (95CI: 1.84%-1.96%) of current smokers would quit smoking within one month. More male patients (73.16%) were asked about smoking history than female patients (33.32%).  

(2) Current status and influencing factors of integrating smoking cessation intervention into primary health care.

The quantitative survey results showed that after the modification and operation of the smoking cessation intervention module in August 2024, the proportion of outpatient doctors asking about smoking history (30.78%) recorded by the system was higher than that before the modification (13.83%), and the increase was most obvious in health centers (from 19.95% to 55.19%). Smoking cessation intervention can be well integrated into the daily work of grassroots doctors, but the effect of current tobacco control training is not good, only 12.85% of the general practitioners from health centers and 4.35% of the village doctors had certain knowledge of smoking cessation intervention. 61.62% of the municipal doctors, 59.09% of the hospital doctors and 37.12% of the village doctors reported that they asked each patient about smoking history, but 41.67% of the outpatient doctors only suggested smoking cessation without popularization of smoking cessation methods. Only 13.57% of the current smokers with hypertension and type 2 diabetes had tried to quit smoking since the project began, only 1.74% of the current smokers reported that they had quit smoking for one month, and only 0.97% of the current smokers reported that they had quit smoking for six months or more. Most of the quitters (65.08%) only quit smoking by perseverance and did not try scientific smoking cessation methods.   

The results of the qualitative survey showed that although the implementation of smoking cessation intervention programs in primary hospitals was supported by the policy environment, there were still the following obstacles. ①The large number of outpatients and the limited time for diagnosis and treatment made it difficult to implement smoking cessation intervention in tertiary hospitals. ②The failure to implement smoking cessation intervention programs due to the insufficient capacity of the leadership of the health sector and the lack of knowledge and skills of smoking cessation intervention among primary medical staff. ③There was a lack of willingness to quit smoking and demand for smoking cessation services, especially among the elderly and children in rural areas, so it was difficult to promote mobile smoking cessation services such as smoking cessation App. ④The supervision and assessment mechanism relying on data reports affect the quality and effect of smoking cessation intervention. ⑤The high cost and difficulty in coordinating the modification of the outpatient smoking cessation intervention module made it difficult to modify and operate. ⑥The lack of financial support for tobacco control at county level restricts the development of smoking cessation services at grassroots level.

(3) Improvement strategies for integrating smoking cessation intervention into primary health care.

In view of the above obstacles, improvement strategies include: ①Secondary hospitals (township health centers and community health service centers) should be selected as the main institutions for smoking cessation intervention. ②Implement tobacco control training for frontline doctors and strengthen the capacity building of health department leadership and medical staff. At the same time, the project team should lead the local government to develop a detailed intervention plan. ③To improve smokers' intention to quit smoking by strengthening tobacco control education, carrying out smoking cessation activities and behavior intervention. ④Improve the supervision and assessment mechanism, strengthen the process and effect evaluation. ⑤ Strengthen top-level design to modify and operate the smoking cessation intervention module in the outpatient system with the help of the government and health departments. ⑥Smoking cessation intervention should be carried out by utilizing existing health programs and activities.

Conclusion: Integration of smoking cessation interventions into primary health care is feasible, However, it is still necessary to overcome the obstacles to the implementation of tobacco control in primary care, such as insufficient capacity of the leadership in policy implementation and project implementation, lack of smoking cessation intervention skills of medical staff, insufficient willingness of smokers to quit smoking and demand for smoking cessation services, imperfect training and assessment systems, difficulties in modifying smoking cessation intervention modules in outpatient system, and lack of funds in primary care. In order to improve the accessibility of smoking cessation services in primary care Settings, it is recommended to strengthen the capacity building of primary care personnel, promote the implementation of relevant systems and improve hardware facilities, continue to strengthen tobacco control education, and integrate existing health programs and resources to enrich smoking cessation activities in primary care Settings.