Understanding the potential of teachable moments: the case of smoking cessation

Barriers and facilitators for healthy lifestyle and recommendations for counseling in endometrial cancer follow-up care: a qualitative study

OBJECTIVES

Lifestyle promotion during follow-up consultations may improve long-term health and quality of life in endometrial cancer patients. This study aimed to identify barriers and facilitators to improve and sustain a healthy lifestyle that can be translated to behavioral methods and strategies for lifestyle counseling.

METHODS

Endometrial cancer patients from three hospitals were recruited to participate in a semi-structured interview. The data were transcribed and coded. Thematic analysis was applied to identify themes and the behavior change wheel was used as a theoretical framework. Data saturation was confirmed after 18 interviews.

RESULTS

Barriers included knowledge gaps as well as lack of motivation and environmental opportunities to engage in health-promoting behavior. Facilitators included applying incremental lifestyle changes, social support, positive reinforcements, and the ability to overcome setbacks.

CONCLUSIONS

We propose the following intervention functions: education, persuasion, training, environmental restructuring, and enablement. Suitable behavior change techniques to deliver the intervention functions include information about the consequences of certain behavior, feedback on behavior, credible source, graded tasks, habit formation, restructuring of the environment, prompts/cues, goal setting, action planning, and social support. Including these recommendations in lifestyle counseling could aid lasting lifestyle change since it suits the needs and preferences of patients.

Exploring timing and delivery of lifestyle advice following an acute cardiac event hospitalization: The cardiac patient's perspective

OBJECTIVE

To explore the perspective of cardiac patients regarding the timing and manner of delivering lifestyle advice following an acute cardiac event hospitalization.

METHODS

Dutch cardiac patients who experienced a cardiac event hospitalization participated in a semi-structured interview (n = 14) or a cross-sectional survey study (n = 119).

RESULTS

Our findings indicate that cardiac patients are receptive to lifestyle advice throughout the care trajectory. Advice delivered by a cardiologist had the highest self-reported impact. Furthermore, receiving advice at multiple phases during the care trajectory was associated with a greater intention to change lifestyle (B = 0.37, CI = 0.17 - 0.57). Patients favored clear-cut, feasible, and friendly but confronting advice. Moreover, they stressed the importance of advice being aligned with their identity and beliefs about the causes of their disease.

CONCLUSION

The period following an acute cardiac event provides a unique opportunity to offer tailored and patient-centered lifestyle advice. This "teachable window" for lifestyle change, when used wisely, may improve health outcomes for cardiac patients.

PRACTICE IMPLICATIONS

Healthcare professionals should initiate lifestyle advice already during hospitalization and continue during follow-up appointments and cardiac rehabilitation. Advice should be feasible and empathy-based, as well as tailored to the patient's needs, values, and perceptions of the causes of their cardiovascular disease.

Mediational pathways among drug use initiation, use-related consequences, and quit attempts

Background

Factors that predict attempts to discontinue drug use are clinically relevant and may inform treatment. This study investigated drug use-related consequences as a predictor of drug quit attempts and treatment seeking among two cohorts of persons who use drugs.

Methods

Drug use and clinical characteristics were assessed among persons who use cocaine (N=176; urine-verified; 'Cocaine Cohort') and among those who use heroin (N=166; urine-verified; 'Heroin Cohort'). Mediation analyses assessed relationships among age at initial drug use, adverse drug-specific use-related consequences, and drug-specific quit attempts, separately for each cohort. Forward conditional logistic regression models evaluated drug use and clinical symptom scores as predictors of drug-specific treatment seeking.

Results

Controlling for age, mediation models showed that drug use consequences fully mediated the relationship between age at initial drug use and number of drug-specific quit attempts for the 'Cocaine Cohort' and 'Heroin Cohort' (R2=0.30, p<.001; R2=0.17, p<.001; respectively). Reporting more consequences predicted more quit attempts in each cohort, accounting for duration of use (ps<.001). Reporting more consequences also predicted greater likelihood of seeking drug use treatment (ps<.001) and was associated with more severe clinical symptoms in each cohort (ps<.05).

Conclusions

Using a parallel analysis design, we showed that reporting more drug-specific use-related consequences predicted more drug-specific quit attempts and greater likelihood to seek treatment in two cohorts: persons who use cocaine and those who use heroin. Our findings suggest that experiencing more drug use consequences predicts more attempts to seek drug abstinence and that assessment of consequences may be informative for treatment.

Smoking Cessation by Cancer Treatment Status Among Cervical Cancer Survivors

INTRODUCTION

Continued smoking following a cancer diagnosis is associated with poorer cancer treatment outcomes and survival times. Little is known about how cancer treatment status at the time of tobacco treatment enrollment impacts long-term smoking cessation outcomes. Using data from a smoking cessation RCT, this study compared long-term cessation outcomes of women undergoing active treatment for cervical cancer at trial enrollment (n=40) to outcomes of women with a history of cervical cancer or cervical intraepithelial neoplasia (CIN) who were not undergoing active cancer treatment at enrollment (n=154).

METHODS

Participants (n=194) were randomized to Standard Treatment (ST) or ST plus a 6-session Motivation And Problem Solving (MAPS) telephone counseling protocol (data collected: 2017-2021; analyzed: 2023). Sociodemographic differences between participants undergoing (versus not undergoing) active cancer treatment at enrollment were examined. Significant covariates were included in a logistic regression analysis comparing the 2 groups' smoking cessation outcomes at 12 months, the end of the tobacco treatment period.

RESULTS

Participants in active cancer treatment at enrollment were significantly younger and less educated than those not in active cancer treatment. Race/ethnicity, relationship status, household income, nicotine dependence, and tobacco treatment condition did not vary by cancer treatment status. After adjusting for tobacco treatment condition, age, and education, being in active cancer treatment at the time of enrollment was associated with lower odds of abstinence at 12 months (5% vs 20%, aOR=0.22, 95% CI [0.05-0.998]).

CONCLUSIONS

Further research is necessary to identify and overcome barriers to abstinence among cancer survivors undergoing active treatment.

Cardiovascular disease and preventive care service utilization among midlife adults: The roles of diagnosis and depression

Objectives

Secondary preventive care is important for monitoring the progression of cardiovascular disease (CVD). However, the factors that promote secondary prevention were not well understood. This study addressed this gap by investigating the impact of CVD diagnosis on preventive care utilization among midlife adults. Given the high prevalence of depression among this population, it further examined whether depression interacted with CVD diagnosis to affect preventive care utilization.

Methods

The study sample included 6,222 midlife adults from six waves of the National Longitudinal Survey of Youth 1979 (NLSY79) collected between 2006 and 2016. Multiple logistic regressions were conducted to examine the relationship between a CVD diagnosis and each of the five types of preventive care utilization: influenza vaccinations, electrocardiography (EKG) and screening for high blood pressure, cholesterol, and blood sugar. Depression was then added to examine its possible moderation effect.

Results

The results showed that midlife adults with a CVD diagnosis were more likely to utilize all five types of preventive care services. EKG, the most relevant preventive care type with CVD diagnosis, had the largest strength of likelihood. Depression strengthened the relationship between a CVD diagnosis and the utilization of blood pressure tests, but it showed no associations with other four types of preventive care utilization.

Conclusions

The study findings indicate that a CVD diagnosis could serve as an opportunity for promoting secondary preventive care utilization. Future research needs to explore how a CVD diagnosis affects different population groups, and further explore the roles of depression.

Hospitalization as an opportunity to improve lung cancer screening in high-risk patients

BACKGROUND

Lung cancer screening with annual low-dose computed tomography (LDCT) in high-risk patients with exposure to smoking reduces lung cancer-related mortality, yet the screening rate of eligible adults is low. As hospitalization is an opportune moment to engage patients in their overall health, it may be an opportunity to improve rates of lung cancer screening. Prior to implementing a hospital-based lung cancer screening referral program, this study assesses the association between hospitalization and completion of lung cancer screening.

METHODS

A retrospective cohort study of evaluated completion of at least one LDCT from 2014 to 2021 using electronic health record data using hospitalization as the primary exposure. Patients aged 55-80 who received care from a university-based internal medicine clinic and reported cigarette use were included. Univariate analysis and logistic regression evaluated the association of hospitalization and completion of LDCT. Cox proportional hazard model examined the time relationship between hospitalization and LDCT.

RESULTS

Of the 1935 current smokers identified, 47% had at least one hospitalization, and 21% completed a LDCT during the study period. While a higher proportion of patients with a hospitalization had a LDCT (24%) compared to patients without a hospitalization (18%, p<0.001), there was no association between hospitalization and completion of a LDCT after adjusting for potentially confounding covariates (95%CI 0.680 - 1.149). There was an association between hospitalization time to event and LDCT completion, with hospitalized patients having a lower probability of competing LDCT compared to non-hospitalized patients (HR 0.747; 95% CI 0.611 - 0.914).

CONCLUSIONS

In a cohort of patients at risk for lung cancer and established within a primary care clinic, only 1 in 4 patients who had been hospitalized completed lung cancer screening with LDCT. Hospitalization events were associated with a lower probability of LDCT completion. Hospitalization is a missed opportunity to refer at-risk patients to lung cancer screening.

Turning a Curve: How People Use Everyday Resources to Negotiate Recovery From Cancer Treatment With Curative Intent

Many more cancers are treated with intent to cure now than in previous decades, but for most, this involves significant effects from which people need to recover psychologically and socially, as well as physically. This longitudinal photo-elicitation interview study uses grounded theory to explain how people discharged from specialist care made use of everyday social and material resources to manage this process at home. Recovery is presented as a curve in life's pathway requiring gradual reorientation, drawing on social worlds and domestic resources to calibrate this process. Findings are described in three stages: (1) responding to diagnosis and treatment, (2) using social resources for meaning-making, and (3) developing assets for recovery. During treatment, participants drew on past identities to reinforce their sense of self, and personalized health care communication supported this process. In the weeks after treatment, new frameworks of understanding were constructed from perspectives on cancer encountered in the family, workplace, and outpatient clinics. Recovery processes included the negotiation of personal change, the renegotiation of close relationships, and the use of everyday resources to regain three sensations: control, comfort, and continuity. Supportive care would benefit from an individualized exploration of the assets that can help people to negotiate this challenging phase as treatment comes to a close. Possibilities for self-care (the maintenance of health and well-being in the context of everyday life) can be explored and assessed through personalized discussion around the identities, social worlds, and everyday resources available to each individual.

Examining adverse childhood experiences and Black youth's engagement in a hospital-based violence intervention program using administrative data

BACKGROUND

Stemming from poverty and systemic racism, Black youth are disproportionately represented in hospital-based violence intervention programs (HVIPs) due to greater violence exposure. HVIPs are a critical intervention that have been shown to reduce rates of reinjury in urban hospitals and trauma centers across the United States; however, they are plagued by low enrollment and engagement rates. Few studies have examined factors related to engagement, particularly among Black youth.

METHODS

Guided by Trauma Theory and Critical Race Theory, this study uses a retrospective cohort design. Between-group differences of adverse childhood experiences (ACEs) among engaged youth compared to nonengaged youth who were violently injured and recruited for a HVIP were examined using chi-square and logistic regression. ACEs were approximated using a novel approach with administrative data.

RESULTS

Results indicated that the total ACE score was not significantly associated with engagement status. Individual ACEs were tested across age groups.

CONCLUSIONS

This study highlights a novel approach to understanding ACEs among a hard-to-reach population and illuminates the significant level of ACEs faced by violence-exposed Black youth at young ages. Considering theory, Black families may be more reluctant to engage due to fear and past harms in social service systems stemming from systemic racism. Though ACEs did not predict engagement in this study, considering the high rates of ACEs experienced by Black youth and their families in the context of systemic racism suggests that HVIPs should acknowledge historical harms and foster trauma-informed and healing-centered interactions during recruitment and later stages of engagement.

Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose

Importance

Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking.

Objective

To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization.

Design, Setting, and Participants

This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023.

Exposure

Hospital OORP implementation.

Main Outcomes and Measures

The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access.

Results

A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities.

Conclusions and Relevance

In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

Midwives' experiences of discussing health behaviour change within routine maternity care: A qualitative systematic review and meta-synthesis

PROBLEM

Behaviours, such as smoking, alcohol use, unhealthy diet, lack of physical activity and vaccination non-adherence may lead to adverse pregnancy outcomes.

BACKGROUND

Pregnancy has been identified as an opportune time for midwives to support women to make health behaviour changes.

AIM

To synthesise existing qualitative research exploring midwives' experiences of discussing health behaviour change with women within routine care.

METHODS

A systematic search was conducted across: Maternity and Infant Care, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Applied Social Sciences Index and Abstracts. Thematic analysis was used to synthesise the data. A professional and public advisory group provided feedback during the synthesis stage.

FINDINGS

Twenty-two studies, published between 2005 and 2023, which represented findings from eight countries, were included in the review. The meta-synthesis revealed three themes: The midwife-woman relationship; Reflective and tailored behaviour change communication; Practical barriers to behaviour change conversations. This led to one overarching theme: Although midwives recognised the importance of behaviour change discussions, these conversations were not prioritised in clinical practice.

CONCLUSION

Health behaviour change discussions were de-prioritised in midwives' clinical practice. Future research should explore intervention development to support midwives with their health behaviour change communication.

A cross-sectional analysis of factors associated with the teachable moment concept and health behaviors during pregnancy

BACKGROUND

Pregnancy is often associated with a change in health behaviors, leading some to suggest that pregnancy could be a teachable moment for lifestyle change. However, the prevalence and underlying mechanism of this phenomenon is not well understood. The aim of this study is to explore the prevalence of a teachable moment during pregnancy, the psychosocial factors that are associated with experiencing such a moment, and its association with actual health behaviors.

METHODS

In this cross-sectional study, 343 pregnant Dutch women completed an online questionnaire. Participants reported on their intentions to change lifestyle due to pregnancy, their current health behaviors, and several psychosocial factors that were assumed to be linked to perceiving a teachable moment during pregnancy: perceived risk, affective impact, changed self-concept, and social support. Multivariable linear and logistic regression were applied to the data analysis.

RESULTS

Results demonstrate that 56% of the women experienced a teachable moment based on intentions to change their health behavior. Multivariate regression analyses revealed that changed self-concept (β = 0.21; CI = 0.11-0.31), positive affect (positive β = 0.28; CI = 0.21-0.48), and negative affect (β = 0.12; CI = 0.00-0.15) were associated with higher intentions to change health behavior. Conversely, more perceived risk was associated with lower intentions to change health behavior (β=-0.29; CI = 0.31 - 0.13). Multivariate regression analyses showed a positive association between intentions to change health behavior and diet quality (β = 0.11; CI = 0.82-1.64) and physical activity (OR = 2.88; CI = 1.66-5.00).

CONCLUSIONS

This study suggests that pregnancy may be experienced as a teachable moment, therefore providing an important window of opportunity for healthcare professionals to efficiently improve health behaviors and health in pregnant women and their children. Results suggest that healthcare professionals should link communication about pregnancy-related health behaviors to a pregnant women's change in identity, affective impact (predominantly positive affective impact) and risk perception to stimulate the motivation to change healthy behavior positively.

Prescribing pre- and post-operative physical activity interventions for people undergoing breast cancer surgery: A qualitative systematic review

INTRODUCTION

Undertaking physical activity, pre- and post-operatively, can benefit recovery time and improve post-surgical outcomes. One cohort of patients that have reported these benefits are those undergoing surgery for breast cancer. Yet, what remains unclear is the level to which physical activity interventions are implemented into standard surgical care for patients with breast cancer.

AIMS

This systematic review aimed to examine existing qualitative evidence focusing on pre- and post-operative physical activity interventions to better understand the benefits and shortcomings of physical activity within the surgical journey.

METHODS

A systematic literature search was undertaken in November 2022, across five databases: MEDLINE, PsycINFO, Embase, CINAHL, and Scopus. Qualitative studies involving people with breast cancer who had undertaken a physical activity intervention, either pre- and/or post-operatively, were included for analysis. The review was registered on PROSPERO: CRD42022372466 and performed according to PRISMA guidelines. The Critical Appraisal Skills Programme qualitative study checklist was used to assess study quality.

RESULTS

Fourteen studies were included, comprising the perspectives of 418 people receiving surgery for breast cancer. One study implemented preoperative physical activity interventions; the remaining studies focused on post-operative interventions. A narrative systematic review was undertaken due to heterogeneity in reported results. Four themes were developed by thematic analysis, centring on: (1) factors promoting engagement with physical activity interventions; (2) factors preventing engagement with physical activity interventions; (3) the impact of pre- and post-operative interventions on physical and psychological health; and (4) participant recommendations for pre- and post-operative interventions.

CONCLUSION

Pre- and post-operative physical activity interventions were well-accepted. Patients recognised factors which promoted or prevented engagement with interventions, as well as pre- and post-operative physical and psychological benefits that arose as a result. Evidence based co-design studies may further inform successful implementation of prescribed physical activity into standard care for surgical breast cancer patients.

Understanding cancer patients' desire to quit tobacco without assistance: A mixed-methods study

While many cancer patients who use tobacco try to quit post-diagnosis, some prefer to quit without using tobacco treatment, despite evidence against unassisted quit attempts. This study aimed to understand the rationale for some cancer patients' desire to quit tobacco without assistance. Thirty-five adult cancer patients who currently used tobacco and declined tobacco treatment because of the desire to quit unassisted provided data via a standardized questionnaire and a semi-structured interview. The sample was predominately White, non-Hispanic (85.71%) and female (68.57%). The most common cancer site was gynecological. Key themes that emerged from the interviews were: self-reliance, willpower, social norms, and negative attitudes toward tobacco treatment. The most frequently endorsed barrier to tobacco treatment was "I know others who have quit without tobacco treatment" (82.86%). This study with cancer patients identified affective, cognitive, and personality factors related to quitting unassisted, and social and systemic reasons to not use tobacco treatment.

Evaluating Preconception Health and Behaviour Change in Australian Women Planning a Pregnancy: The OptimalMe Program, a Digital Healthy Lifestyle Intervention with Remotely Delivered Coaching

OptimalMe is a digital healthy lifestyle intervention for women planning a pregnancy, with remotely delivered coaching. This follow-up study of Australian women, stratified by coaching delivery mode (phone vs. videoconferencing), assessed alignment to preconception care guidelines and self-reported behaviour change. Overall, 298 women enrolled with a mean (SD) age of 31.8 (4.3) years and mean BMI of 25.7 (6.1) kg/m2. Suboptimal preconception behaviours were reported at baseline, including alcohol consumption (57.2%), infrequent weighing (37.2%) and incomplete cervical cancer screening (15.8%) and prenatal supplementation (38.5). At follow-up (4.5 months) (n = 217), a statistically significant shift towards desired behaviours was reported for alcohol consumption (z = -2.6045, p = 0.00932), preconception supplementation (z = -2.7288, p = 0.00634) and frequent weight monitoring (z = -5.2911, p < 0.00001). An insignificant shift towards adherence to cervical cancer screening (z = -1.8679, p = 0.06148) was observed, with a positive trend towards adherence. Results indicate that women who are actively planning a pregnancy require support to optimise health and lifestyle in preparation for pregnancy and general health and lifestyle improvement. Women demonstrated improvement in lifestyle behaviours and self-monitoring, indicating the uptake of low-intensity, non-prescriptive information provision. Supporting the provision of knowledge-enhancing tools and general healthy lifestyle information combines with skilled health coaching as an effective method for behaviour change and self-management. OptimalMe also shows significant improvements in rates of healthcare engagement, which suggests coaching-based digital health interventions may decrease women's barriers for preconception care and improve engagement in clinical settings.

Tobacco treatment in the setting of lung cancer screening

PURPOSE OF REVIEW

Lung cancer screening by low-dose CT is an increasingly implemented preventive medicine tool. Screening for lung cancer is incomplete without addressing problematic tobacco use, the greatest modifiable risk factor in the development of lung cancer. This review describes recent work related to lung cancer screening and treatment of tobacco use in that context.

RECENT FINDINGS

Implementation of lung cancer screening demonstrates socioeconomic disparities in terms of adherence to screening as well as likelihood of successful tobacco dependence treatment. Active tobacco dependence is a common comorbidity for patients undergoing lung cancer screening. The optimal implementation of tobacco dependence treatment in the context of lung cancer screening is still an area of active investigation.

SUMMARY

Treatment of tobacco dependence at time of lung cancer screening is a major opportunity for clinicians to intervene to reduce the major modifiable risk factor for lung cancer, tobacco use. Providing comprehensive tobacco dependence treatment is most effective using combination pharmacologic and behavioral interventions. Practices providing comprehensive treatment will benefit from accurate documentation for billing and coding and supplementing with external resources such as state Quit Lines.

Barriers and facilitators to engaging in smoking cessation support among lung screening participants

INTRODUCTION

Embedded smoking cessation support within lung cancer screening is recommended in the UK; however, little is known about why individuals decline smoking cessation support in this setting. This study identified psychosocial factors that influence smoking cessation and quit motivation among those who declined support for quitting smoking alongside lung cancer screening.

METHODS

Qualitative interviews conducted between August 2019 - April 2021 with thirty adults with a smoking history, recruited from the Yorkshire Lung Screening Trial. Participants had declined smoking cessation support. Verbatim interview transcripts were thematically analysed.

RESULTS

Fifty percent of participants were male and the majority were from the most deprived groups. Participants reported low motivation and a variety of barriers to stopping smoking. Participants described modifiable behavioural factors that influenced their quit motivation including self-efficacy, perceived effectiveness of stop-smoking services including smoking cessation aids, risk-minimising beliefs, lack of social support, absence of positive influences on smoking and beliefs about smoking/smoking cessation. Broader contextual factors included social isolation and stigma, COVID-19 and comorbid mental and physical health conditions that deterred smoking cessation.

CONCLUSIONS

To encourage engagement in smoking cessation support during lung cancer screening, interventions should seek to encourage positive beliefs about the effectiveness of smoking cessation aids and increase confidence in quitting as part of supportive, person-centred care. Interventions should also acknowledge the wider social determinants of health among the lung screening-eligible population.

IMPLICATIONS

This study provides an in-depth understanding of the beliefs surrounding smoking and smoking cessation and further potential psychosocial factors that influence those attending lung cancer screening. Many of the barriers to smoking cessation found in the present study are similar to those outside of a lung screening setting however this work offers an understanding of potential facilitators that should be considered in future lung screening programmes.

Abnormal cervical cancer screening results among US Veteran and non-Veteran participants in the National Health Interview Survey (NHIS)

Female Veterans report cervical cancer risk factors at higher rates than non-Veterans. Using data from the National Health Interview Survey (NHIS), we tested whether Veterans with a recent cervical cancer screening test were more likely than non-Veterans to have received an abnormal result. NHIS is a population-based cross-sectional household survey with a stratified, multistage sampling design. We pooled screening data from 2010, 2015, and 2018, and restricted the sample to female participants without a hysterectomy who had a cervical cancer screening test in the prior 3 years. The primary outcome was self-reported abnormal result on a Pap and/or HPV test in the prior 3 years. Our main predictor was Veteran status. We used survey-weighted multivariable logistic regression to estimate odds of an abnormal screening result in the prior 3 years as a function of Veteran status, controlling first for age and survey year, then adding sociodemographic and health factors in subsequent models. The sample included 380 Veterans and 25,102 non-Veterans (weighted total population 104.9 million). Overall, 19.0% of Veterans and 13.7% of non-Veterans reported an abnormal cervical cancer screening test result in the prior 3 years (unadjusted p = 0.03). In the adjusted regression model, the previously observed association between Veteran status and abnormal screening result was explained by differences in sociodemographic and health factors between Veterans and non-Veterans (aOR 1.21, 95%CI 0.78-1.87). Nearly 1 in 5 Veterans with a recent cervical cancer screening test received an abnormal result. Clinicians should address modifiable risk factors and provide evidence-based follow-up for abnormal results.

Implementation of a group-based lifestyle intervention programme (Healthy Heart) in general practices in The Netherlands: a mixed-methods study

BACKGROUND

Lifestyle intervention programmes target behavioural risk factors that contribute to cardiovascular diseases (CVDs). Unfortunately, sustainable implementation of these programmes can be challenging. Gaining insights into the barriers and facilitators for successful implementation is important for maximising public health impact of these interventions. The Healthy Heart (HH) programme is an example of a combined lifestyle intervention programme.

AIM

To analyse the reach, adoption, and implementation of the HH programme.

DESIGN & SETTING

A mixed-methods study conducted in a general practice setting in The Netherlands.

METHOD

Quantitative data were collected from the Healthy Heart study (HH study), a non-randomised cluster stepped-wedge trial to assess the effect of the HH programme on patients at high risk of developing CVDs at practice level. Qualitative data were obtained through focus groups.

RESULTS

Out of 73 approached general practices, 55 implemented the HH programme. A total of 1082 patients agreed to participate in the HH study, of whom 64 patients were referred to the HH programme and 41 patients participated. Several barriers for participation were identified such as time investment, lack of risk perception, and being confident in changing lifestyle on their own. Important barriers for healthcare providers (HCPs) to refer a patient were time investment, lack of information to sufficiently inform patients, and preconceived notions regarding which patients the programme was suitable for.

CONCLUSION

This study has offered insights from a patient and HCP perspective regarding barriers and facilitators for implementation of the group-based lifestyle intervention programme. The identified barriers and facilitators, and the suggested improvements, can be used by others who wish to implement a similar programme.

Smoking status among cancer patients by specialty: A U.S. nationwide representative analysis

BACKGROUND

Persistence in tobacco use among cancer survivors has been associated with a multitude of clinicodemographic factors. However, there is a paucity of understanding regarding the role the healthcare professional's specialty plays in tobacco cessation in tobacco-related cancer survivors.

METHODS

We conducted a cross-sectional analysis of data from cancer survivors with a smoking history using the Behavioral Risk Factor Surveillance System (BRFSS) database to examine differences in the proportion of patients continuing tobacco use among patients with a diagnosis of cancer segregated by cancer site specialty over the 2016-2020 period. We accounted for complex survey design and used sampling weights to obtain a nationwide representative sample. We employed modified Poisson regression adjusting for age, gender, education, income, race, marital status, and medical specialty.

RESULTS

We analyzed 19,855 cancer survivors with a current or past history of tobacco use, of whom 5222 (26,3%) self-reported to be current smokers. Patients with urological and gynecological tobacco-related malignancies had a higher relative risk (RR) of being current smokers with a RR of 1.30 (95% confidence interval, 1.12-1.51) and 1.25 (95% confidence interval, 1.12-1.39) respectively. Malignant Hematology had the lowest RR of smoking status among all other specialties RR 0.85 (95% confidence interval, 0.59-1.21).

CONCLUSIONS

Continuing smoking rates among tobacco-related cancer survivors were different between specialties. One in four cancer survivors were current smokers; this emphasizes health professionals' paramount role in tobacco cessation counseling.

Making sense of a myocardial infarction in relation to changing lifestyle in the five months following the event: An interpretative phenomenological analysis

OBJECTIVE

Previous research has shown that experiencing an acute cardiac event, such as a myocardial infarction (MI), can lead to lifestyle changes. This study aimed to explore the potential of a MI as a 'teachable moment' (TM) for positive lifestyle changes and to identify psychosocial sensemaking processes that facilitate or hinder the presence of a TM.

METHOD

We conducted semi-structured interviews with 14 patients who suffered their first MI and were hospitalized in a larger Dutch city. Participants were interviewed twice, respectively one and five months after their hospitalization. They were encouraged to explain how they experienced their MI and how this had affected their lifestyle. We used an Interpretative Phenomenological Analysis approach to the data collection and analysis.

FINDINGS

The participants varied in their willingness to adopt a healthy lifestyle due to their MI. Most participants experienced their event as a TM for changing specific health behaviors, for example facilitated by reflecting on self-concept or social roles and by constructing and comprehending a personal narrative of their MI. Some participants struggled to follow through on their intentions to change their behavior, for example because of a negative attitude towards a healthy behavior or because they perceived it as incongruent to their identity. Only three participants maintained most former health behaviors, for example because they failed to acknowledge their MI as severe or because of earlier life events that elicited more blunted cognitive responses.

CONCLUSION

Cardiac patients may experience a TM, which is the consequence of interrelated processes of psychosocial sensemaking. As this does not occur at a singular time point, we suggest using the term 'teachable window' rather than 'moment'. Given these findings, there is a window of opportunity to provide continuous psychosocial and lifestyle support during and after hospitalization for acute cardiac events.

"It Is A Carrot-Stick Model": A Qualitative Study of Rural-Serving Clinician and Rural-Residing Veteran Perceptions of Requirements to Quit Smoking prior to Elective Surgery

Introduction

Some medical centers and surgeons require patients to stop smoking cigarettes prior to elective orthopaedic surgeries in an effort to decrease surgical complications. Given higher rates of smoking among rural individuals, rural patients may be disproportionately impacted by these requirements. We assessed the perceptions and experiences of rural-residing Veterans and clinicians related to this requirement.

Methods

We conducted qualitative semistructured one-on-one interviews of 26 rural-residing veterans, 10 VA orthopaedic surgery staff (from two Veterans Integrated Services Networks), 24 PCPs who serve rural veterans (14 VA; 10 non-VA), and 4 VA pharmacists. Using the knowledge, attitudes, and behavior framework, we performed conventional content analysis.

Results

We found three primary themes across respondents: (1) knowledge of and the evidence base for the requirement varied widely; (2) strong personal attitudes toward the requirement; and (3) implementation and possible implications of this requirement. All surgery staff reported knowledge of requirements at their institution. VA PCPs reported knowledge of requirements but typically could not recall specifics. Most patients were unaware. The majority of respondents felt this requirement could increase motivation to quit smoking. Some PCPs felt a more thorough explanation of smoking-related complications would result in increased quit attempts. About half of all patients reported belief that the requirement was reasonable regardless of initial awareness. Respondents expressed little concern that the requirement might increase rural-urban disparities. Most PCPs and patients felt that there should be exceptions for allowing surgery, while surgical staff disagreed. Discussion. Most respondents thought elective surgery was a good motivator to quit smoking; but patients, PCPs, and surgical staff differed on whether there should be exceptions to the requirement that patients quit preoperatively. Future efforts to augment perioperative smoking cessation may benefit from improving coordination across services and educating patients more about the benefits of quitting.

Development of a Brief Intervention for Emergency Department Attendees Presenting With Self-Harm and Co-Occurring Substance Use Problems

Background: People who present to the emergency department with self-harm and co-occurring substance use problems often have difficulty accessing effective care. Aims: To develop a brief psychosocial intervention for this population, which would be suitable for testing in a future randomized controlled trial. Methods: A modified Delphi method was used. A 34-item, 3-round, online Delphi survey was informed by a literature review and stakeholder telephone discussions (n = 17). Two panels consisting of people with lived experience (PWLE: n = 15) and people with occupational experience (PWOE: n = 21) participated in the survey. The threshold for consensus was a pooled agreement rate across the two panels of 80% or more. Results: Expert consensus was achieved for 22 items. The new intervention consists of weekly follow-up phone calls for up to 1 month, delivered by Liaison Psychiatry practitioners, in which both self-harm and substance use problems are explored and addressed, and patients are supported in accessing community services. Limitations: Some stakeholder ideas regarding intervention components could not be included as survey options due to anticipated difficulties with implementation. Conclusions: The key elements of a brief psychosocial intervention for self-harm and co-occurring substance use problems have been agreed. Feasibility testing is currently underway.

International and national frameworks, guidelines, recommendations, and strategies for maternal tobacco prevention and cessation: A scoping review protocol

Tobacco use during and around pregnancy can significantly increase the risk of stillbirth, congenital disabilities, premature birth, and low-weight birth. To establish maternal tobacco prevention and cessation frameworks for primary care and dental providers and to facilitate cross-national learning, this scoping review aims: 1) to analyze the body of literature on maternal tobacco prevention and cessation frameworks, guidelines, recommendations, and strategies at the international and national level; 2) to identify common core elements; and 3) to identify gaps in the literature, and propose future initiatives and policy development directions. A systematic database search based on the JBI methodology and corresponding PRISMA-ScR guidelines will be conducted from January 2015 to August 2023. Searches in different databases will be combined with an expert survey among the members of the World Federation of Public Health Associations (WFPHA) - Oral Health, Tobacco Control, and the Women, Adolescent, and Children's Working Groups to evaluate the search outcomes and add maternal tobacco prevention and cessation frameworks, guidelines, recommendations, or strategies. Using a systematic review tool to support the screening, two independent reviewers will screen the titles and abstracts of all articles, in order to include the relevant ones for full-text screening, and an independent third author will resolve conflicts, if there is any discrepancy between the two independent reviewers' search. After a full-text review, data extraction will be conducted for analysis. Descriptive analyses include the publication year, country, legal quality, and target group addressed. A narrative synthesis will describe the scope and content of the frameworks, guidelines, recommendations, and strategies. The scoping review will serve as a stepping-stone to creating a WFPHA policy resolution on tobacco prevention and cessation framework for women of childbearing age led by the WFPHA Oral Health, Tobacco Control and the Women, Adolescent, and Children's Working Group members. This WFPHA policy resolution 'Maternal Tobacco Cessation and Prevention Recommendations for Primary Care Providers and Dental Providers' will be forwarded to the WFPHA General Council and the General Assembly for approval and will be disseminated to the WFPHA public health association members. Ultimately, this recommendation will be used by each national public health association to consider integrating it into their maternal health strategy.

Smoking cessation behavior in patients with a diagnosis of a non-communicable disease: The impact of perceived disease severity of and susceptibility to the disease

INTRODUCTION

The Health Belief Model comprises two constructs influencing changed behaviors impacting on health, namely perceived severity and susceptibility. The aim of this study was to identify the impact of the combination of, or interactions between, these two constructs on quitting smoking in smokers with a diagnosis of a non-communicable disease (NCD).

METHODS

From the large insurance claims database maintained by JMDC database (JMDC, Tokyo), we extracted data on 13284 participants who smoked. All participants were stratified according to their NCD diagnosis based on perceived severity and susceptibility as follows: Category I (high severity and high susceptibility) - acute myocardial infarction, and lung cancer; Category II (high severity and low susceptibility) - colorectal cancer, and stomach cancer; Category III (low severity and high susceptibility) - asthma, and transient ischemic attack; Category IV (low severity and low susceptibility) - appendicitis, and glaucoma. We performed multi-variable logistic regression analysis and calculated the proportion of those who were smoking at the first health check-up after the diagnosis and every three years thereafter.

RESULTS

Using glaucoma as the reference, the adjusted odds ratios for smoking cessation were 14.2 (95% CI: 11.4-17.8) to 14.8 (95% CI: 12.5-17.4) in Category I; 4.5 (95% CI: 3.8-5.4) to 6.6 (95% CI: 5.4-8.0) in Category II; and 1.9 (95% CI: 1.7-2.1) to 2.8 (95% CI: 2.2-3.7) in Category III. In Categories I and II, the proportion of smokers rapidly decreased after diagnosis and mostly remained low thereafter. Smoking cessation rates for Categories I and II were not associated with readiness to improve lifestyles prior to NCD diagnosis.

CONCLUSIONS

Our study confirms the significant impact of perceived severity of and susceptibility to the diagnosed disease on smoking cessation. The multiplicative effect of these two constructs at NCD diagnosis represents a 'teachable moment', a window of opportunity, for encouraging successful long-term smoking cessation.

Integrating Smoking Cessation Into Low-Dose Computed Tomography Lung Cancer Screening: Results of the Ontario, Canada Pilot

INTRODUCTION

Low-dose computed tomography screening in high-risk individuals reduces lung cancer mortality. To inform the implementation of a provincial lung cancer screening program, Ontario Health undertook a Pilot study, which integrated smoking cessation (SC).

METHODS

The impact of integrating SC into the Pilot was assessed by the following: rate of acceptance of a SC referral; proportion of individuals who were currently smoking cigarettes and attended a SC session; the quit rate at 1 year; change in the number of quit attempts; change in Heaviness of Smoking Index; and relapse rate in those who previously smoked.

RESULTS

A total of 7768 individuals were recruited predominantly through primary care physician referral. Of these, 4463 were currently smoking and were risk assessed and referred to SC services, irrespective of screening eligibility: 3114 (69.8%) accepted referral to an in-hospital SC program, 431 (9.7%) to telephone quit lines, and 50 (1.1%) to other programs. In addition, 4.4% reported no intention to quit and 8.5% were not interested in participating in a SC program. Of the 3063 screen-eligible individuals who were smoking at baseline low-dose computed tomography scan, 2736 (89.3%) attended in-hospital SC counseling. The quit rate at 1 year was 15.5% (95% confidence interval: 13.4%-17.7%; range: 10.5%-20.0%). Improvements were also observed in Heaviness of Smoking Index (p < 0.0001), number of cigarettes smoked per day (p < 0.0001), time to first cigarette (p < 0.0001), and number of quit attempts (p < 0.001). Of those who reported having quit within the previous 6 months, 6.3% had resumed smoking at 1 year. Furthermore, 92.7% of the respondents reported satisfaction with the hospital-based SC program.

CONCLUSIONS

On the basis of these observations, the Ontario Lung Screening Program continues to recruit through primary care providers, to assess risk for eligibility using trained navigators, and to use an opt-out approach to referral for cessation services. In addition, initial in-hospital SC support and intensive follow-on cessation interventions will be provided to the extent possible.

Personalization and localization as key expectations of digital health intervention in women pre- to post-pregnancy

Health behaviors before, during and after pregnancy can have lasting effects on maternal and infant health outcomes. Although digital health interventions (DHIs) have potential as a pertinent avenue to deliver mechanisms for a healthy behavior change, its success is reliant on addressing the user needs. Accordingly, the current study aimed to understand DHI needs and expectations of women before, during and after pregnancy to inform and optimize future DHI developments. Forty-four women (13 pre-, 16 during and 15 postpregnancy; age range = 21-40 years) completed a 60-minute, semistructured, qualitative interview exploring participant's experience in their current phase, experience with digital health tools, and their needs and expectations of DHIs. Interviews were audio-recorded, transcribed verbatim and thematically analyzed. From the interviews, two core concepts emerged-personalization and localization of DHI. Between both concepts, five themes and nine subthemes were identified. Themes and subthemes within personalization cover ideas of two-way interactivity, journey organization based on phases and circumstances, and privacy trade-off. Themes and subthemes within localization cover ideas of access to local health-related resources and information, and connecting to local communities through anecdotal stories. Here we report, through understanding user needs and expectations, the key elements for the development and optimization of a successful DHI for women before, during and after pregnancy. To potentially empower downstream DHI implementation and adoption, these insights can serve as a foundation in the initial innovation process for DHI developers and be further built upon through a continued co-design process.

Randomised controlled trial testing effectiveness of feedback about lung age or exhaled CO combined with very brief advice for smoking cessation compared to very brief advice alone in North Macedonia: findings from the Breathe Well group

INTRODUCTION

In 2019, smoking prevalence in North Macedonia was one of the world's highest at around 46% in adults. However, access to smoking cessation treatment is limited and no co-ordinated smoking cessation programmes are provided in primary care.

METHODS

We conducted a three parallel-armed randomised controlled trial (n = 1368) to investigate effectiveness and cost-effectiveness of lung age (LA) or exhaled carbon monoxide (CO) feedback combined with very brief advice (VBA) to prompt smoking cessation compared with VBA alone, delivered by GPs in primary care in North Macedonia. All participants who decided to attempt to quit smoking were advised about accessing smoking cessation medications and were also offered behavioural support as part of the "ACT" component of VBA. Participants were aged ≥ 35 years, smoked ≥ 10 cigarettes per day, were recruited from 31 GP practices regardless of motivation to quit and were randomised (1:1:1) using a sequence generated before the start of recruitment. The primary outcome was biochemically validated 7-day point prevalence abstinence at 4 weeks (wks). Participants and GPs were not blinded to allocation after randomisation, however outcome assessors were blind to treatment allocation.

RESULTS

There was no evidence of a difference in biochemically confirmed quitting between intervention and control at 4wks (VBA + LA RR 0.90 (97.5%CI: 0.35, 2.27); VBA + CO RR 1.04 (97.5%CI: 0.44, 2.44)), however the absolute number of quitters was small (VBA + LA 1.6%, VBA + CO 1.8%, VBA 1.8%). A similar lack of effect was observed at 12 and 26wks, apart from in the VBA + LA arm where the point estimate was significant but the confidence intervals were very wide. In both treatment arms, a larger proportion reported a reduction in cigarettes smoked per day at 4wks (VBA + LA 1.30 (1.10, 1.54); VBA + CO 1.23 (1.03, 1.49)) compared with VBA. The point estimates indicated a similar direction of effect at 12wks and 26wks, but differences were not statistically significant. Quantitative process measures indicated high fidelity to the intervention delivery protocols, but low uptake of behavioural and pharmacological support. VBA was the dominant intervention in the health economic analyses.

CONCLUSION

Overall, there was no evidence that adding LA or CO to VBA increased quit rates. However, a small effect cannot be ruled out as the proportion quitting was low and therefore estimates were imprecise. There was some evidence that participants in the intervention arms were more likely to reduce the amount smoked, at least in the short term. More research is needed to find effective ways to support quitting in settings like North Macedonia where a strong smoking culture persists.

TRIAL REGISTRATION

The trial was registered at http://www.isrctn.com (ISRCTN54228638) on the 07/09/2018.

The tobacco quitline setting as a teachable moment: The Educating Quitline Users About Lung (EQUAL) cancer screening randomized trial

Although lung cancer screening (LCS) using low-dose CT is recommended for high-risk individuals, screening adherence remains low. We conducted a randomized trial to compare two methods of providing LCS education to Maryland Tobacco Quitline (MTQ) callers in order to assess whether this setting may serve as a teachable moment for LCS-eligible individuals. MTQ callers (50-80 years, 20+ pack-years, prior LCS ≥12 months) completed the baseline and were randomized to the Print- or Web-based version of ShouldIScreen.com. Participants completed 1- and 4-month follow-up assessments to evaluate intervention engagement and LCS-related outcomes. Participants (Print = 152, Web = 146) were 61.7 (SD = 6.3) years old and reported 63.5 pack-years (SD = 36.0). Most identified as Black (54.2%), female (66.1%), having internet access (78.9%), completing other recommended cancer screenings (86.3%), and that they would undergo LCS if recommended by their provider (91.3%). By 4 months, significantly more Print (75.0%) than Web (61.6%) participants had read the materials (P = .01). Most reported the interventions contained "the right amount" of information (92.6%) and prepared them to talk with their doctor (57.2%). Regarding screening-related outcomes, 42.8% (Print) and 43.8% (Web) had scheduled or completed a low-dose CT scan or a shared decision-making visit (P = .86). In a racially diverse sample of LCS-eligible quitline callers, offering LCS educational materials resulted in high intervention engagement and screening-related appointments. As >20% did not have internet access, providing participants' preferred modality (web/print) may improve intervention engagement and knowledge. Improving LCS awareness represents an important opportunity to increase screening among eligible but unscreened quitline callers.

Study protocol of an economic evaluation embedded in the Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) trial

BACKGROUND

Tobacco smoking during pregnancy is the most important preventable risk factor for pregnancy complications and adverse birth outcomes and can have lifelong consequences for infants. Smoking during pregnancy is associated with higher healthcare costs related to birth complications and during childhood. Psychosocial interventions to support pregnant women to quit are effective, yet provision of smoking cessation support has been inconsistent. The Midwives and Obstetricians Helping Mothers to Quit Smoking (MOHMQuit) intervention provides systems change, and leadership and clinician elements, to support clinicians to help women stop smoking in pregnancy. There have been few long-term analyses conducted of the cost-effectiveness of smoking cessation interventions for pregnant women that target healthcare providers. This protocol describes the economic evaluation of the MOHMQuit trial, a pragmatic stepped-wedge cluster-randomised controlled implementation trial in nine public maternity services in New South Wales (NSW), Australia, to ascertain whether MOHMQuit is cost-effective in supporting clinicians to help women quit smoking in pregnancy compared to usual care.

METHODS

Two primary analyses will be carried out comparing MOHMQuit with usual care from an Australian health care system perspective: i) a within-trial cost-effectiveness analysis with results presented as the incremental cost per additional quitter; and ii) a lifetime cost-utility analysis using a published probabilistic decision analytic Markov model with results presented as incremental cost per quality-adjusted life-year (QALY) gained for mother and child. Patient-level data on resource use and outcomes will be used in the within-trial analysis and extrapolated and supplemented with national population statistics and published data from the literature for the lifetime analysis.

DISCUSSION

There is increasing demand for information on the cost-effectiveness of implementing healthcare interventions to provide policy makers with critical information for the best value for money within finite budgets. Economic evaluation of the MOHMQuit trial will provide essential, policy-relevant information for decision makers on the value of evidence-based implementation of support for healthcare providers delivering services for pregnant women.

TRIAL REGISTRATIONS

ACTRN12622000167763, registered 2 February 2022.

Mitigating long-term and delayed adverse events associated with cancer treatment: implications for survivorship

Despite the importance of chemotherapy-associated adverse events in oncology practice and the broad range of interventions available to mitigate them, limited systematic efforts have been made to identify, critically appraise and summarize the totality of evidence on the effectiveness of these interventions. Herein, we review the most common long-term (continued beyond treatment) and late or delayed (following treatment) adverse events associated with chemotherapy and other anticancer treatments that pose major threats in terms of survival, quality of life and continuation of optimal therapy. These adverse effects often emerge during and continue beyond the course of therapy or arise among survivors in the months and years following treatment. For each of these adverse effects, we discuss and critically evaluate their underlying biological mechanisms, the most commonly used pharmacological and non-pharmacological treatment strategies, and evidence-based clinical practice guidelines for their appropriate management. Furthermore, we discuss risk factors and validated risk-assessment tools for identifying patients most likely to be harmed by chemotherapy and potentially benefit from effective interventions. Finally, we highlight promising emerging supportive-care opportunities for the ever-increasing number of cancer survivors at continuing risk of adverse treatment effects.

A telephone-based smoking cessation intervention for individuals with COVID-19: A randomized controlled feasibility study

INTRODUCTION

Increasing evidence suggests that a diagnosis of a respiratory health condition, such as COVID-19, can prompt a smoker to quit, providing an opportunity to promote and support smoking cessation. However, mandatory quarantine, because of a COVID-19 infection, may stimulate an increase in smoking, making such efforts seem inappropriate or ineffective. This study aimed to investigate the feasibility of a telephone-based smoking cessation intervention for smokers with COVID-19 in Malta.

METHODS

An experimental design with a mixed-methods approach was adopted. Participants (n=80) were recruited from a COVID-19 testing center and equally randomized to the intervention (advised to quit and offered three or four telephone-based smoking cessation support sessions) and control (no intervention) groups. Both groups were asked about their smoking habits at baseline and at follow-up at 1 month and at 3 months. The participants in the intervention group were invited to provide feedback on the intervention using questionnaires and by holding interviews.

RESULTS

Participants were recruited at a rate of 74.1% between March and April 2022. Most participants were female (58.8%), with a mean age of 41.6 years who smoked about 13 cigarettes per day. The majority (75%) accepted the offered smoking cessation support, receiving an average of two to three sessions. Findings indicate that the participants were satisfied with the support, finding it useful for attempting to quit. More participants in the intervention group reported a serious quitting attempt and a 7-day point prevalence abstinence at any point during the first month. However, 7-day point prevalence abstinence rates did not differ at the follow-up at 3 months.

CONCLUSIONS

The study suggests that providing smoking cessation support to individuals with COVID-19 is feasible and well-received. However, the findings suggest that the intervention's impact may have been brief. Thus, further research is recommended before conducting a conclusive trial.

The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: A systematic review and meta-analyses

BACKGROUND

Prehabilitation interventions are being delivered across surgical specialities to improve health risk behaviours leading to better surgical outcomes and potentially reduce length of hospital stay. Most previous research has focused on specific surgery specialities and has not considered the impact of interventions on health inequalities, nor whether prehabilitation improves health behaviour risk profiles beyond surgery. The aim of this review was to examine behavioural Prehabilitation interventions across surgeries to inform policy makers and commissioners of the best available evidence.

METHODS AND FINDINGS

A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to determine the effect of behavioural prehabilitation interventions targeting at least one of: smoking behaviour, alcohol use, physical activity, dietary intake (including weight loss interventions) on pre- and post-surgery health behaviours, health outcomes, and health inequalities. The comparator was usual care or no treatment. MEDLINE, PubMed, PsychINFO, CINAHL, Web of Science, Google Scholar, Clinical trials and Embase databases were searched from inception to May 2021, and the MEDLINE search was updated twice, most recently in March 2023. Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Outcomes were length of stay, six-minute walk test, behaviours (smoking, diet, physical activity, weight change, and alcohol), and quality of life. Sixty-seven trials were included; 49 interventions targeted a single behaviour and 18 targeted multiple behaviours. No trials examined effects by equality measures. Length of stay in the intervention group was 1.5 days shorter than the comparator (n = 9 trials, 95% CI -2.6 to -0.4, p = 0.01, I2 83%), although in sensitivity analysis prehabilitation had the most impact in lung cancer patients (-3.5 days). Pre-surgery, there was a mean difference of 31.8 m in the six-minute walk test favouring the prehabilitation group (n = 19 trials, 95% CI 21.2 to 42.4m, I2 55%, P <0.001) and this was sustained to 4-weeks post-surgery (n = 9 trials, mean difference = 34.4m (95%CI 12.8 to 56.0, I2 72%, P = 0.002)). Smoking cessation was greater in the prehabilitation group before surgery (RR 2.9, 95% CI 1.7 to 4.8, I2 84%), and this was sustained at 12 months post-surgery (RR 1.74 (95% CI 1.20 to 2.55, I2 43%, Tau2 0.09, p = 0.004)There was no difference in pre-surgery quality of life (n = 12 trials) or BMI (n = 4 trials).

CONCLUSIONS

Behavioural prehabilitation interventions reduced length of stay by 1.5 days, although in sensitivity analysis the difference was only found for Prehabilitation interventions for lung cancer. Prehabilitation can improve functional capacity and smoking outcomes just before surgery. That improvements in smoking outcomes were sustained at 12-months post-surgery suggests that the surgical encounter holds promise as a teachable moment for longer-term behavioural change. Given the paucity of data on the effects on other behavioural risk factors, more research grounded in behavioural science and with longer-term follow-up is needed to further investigate this potential.

Assessing the clinical utility of toxicology testing in the peripartum period

BACKGROUND

Toxicology testing is frequently used as a means of gathering objective data about substance use in pregnancy, but little is known about the clinical utility of testing in the peripartum setting.

OBJECTIVE

This study aimed to characterize the utility of obtaining maternal-neonatal dyad toxicology testing at the time of delivery.

STUDY DESIGN

We performed a retrospective chart review of all deliveries in a single healthcare system in Massachusetts between 2016 and 2020, and identified deliveries with either maternal or neonatal toxicology testing at delivery. An unexpected result was defined as a positive test for a nonprescribed substance that was not known on the basis of clinical history, self-report, or previous toxicology testing within a week of delivery, excluding results for cannabis. We evaluated the characteristics of maternal-infant dyads with unexpected positive results, unexpected positive results by rationale for testing, changes in clinical management after an unexpected positive test, and maternal outcomes in the year after delivery using descriptive statistics.

RESULTS

Of the 2036 maternal-infant dyads with toxicology tests performed during the study period, there were 80 (3.9%) with an unexpected positive result. Diagnosis of substance use disorder with active use in the last 2 years was the clinical rationale for testing that yielded the greatest number of unexpected positive results (10.7% of total tests ordered for this rationale). Inadequate prenatal care (5.8%), maternal use of medication for opioid use disorder (3.8%), maternal medical indications such as hypertension or placental abruption (2.3%), history of substance use disorder in remission (1.7%), or maternal cannabis use (1.6%) yielded lower rates of unexpected results compared with a recent substance use disorder (within the last 2 years). Solely on the basis of findings from unexpected test results, 42% of dyads were referred to child protective services, 30% of dyads had no documentation of maternal counseling during delivery hospitalization, and 31% did not receive breastfeeding counseling after an unexpected test; 22.8% had monitoring for neonatal opioid withdrawal syndrome. Postpartum, 26 (32.5%) were referred to substance use disorder treatment, 31 (38.8%) attended a postpartum mental health visit, and only 26 (32.5%) attended a postpartum visit. Fifteen individuals (18.8%) were readmitted in the year after delivery, all for substance-related medical complications.

CONCLUSION

Unexpected positive toxicology results at delivery were uncommon, particularly when tests were sent for frequently used clinical rationales for testing, suggesting a need to revisit guidelines surrounding appropriateness of indications for toxicology testing. The poor maternal outcomes in this cohort highlight a missed opportunity for maternal connection to counseling and treatment in the peripartum period.

Patients' Views on Medical Events in Lung Cancer Screening as Teachable Moments for Smoking Behaviour Change: A Systematic Review and Metasynthesis

Although medical events in lung cancer screening (LCS) such as receiving scan results or interactions with clinicians are recognised as teachable moments (TMs), the views of patients about why this is the case for smoking behaviour change remain uncertain. This systematic review and metasynthesis study is aimed at identifying the reasons why patients believed that medical events during LCS act as TMs for smoking behaviour change. A search strategy was developed for use with MEDLINE, PsycINFO, EMBASE, CINAHL-P, Web of Science databases, and Google Scholar. This helped identify qualitative and mixed-method research which mentioned patients' views of how these TMs result in smoking behaviour change. After screening, final articles were critically appraised; general characteristics and data relevant to the aims were extracted to conduct a line-of-argument metasynthesis. After screening 695 papers, 11 were included. Undergoing LCS scans was seen to act on their intrinsic motivation to reduce smoking as it served as a "wake-up call" and increased awareness of the health consequences of smoking. Receiving positive or negative LCS results resulted in cessation as it was a "health scare" and challenged smoking habits. Interactions with clinicians addressed misconceptions and signposted them to specialist cessation services. Attendees believed that the following encouraged them to change their smoking behaviour: having an intrinsic motivation to quit, their beliefs on smoking and health reframed, their negative emotions appraised, and using LCS to access specialist support. In line with the TM heuristic, these experiences provided the necessary skills, confidence, and motivation to quit. Future research should explore whether the views of the clinicians match those of the attendees to address misconceptions and further develop clinical guidelines.

Smoking cessation pharmacotherapy use during index hospital admission following cystectomy for bladder cancer: A retrospective cohort study

BACKGROUND

To identify gaps in urologic oncology quality and evidence-based smoking cessation care by assessing how often smoking cessation pharmacotherapy (SCP) is given in the inpatient setting following cystectomy.

METHODS

The Premier Healthcare Database (PHD), a deidentified all-payer dataset, was used to generate nationally representative estimates of SCP receipt during hospitalization following cystectomy for patients with bladder cancer who smoke. Regressions were used to model associations between SCP receipt and patient- and hospital-level factors.

RESULTS

Of the 21,624 patients who underwent cystectomy for bladder cancer, 3,676 patients (17.0%) were identified as current smokers, representing a weighted estimate of 16,063 admissions. Among these admissions, 27.9% of patients received SCP, the vast majority of which (91.5%) received exclusively nicotine replacement therapy. Rates of SCP receipt varied substantially across hospitals (median: 25.0%, IQR: 20.0-33.3, range: 0.0-60.0). Older age and black race (aOR = 0.59, 95% CI: 0.42-0.82) were associated with lower odds of SCP receipt. Increased patient comorbidity score was associated with higher odds of SCP receipt (aOR = 1.02, 95% CI: 1.01-1.03); specifically, chronic pulmonary disease, alcohol abuse, and depression were independently associated with SCP receipt. Hospital teaching status, bed capacity, and mean annual cystectomy volume were not associated with SCP receipt. SCP receipt was not associated with hospital length of stay nor 90-day readmission or mortality following cystectomy.

CONCLUSIONS

SCP is infrequently given to patients who smoke during their hospitalization following cystectomy for bladder cancer, representing a gap in quality urologic oncology care and a missed opportunity to effectively intervene with evidence-based treatment.

Integrated smoking cessation and mood management following acute coronary syndrome: Protocol for the post-acute cardiac event smoking (PACES) trial

BACKGROUND

Approximately 400,000 people who smoke cigarettes survive Acute Coronary Syndrome (ACS; unstable angina, ST and non-ST elevation myocardial infarction) each year in the US. Continued smoking following ACS is an independent predictor of mortality. Depressed mood post-ACS is also predictive of mortality, and smokers with depressed mood are less likely to abstain from smoking following an ACS. A single, integrated treatment targeting depressed mood and smoking could be effective in reducing post-ACS mortality.

METHOD/DESIGN

The overall aim of the current study is to conduct a fully powered efficacy trial enrolling 324 smokers with ACS and randomizing them to 12 weeks of an integrated smoking cessation and mood management treatment [Behavioral Activation Treatment for Cardiac Smokers (BAT-CS)] or control (smoking cessation and general health education). Both groups will be offered 8 weeks of the nicotine patch if medically cleared. Counseling in both arms will be provided by tobacco treatment specialists. Follow-up assessments will be conducted at end-of-treatment (12-weeks) and 6, 9, and 12 months after hospital discharge. We will track major adverse cardiac events and all-cause mortality for 36 months post-discharge. Primary outcomes are depressed mood and biochemically validated 7-day point prevalence abstinence from smoking over 12 months.

DISCUSSION

Results of this study will inform smoking cessation treatments post-ACS and provide unique data on the impact of depressed mood on success of post-ACS health behavior change attempts.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03413423. Registered 29 January 2018. https://beta.

CLINICALTRIALS

gov/study/NCT03413423 .

Racial, Lifestyle, and Healthcare Contributors to Perceived Cancer Risk among Physically Active Adolescent and Young Adult Women Aged 18-39 Years

The cancer incidence among adolescents and young adults (AYAs) has significantly increased in recent years, but there is limited information about the factors that influence the perceived cancer risk among AYAs. A cross-sectional, web-based survey of 281 physically active Black and White AYA women was administered to assess the influences of demographic characteristics, family history of cancer, cancer risk factor knowledge, and lifestyle-related risk and protective behaviors on perceived cancer risk. Linear regression analyses were performed in SAS version 9.4. Self-reported Black race (β = -0.62, 95% CI: -1.07, -0.17) and routine doctor visits (β = -0.62, 95% CI: -1.18, -0.07) were related to a lower perceived cancer risk. Family history of cancer (β = 0.56, 95% CI: 0.13, 0.99), cancer risk factor knowledge (β = 0.11, 95% CI: 0.03, 0.19), and current smoking status (β = 0.80, 95% CI: 0.20, 1.40) were related to a higher perceived cancer risk. Perceptions of cancer risk varied among this sample of physically active, AYA women. Lower perceptions of cancer risk among Black AYA women demonstrate a need for culturally tailored cancer educational information that presents objective data on lifetime cancer risk. Reportedly higher perceptions of cancer risk among AYA smokers presents an ideal opportunity to promote smoking cessation interventions. Future interventions to address cancer risk perception profiles among physically active, AYA women should tailor approaches that are inclusive of these unique characteristics.

Emotional Reactions to High-Risk Sex among Sexual Minority Men: Exploring Potential Opportunities for Just-In-Time Intervention

Rates of HIV and other sexually transmitted infections (STIs) are high among sexual minority men (SMM). A large body of research has explored determinants of HIV/STI risk behavior, but few studies have explored emotional consequences of these events. Understanding the valence, timing, and strength of emotional reactions to sexual risk could inform use of specific behavior change techniques in interventions (such as anticipated regret) and identify new opportunities for intervention, including just-in-time interventions. We analyzed data from an ecological momentary assessment (EMA) study of 100 HIV-negative/unknown-status SMM to understand patterns of positive affect, negative affect, shame, and stress in the 24 hours after sex. Mixed-effects models showed that the probability of negative affect was higher in the hours following condomless anal sex (CAS) with high-risk partners during which SMM reported being under the influence of alcohol or drugs (A/D involved CAS), versus all other types of sex events (OR = 0.92, SE = 0.03, p = .017). The probability of shame was also higher after A/D-involved CAS, versus other sex events (OR = 1.14, SE = 0.07, p = .035). Findings suggest that the hours following A/D-involved CAS events may be an opportune time to intervene to help SMM avoid similarly aversive experiences in the future.

Implementation of a relapse prevention program among smokers undergoing arthroplasty: lessons learned

BACKGROUND

Surgery is a potent motivator to help people quit smoking to reduce the risk of complications. Many patients who smoke receive tobacco cessation counseling prior to surgery and are able to quit, but do not receive the same resources after surgery and often resume smoking.

METHODS

We present a case study describing the recruitment process, study components, and lessons learned from StayQuit, a comprehensive relapse prevention program designed to prevent relapse after arthroplasty. Lessons learned were examined post hoc to determine challenges related to program implementation, using existing study procedures and information collected.

RESULTS

While a comprehensive postoperative relapse prevention program may be beneficial to patients, implementation of StayQuit is unlikely to be feasible under current circumstances. The primary challenges to successful implementation of StayQuit focused on themes of lack of engagement in the preoperative Orthopedic Surgery Quit Smoking Program (OSQSP) and an environment unfavorable to in-person enrollment on the day of surgery.

CONCLUSIONS

Postoperative relapse prevention programs may be beneficial for patients who quit smoking prior to elective surgery. To help guide implementation, it is important to consider surgeon behavior, the collaboration of clinical and non-clinical teams, and best practices for study enrollment in surgical settings.

Perceived Racial/Ethnic Discrimination and Smoking Outcome Expectancies among Adult Latinx Smokers Living in the United States

Background: Smoking-related health disparities are prevalent in the Latinx community in the United States (US). Although Social Determinants of Health (SDoH) are known to contribute to a myriad of health problems among the Latinx population, there is relatively limited work expressly aimed at elucidating SDoH among Latinx smokers. Perceived racial/ethnic discrimination is one SDoH construct that may be especially relevant to understanding smoking-related cognition for Latinx smokers in the US. Smoking outcome expectancies, reflecting beliefs about the consequences of smoking, are established cognitive processes that have been linked to the maintenance and relapse of smoking. The purpose of the present work is to investigate perceived racial/ethnic discrimination in relation to smoking outcome expectancies amongst Latinx smokers in the US. Method: Participants included 338 English-speaking Latinx adult daily cigarette smokers from the US (Mage = 35.5 years; SD = 8.65; age range 18-61; 37.3% female). Results: Results indicated that perceived racial/ethnic discrimination was related to greater levels of negative reinforcement, positive reinforcement, and appetite-weight control expectancies, but not negative consequences expectancies. Discussion: Overall, the current findings provide novel insight into the relationship between perceived racial/ethnic discrimination and smoking outcome expectancies amongst English-speaking Latinx cigarette users in the US.

Factors Associated With Postpartum Smoking Relapse Among Women Who Quit in Early Pregnancy: The Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

BACKGROUND

While a wide range of predictors of postpartum smoking relapse have been suggested, population-based studies have rarely examined these factors exclusively among women who quit in early pregnancy. Furthermore, workplace secondhand smoke (SHS) exposure has never been examined.

METHODS

We analyzed data from 10,466 pregnant women who participated in the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Age, education, parity, breastfeeding, postpartum depression, SHS exposure at home, and SHS exposure at work (not working, working without SHS exposure, working with SHS exposure) were evaluated as possible predictors. Multiple logistic regression analyses were conducted to examine the associations between these factors and smoking relapse by 1 year postpartum among women who quit in early pregnancy. Analyses stratified by SHS exposure at home were also conducted.

RESULTS

About one-fourth of early-pregnancy quitters had relapsed into smoking by 1 year postpartum. Lower education, multiparity, not breastfeeding, postpartum depression, and SHS exposure at home were associated with increased risks of smoking relapse. Working with SHS exposure was associated with an increased risk of smoking relapse; the multivariate-adjusted odds ratios of working without SHS exposure and working with SHS exposure compared with not working were 1.14 (95% confidence interval [CI], 0.82-1.59) and 2.18 (95% CI, 1.37-3.46), respectively. The significant association of workplace SHS exposure was observed only among women without SHS exposure at home.

CONCLUSION

SHS exposure at work, as well as education, multiparity, breastfeeding, postpartum depression, and SHS exposure at home were associated with postpartum smoking relapse among early-pregnancy quitters.

Putting the 'teachable moment' in context: A view from critical health psychology

The concept of 'Teachable Moment' (TM) is an increasingly used term within mainstream health psychology in relation to interventions and health behaviour change. It refers to a naturally occurring health event where individuals may be motivated to change their behaviours from unhealthy ones to healthier choices. Pregnancy is seen as a key time for behaviour change interventions, partly due to the idea that the mother has increased motivations to protect her unborn child. This paper proposes a Critical Health Psychological (CHP) re-examination of the concept and explores the 'teachable moment' within a wider framing of contemporary parenting ideologies in order to offer a more critical, nuanced and contextual consideration of pregnancy and the transition to motherhood. The paper locates these discussions using an example of alcohol usage in pregnancy. In doing so, this paper is the first of its kind to consider the 'teachable moment' from a critical health psychological perspective.

Effectiveness of healthy lifestyle-based interventions in lung cancer survivors: a systematic review and meta-analysis

PURPOSE

To assess the effectiveness of healthy lifestyle-based interventions in lung cancer survivors.

METHODS

We performed a literature search using PubMed, Web of Science, and Science Direct (last search March 2022). Quality assessment and risk of bias were assessed using the Downs and Black scale and the Cochrane tool. A systematic review and meta-analysis of randomized controlled trials were performed. We included controlled trials testing the effect of healthy lifestyle-based interventions in lung cancer survivors versus a control intervention where lung cancer patients had no treatment, were receiving the usual care, or had not an active role in the intervention. The data were pooled and a meta-analysis was completed for quality of life, psychological distress, and cancer-related symptoms.

RESULTS

We selected 14 studies, which included 1519 patients with lung cancer. The treatment status of these patients was heterogeneous. Healthy lifestyle programs were applied isolated or in combination with usual care in most of the studies. The components of the healthy lifestyle programs were also heterogeneous. Results showed significant differences in favor of healthy lifestyle-based interventions in comparison to the control group for quality of life (p = 0.01), psychological distress (p = 0.05), and cancer-related symptoms (p = 0.03).

CONCLUSIONS

The findings indicated a beneficial effect of healthy lifestyle-based interventions for improving quality of life, psychological distress, and cancer-related symptoms in lung cancer patients. However, this review could not show any conclusion about the better treatment moment to apply healthy lifestyle-based interventions.

REVIEW REGISTRATION

PROSPERO Identifier: CRD42021292152.

REVIEW REGISTRATION DATE

19/12/2021.

Knowledge, Attitudes, and Beliefs about Relapse Prevention Research Involving Bupropion among Current and Former Pregnant Individuals Who Smoke

Introduction

While many individuals quit smoking during pregnancy, most relapse within one year postpartum. Research into methods to decrease smoking relapse postpartum has been hampered by difficulties with recruitment.

Method

We conducted individual interviews with pregnant women (N = 22) who were interested in quitting smoking while pregnant about their attitudes regarding smoking and quitting during pregnancy, clinical trial participation, and smoking cessation medication use.

Results

Participants were aware of the risks of smoking while pregnant. Many wanted to quit smoking before delivery. Few used empirically supported treatments to quit. While research was viewed positively, interest in taking on new commitments postpartum and taking a medication to prevent relapse was low. Medication concerns were evident among most participants, especially among those planning to breastfeed. Further, several women noted medication was unnecessary, as they did not believe they would relapse postpartum. Financial incentives, childcare, and fewer and/or remote visits were identified as facilitators to participating in research. However, these factors did not outweigh women's concerns about medication use and time commitments.

Conclusions

Women are aware that quitting smoking during pregnancy and remaining smoke-free postpartum are important. However, beliefs that personal relapse risk is low and that medications are dangerous reduced enthusiasm for taking medication for postpartum relapse prevention. Future medication trials should educate women about the high likelihood of relapse, prepare to answer detailed questions about risks of cessation medications, and connect with participants' clinicians. For new mothers, studies conducted remotely with few scheduled appointments would reduce barriers to participation.

A qualitative exploration of influences on eating behaviour throughout pregnancy

BACKGROUND

Pregnancy is often conceptualised as a 'teachable moment' for health behaviour change. However, it is likely that different stages of pregnancy, and individual antenatal events, provide multiple distinct teachable moments to prompt behaviour change. Whilst previous quantitative research supports this argument, it is unable to provide a full understanding of the nuanced factors influencing eating behaviour. The aim of this study was to explore influences on women's eating behaviour throughout pregnancy.

METHODS

In-depth interviews were conducted online with 25 women who were less than six-months postpartum. Interviews were audio-recorded and transcribed verbatim. Data were analysed thematically.

RESULTS

Five themes were generated from the data that capture influences on women's eating behaviour throughout pregnancy: 'The preconceptual self', 'A desire for good health', 'Retaining control', 'Relaxing into pregnancy', and 'The lived environment'.

CONCLUSION

Mid-pregnancy may provide a more salient opportunity for eating behaviour change than other stages of pregnancy. Individual antenatal events, such as the glucose test, can also prompt change. In clinical practice, it will be important to consider the changing barriers and facilitators operating throughout pregnancy, and to match health advice to stages of pregnancy, where possible. Existing models of teachable moments may be improved by considering the dynamic nature of pregnancy, along with the influence of the lived environment, pregnancy symptoms, and past behaviour. These findings provide an enhanced understanding of the diverse influences on women's eating behaviour throughout pregnancy and provide a direction for how to adapt existing theories to the context of pregnancy.

Understanding dietary behaviour change after a diagnosis of diabetes: A qualitative investigation of adults with type 2 diabetes

Type 2 diabetes (T2D) is a major public health concern. Optimal management of T2D often requires individuals to make substantial changes to their dietary intake. This research employed a qualitative methodology to examine decision making processes underpinning dietary behaviour change. Semi-structured telephone interviews were conducted on a purposive sample of 21 Australian adults who had recently consulted a dietitian after being diagnosed with T2D. Data were analysed using theoretical thematic analysis and themes were matched deductively with constructs that underpin motivational, volitional, and implicit processes which exist in common models of behaviour change. Influences on motivation, such as a desire to improve health status and making use of valuable support networks featured in participant narratives. Volitional influences included knowing their limits, dealing with falling off the wagon, and learning how their body responds to food. The themes unlearning habits and limit the availability were identified as underpinning implicit influences on dietary change. Individual differences and emotions were constructs additional to the model that influenced dietary change. These findings contribute to a richer understanding of the subjective experiences of adults with T2D regarding dietary change and highlight the multiple processes that guide their decision making in this context.

The MOHMQuit (Midwives and Obstetricians Helping Mothers to Quit Smoking) Trial: protocol for a stepped-wedge implementation trial to improve best practice smoking cessation support in public antenatal care services

BACKGROUND

Smoking during pregnancy is the most important preventable cause of adverse pregnancy outcomes, yet smoking cessation support (SCS) is inconsistently provided. The MOMHQUIT intervention was developed to address this evidence-practice gap, using the Behaviour Change Wheel method by mapping barriers to intervention strategies. MOHMQuit includes systems, leadership and clinician elements. This implementation trial will determine the effectiveness and cost-effectiveness of MOHMQuit in improving smoking cessation rates in pregnant women in public maternity care services in Australia; test the mechanisms of action of the intervention strategies; and examine implementation outcomes.

METHODS

A stepped-wedge cluster-randomised design will be used. Implementation of MOHMQuit will include reinforcing leadership investment in SCS as a clinical priority, strengthening maternity care clinicians' knowledge, skills, confidence and attitudes towards the provision of SCS, and clinicians' documentation of guideline-recommended SCS provided during antenatal care. Approximately, 4000 women who report smoking during pregnancy will be recruited across nine sites. The intervention and its implementation will be evaluated using a mixed methods approach. The primary outcome will be 7-day point prevalence abstinence at the end of pregnancy, among pregnant smokers, verified by salivary cotinine testing. Continuous data collection from electronic medical records and telephone interviews with postpartum women will occur throughout 32 months of the trial to assess changes in cessation rates reported by women, and SCS documented by clinicians and reported by women. Data collection to assess changes in clinicians' knowledge, skills, confidence and attitudes will occur prior to and immediately after the intervention at each site, and again 6 months later. Questionnaires at 3 months following the intervention, and semi-structured interviews at 6 months with maternity service leaders will explore leaders' perceptions of acceptability, adoption, appropriateness, feasibility, adaptations and fidelity of delivery of the MOHMQuit intervention. Structural equation modelling will examine causal linkages between the strategies, mediators and outcomes. Cost-effectiveness analyses will also be undertaken.

DISCUSSION

This study will provide evidence of the effectiveness of a multi-level implementation intervention to support policy decisions; and evidence regarding mechanisms of action of the intervention strategies (how the strategies effected outcomes) to support further theoretical developments in implementation science.

TRIAL REGISTRATION

ACTRN12622000167763, registered February 2nd 2022.