Predictors of successful smoking cessation following advice from nurses in general practice

Do professional perspectives on evidence-based smoking cessation methods align? A Delphi study among researchers and healthcare professionals

The use of evidence-based smoking cessation interventions (SCIs) can significantly increase the number of successful smoking cessation attempts. To obtain an overview of the knowledge and viewpoints on the effectiveness and use of SCIs, a three-round online Delphi study was conducted among researchers and primary care professionals (PCPs). The four objectives of this study are to gain an overview of (i) the criteria important for recommending SCIs, (ii) the perceptions of both groups on the effectiveness of SCIs, (iii) the factors to consider when counseling different (high-risk) groups of smokers and (iv) the perceptions of both groups on the use of e-cigarettes as an SCI. We found a high level of agreement within groups on which smoker characteristics should be considered when recommending an SCI to smokers. We also found that PCPs display a lower degree of consensus on the effectiveness of SCIs. Both groups see a value in the use of special protocols for different (high-risk) groups of patients, but the two groups did not reach consensus on the use of e-cigarettes as a means to quit. Making an inventory of PCPs' needs regarding SCIs and their usage may provide insight into how to facilitate a better uptake in the primary care setting.

Socioeconomic differences in smoking cessation: the role of social participation

Objectives: The aim of this study was to investigate whether psychosocial resources explain socioeconomic differences in smoking cessation and its maintenance. Methods: A subpopulation of 11,837 individuals from the Malmö Diet and Cancer Study interviewed in 1992-94, age range 45-64 years, was investigated in this cross-sectional study. A multivariate logistic regression model was used to assess relative risks of having stopped smoking, adjusting for age, country of origin, previous/ current diseases, and marital status. Results: An odds ratio of 1.9 (1.4-2.5; 95% CI) for men and 2.0 (1.4-2.7; 95% CI) for women of having stopped smoking was found for higher non-manual employees when compared with unskilled manual workers. A decrease in these odds ratios was found when social participation was introduced into the model. The other three social network and social support variables were non-significant. Conclusion: High social participation is a predictor of maintenance of smoking cessation. It seems possible to interpret parts of the socioeconomic differences in smoking cessation and its maintenance as a consequence of differing social network resources and social capital between socioeconomic groups.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

Background  Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness. Objectives  This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors. Search Strategy  A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials. Selection Criteria  This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness. Results  Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions. Conclusions  While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

College smokers' estimates of their probabilities of remaining a smoker in the near future

Community college and university smokers (N = 662) estimated their probability (0% to 100%) of remaining a smoker one and six months later and reported their confidence in their estimates. Smoking status was assessed at each time point. Analyses controlled for several correlates of both smoking status and probability estimates of remaining a smoker. Estimates of smoking status interacted with confidence to predict smoking status at one month, but only estimates predicted smoking status at six months. Findings suggest that: 1) personal estimate of future smoking status is a unique correlate of continued smoking; and 2) confidence in personal estimates is a strong moderator for short-term projections of smoking status.

Role of nicotine gum and pretreatment depressive symptoms in smoking cessation: twelve-month results of a randomized placebo controlled trial

OBJECTIVE

The aim was to investigate the role of nicotine gum and pretreatment depressive symptoms in long-term smoking cessation.

METHODS

12-month follow-up of 608 participants within a randomized, controlled trial was conducted. Participants received brief counseling plus nicotine or placebo treatment. Based on the Center for Epidemiological Studies Depression Scale pre-treatment score (> or =16), 32% of the participants were classified as depressed at baseline.

RESULTS

At the 12-month follow-up the non-depressed participants with nicotine replacement therapy (NRT) were most successful (20.1%), while the depressed ones with placebo were least successful (5.7%) (p = .004). However, the depressed participants with NRT (15.1%) were not significantly less successful than the non-depressed ones with NRT (20.1%, p = .23). Survival analysis showed significant depression (p = .01) and treatment effects (p = < .001) on the abstinence. Further, when adjusted for marital status and education, the treatment effect remained significant (p < .001), whereas the depression effect became non-significant (p = .08).

CONCLUSIONS

NRT improved cessation both among the depressed and non-depressed. To understand discrepancies in literature reporting depression and smoking cessation outcome, the pharmacological treatment modality and social-demographic variables should be examined as additional variables.

Smoking cessation in England: intentionality, anticipated ease of quitting and advice provision

Smoking prevalence in England continues to reduce but further reduction is increasingly difficult. Cessation policy has successfully targeted those who want to quit but further reduction will need to shift attention to more difficult 'core smoker' populations. Following the established 'stages of change' perspective, this paper considers the characteristics of people who do not intend to quit smoking, anticipate difficulties in quitting and have not received advice about quitting. We deploy multilevel models of data drawn from the Health Survey for England years 2002-2004, and the NHS Primary Care Trust Patient Surveys for 2004 and 2005. It was found that variations in intentionality and anticipated ease of quitting are associated with individual factors such as smoking intensity, parental smoking, age/length of time as a smoker and the nature of the advice-giving consultation. Household composition and household income are also implicated in the intention to quit and anticipated difficulties in quitting. Once individual and household factors are taken into account the only identifiable area-level variation is reduced intentionality towards quitting in rural areas. We conclude by arguing that further gains in smoking cessation must focus on understanding the characteristics of 'hard-to-engage' populations.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

BACKGROUND

Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness.

OBJECTIVES

This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors.

SEARCH STRATEGY

A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials.

SELECTION CRITERIA

This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness.

RESULTS

Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions.

CONCLUSIONS

While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

Impact of Nicotine Replacement Therapy on post-cessation mood profile by pre-cessation depressive symptoms

We evaluated the effects of Nicotine Replacement Therapy (NRT) on the Profile of Mood States (POMS), testing whether pre-cessation depressive symptoms modify NRT's effects on POMS. Out of 608 smokers attempting to quit with NRT, this secondary analysis included 242 participants abstinent for at least two weeks. We measured pre-cessation depressive symptoms with the Center for Epidemiological Studies Depression Scale. At 1, 7, and 14 post-cessation days we examined 6 self-reported POMS, i.e. feeling 'anxious', 'sad', 'confused', 'angry', 'energetic' and 'fatigue'. The results of the ANCOVA models suggested no NRT effects on feeling anxious, energetic or fatigue. We found that pre-cessation depression modified NRT effects in some specific mood states, such as depression by NRT- interaction effects on feeling confused and feeling angry. On average, the depressed participants in the placebo groups had the highest symptom scores. However, those depressed in NRT conditions did not have significantly higher symptom scores compared to the non-depressed groups. In treating those negative moods NRT may be particularly important for persons with depressive symptoms before cessation.

Risk factors and their effects on the dynamic process of smoking relapse among veteran smokers

Smoking cessation programs can help smokers make a successful attempt at quitting, but many initial quitters relapse over time. This study aims to identify risk factors for smoking relapse and examine the influence of these factors on the dynamic relapse process in an outpatient smoking cessation program for veterans. Baseline information included socio-demographic description, medical and psychiatric comorbidities, smoking history and behavior, nicotine dependence, smoking motives, and confidence in the ability to quit. The intervention involved a 4-session group therapy consisting of cognitive and pharmacological treatments. The 189 initial quitters by program completion were followed via a telephone interview 6 months later. We identified six risk factors associated with relapse within the first 6 months post quit. Furthermore, we described characteristics of the dynamic process of smoking relapse and studied the influence of the identified risk factors on the relapse curve. The effects of these risk factors can be categorized into two patterns. Annual income and age at smoking initiation showed a delayed action that influenced the relapse curve after several weeks post quit, whereas age, number of smoking coworkers, history of schizophrenia, and number of sessions attended modified the relapse process soon after quitting. The information will be useful in targeting veteran smokers who are at high risk for relapse, choosing the optimal time for post-cessation services, and developing strategies accordingly.

Marital life course events and smoking behaviour in Sweden 1980–2000

The protective effect of marriage on smoking has been extensively established in the literature. However, less is known about the dynamics of how smoking behaviour is connected to various marital life course events, and whether there are any gender discrepancies in this respect. In this article the connection between the marital life course and smoking is analysed from a stress-related perspective controlling for other socio-economic characteristics. We use information on 81,000 individuals from the Swedish longitudinal micro-level ULF (Survey of Living Conditions) database 1980-2000, which is randomly drawn from the sample population of all Swedes aged 16-84. Logistic regressions on current smoking status and changes in smoking behaviour of participants in the panel part of the data are estimated. The marital life course is strongly linked to smoking behaviour with being or getting married indicating low smoking risks and marital disruption indicating high risks. The divorced smoke to a higher extent than the widowed and there are signs that getting divorced implies higher risks than becoming widowed, both of taking up/relapsing and, for women, not being able to quit. Further, the results indicate that the connection between smoking cessation and living with a partner is stronger for men, whereas women are more affected by the propensity to start smoking after marital disruption. The protective effect of being married on smoking decreases with the age difference between spouses in households where the wife is older than the husband. Taken together, the results yield a rather complex pattern of smoking behaviour over the marital life course. Further, perceived financial stress is strongly connected to smoking and not being able to quit. Controlling for this effect still leaves a socio-economic status gradient in smoking.

Death, depression and 'defensive expansion': closing down smoking as an issue for discussion in GP consultations

This paper examines routine primary care consultations in the UK where smoking is discussed using data from a larger study of the factors influencing discussion of smoking between general practitioners (GPs) and patients. In this study, consultations have been analysed with a focus on the termination of discussion about smoking, using an approach that is informed by the conversation analytic (CA) literature on professional/client interaction. In interviews from the previous larger study, GPs suggested two main reasons for not pursuing discussion of smoking in consultations. One reason was an overarching fear of damaging the GP/patient relationship. The second reason related to clinical judgement, where it was feared that an attempt to stop smoking might exacerbate a patient's existing condition, particularly their mental health. This paper suggests that, while this latter scenario of clinical judgement is borne out by the consultation data, there are two more subtle patient behaviours which are associated with GPs abandoning further discussion of smoking: patients' 'troubles telling', where the issue of smoking is de-emphasised in the face of other 'troubles', and 'defensive expansion', where the patient over-emphasises deficiencies to curtail discussion. Greater awareness of the situations in which doctors end discussion of smoking will help GPs to develop ideas for alternative approaches in these circumstances which could result in more meaningful, effective engagement between doctors and their patients who smoke when smoking is discussed.

Substitution of doctors by nurses in primary care

BACKGROUND

Demand for primary care services has increased in developed countries due to population ageing, rising patient expectations, and reforms that shift care from hospitals to the community. At the same time, the supply of physicians is constrained and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges. The expectation is that nurse-doctor substitution will reduce cost and physician workload while maintaining quality of care.

OBJECTIVES

Our aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilisation including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilisation was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs.

SEARCH STRATEGY

The following databases were searched for the period 1966 to 2002: Medline; Cinahl; Bids, Embase; Social Science Citation Index; British Nursing Index; HMIC; EPOC Register; and Cochrane Controlled Trial Register. Search terms specified the setting (primary care), professional (nurse), study design (randomised controlled trial, controlled before-and-after-study, interrupted time series), and subject (e.g. skill mix).

SELECTION CRITERIA

Studies were included if nurses were compared to doctors providing a similar primary health care service (excluding accident and emergency services). Primary care doctors included: general practitioners, family physicians, paediatricians, general internists or geriatricians. Primary care nurses included: practice nurses, nurse practitioners, clinical nurse specialists, or advanced practice nurses.

DATA COLLECTION AND ANALYSIS

Study selection and data extraction was conducted independently by two reviewers with differences resolved through discussion. Meta-analysis was applied to outcomes for which there was adequate reporting of intervention effects from at least three randomised controlled trials. Semi-quantitative methods were used to synthesize other outcomes.

MAIN RESULTS

4253 articles were screened of which 25 articles, relating to 16 studies, met our inclusion criteria. In seven studies the nurse assumed responsibility for first contact and ongoing care for all presenting patients. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. In five studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations during office hours or out-of-hours. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. The impact on physician workload and direct cost of care was variable. In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost.

AUTHORS' CONCLUSIONS

The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less. While doctor-nurse substitution has the potential to reduce doctors' workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.

Comparison of the smoking behaviour and attitudes of smokers who believe they have smoking-related problems with those who do not

BACKGROUND

Motivation to stop smoking is associated with smokers' possessing substantial smoking-related morbidity or believing that they have symptoms caused by smoking, but it is not clear if this holds for smokers attending general practice consultations.

OBJECTIVE

Our aim was to compare the attitudes and behaviour of smokers attending their GP with symptoms that they believe are smoking related with those who do not.

METHOD

A cross-sectional, pre-consultation survey of patients attending GPs in Leicester, UK was carried out.

RESULTS

A total of 83.8% (2955/3525) of people attending GPs completed the questionnaire and 34.7% were smokers. Multiple logistic regression showed that where smokers perceived that their problems were smoking related they were more likely to have tried stopping in the past [odds ratio (OR) 1.78, 95% confidence interval (CI) 1.26-2.67], to want to stop smoking (OR 1.83, CI 1.15-2.9) or to intend to stop in the near future (OR 1.58, CI 1.03-2.43).

CONCLUSION

Smokers who attend GPs' routine consultations and believe that they have smoking-related problems are more motivated to stop than others. This suggests that it is important for GPs to ascertain patients' views about the aetiology of their symptoms before discussing smoking with them.

Impact of different aspects of social participation and social capital on smoking cessation among daily smokers: a longitudinal study

OBJECTIVE

To investigate differences in different aspects of social participation and social capital among baseline daily smokers that had remained daily smokers, become intermittent smokers, or stopped smoking at one year follow up.

DESIGN/SETTING/PARTICIPANTS/MEASUREMENTS

12,507 individuals, aged 45-69 years, interviewed at baseline between 1992 and 1994 and at a one year follow up were investigated in this longitudinal study. The three groups of baseline daily smokers were compared to the reference population (baseline intermittent smokers and non-smokers) according to different aspects of social participation and social capital. A multivariate logistic regression model was used to assess differences in different aspects of social participation and social capital.

RESULTS

The baseline daily smokers that remained daily smokers at the one year follow up had significantly increased odds ratios of non-participation in study circles in other places than at work, meeting of organisations other than unions, theatre/cinema, arts exhibition, church, sports events, large gatherings of relatives, and private parties compared to the reference population. The baseline daily smokers that had become intermittent smokers at the one year follow up had significantly increased odds ratios of non-participation in church services. The baseline daily smokers that had stopped smoking had increased odds ratios of non-participation in having attended a meeting of organisations other than labour unions during the past year, having been to a theatre or cinema, and of having visited an arts exhibition during the past year. All three categories of baseline daily smokers had significantly decreased odds ratios of non-participation in night club/entertainment.

CONCLUSIONS

The baseline daily smokers that had remained daily smokers at the one year follow up had particularly high rates of non-participation compared to the reference population in both activities specifically related to social capital, such as other study circles, meetings of organisations other than labour unions, and church attendance and cultural activities such as theatre/cinema and arts exhibition, although significantly lower participation in cultural activities and meetings of other organisations was also observed among daily smokers that had stopped smoking. All three baseline daily smoker groups had higher rates of having visited a night club during the past year.

Predictors of 6-month tobacco abstinence among 1224 cigarette smokers treated for nicotine dependence

This study examined baseline characteristics associated with abstinence from tobacco 6 months after treatment for nicotine dependence. A total of 1224 cigarette smokers (619 females, 605 males) receiving clinical services for treatment of nicotine dependence between January 1, 1995 and June 30, 1997 were studied. The intervention involves a 45-min consultation with a nicotine dependence counselor. A treatment plan individualized to the patient's needs is then developed. The main outcome measure was the self-reported 7-day point prevalence abstinence from tobacco obtained by telephone interview 6-months after the consultation. A bootstrap resampling methodology for predictor variable selection was used to identify a set of multivariate predictors of 6-month tobacco abstinence. Five variables were multivariately associated with tobacco abstinence: male gender, no current psychiatric diagnosis, higher stage of change, longest duration of previous abstinence from tobacco of <1 or > or =30 days, and Fagerström Test for Nicotine Dependence (FTND) score of < or =5. Assessment of these variables may be useful clinically by assisting health care providers in tailoring nicotine dependence interventions to enhance outcomes.

Long term and transitional intermittent smokers: a longitudinal study

OBJECTIVE

To investigate differences in snuff consumption, sociodemographic and psychosocial characteristics between baseline intermittent smokers that had become daily smokers, stopped smoking or remained intermittent smokers at the one year follow up.

DESIGN/SETTING/PARTICIPANTS/MEASUREMENTS

A population of 12 507 individuals interviewed at baseline in 1992-94 and at a one year follow up, aged 45-69 years, was investigated in a longitudinal study. The three groups of baseline intermittent smokers were compared to the reference population (all others) according to sociodemographic, psychosocial, and snuff consumption characteristics. A multivariate logistic regression model was used to assess differences in psychosocial conditions, adjusting for age, sex, country of origin, marital status, education, and snuff consumption.

RESULTS

60% of all baseline intermittent smokers had remained intermittent smokers, 16% had become daily smokers, and 24% had stopped smoking at the one year follow up. The long term intermittent smokers and those who had stopped smoking were young, unmarried, highly educated, and snuff consumers to a higher extent than the reference population. They also had more psychosocial resources than the reference population, while the psychosocial resources of those who had become daily smokers were poorer.

CONCLUSIONS

The majority of intermittent smokers are long term intermittent smokers. The results suggest that long term intermittent smokers have other psychosocial characteristics than daily smokers.

Smoking cessation among daily smokers, aged 45-69 years: a longitudinal study in Malmö, Sweden

OBJECTIVE

To investigate differences in snuff consumption, socio-demographic and psychosocial characteristics between baseline daily smokers who had remained daily smokers, become intermittent smokers or stopped smoking at the 1-year follow-up.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

A population of 12 507 individuals aged 45-69 years, interviewed at baseline in 1992-94 and at a 1-year follow-up, was investigated in this longitudinal study. The three groups of baseline daily smokers were compared to the total population according to socio-demographic, psychosocial and snuff consumption characteristics. A multivariate logistic regression model was used to assess differences in psychosocial conditions, adjusting for age, sex, country of origin, marital status, education and snuff consumption.

FINDINGS

Eighty-six per cent of all baseline daily smokers remained daily smokers, 6.5% had become intermittent smokers and 7.3% had stopped smoking at the 1-year follow-up. The daily smokers who remained daily smokers were more likely to be born in other countries than Sweden, not married, have a lower educational level and poorer psychosocial conditions than the total population, while the socio-demographic characteristics and psychosocial resources of those daily smokers who had become intermittent smokers or had stopped smoking were much more similar to the general population, with the exception of a higher snuff consumption, especially for intermittent smokers.

CONCLUSIONS

Daily smokers who remained daily smokers at the 1-year follow-up had poorer psychosocial assets, especially social participation, than baseline daily smokers who had become intermittent smokers or had stopped smoking, and the general population. The results suggest that low levels of social participation are a potent barrier against smoking cessation. Snuff consumption may explain a part of the increase in smoking cessation among men as opposed to women in Sweden.

Predictors of tobacco control among nursing students

As the most numerous health care providers, nurses could reduce tobacco-related morbidity and mortality. A cross-sectional survey of 476 junior and senior students at 12 schools of nursing in the New York metropolitan area was conducted, to determine nurse knowledge of tobacco control, their attitudes, beliefs, and practices. Overall, 76% of all nursing students reported that they practiced tobacco control. Current smokers were less likely to participate in tobacco control with targets ranging from the nurse herself to the community than either never or ex-smokers. Nurses were more likely to engage in tobacco control among individual, family, or group clients than to advocate for changes in the community. Student nurses who were African American or Hispanic, had never smoked or were ex-smokers, those who had better knowledge of cessation approaches, and those who tended to have more confidence in their cessation counseling skills were more likely to engage in multi-target tobacco control than other similar nurses. Tailored interventions that emphasize discrete counseling skills are suggested.

Intermittent and daily smokers: two different socioeconomic patterns, and diverging influence of social participation

OBJECTIVE

To investigate socioeconomic differences in intermittent and daily smoking, and to assess the association between social participation and these two smoking behaviours.

DESIGN/SETTING/PARTICIPANTS/MEASUREMENTS

A population of 11 837 individuals interviewed in 1992-94, aged 45-64 years, was investigated in this cross sectional study. A multivariate logistic regression model was used to assess socioeconomic differences in daily and intermittent smoking, adjusting for age, country of origin, previous/current diseases, and marital status. Finally, social participation as a measure of social capital was introduced in the multivariate model.

RESULTS

When unskilled manual workers were compared to high level non-manual employees, odds ratios of 2.3 (95% confidence interval (CI) 1.7 to 3.0) for men and 1.9 (95% CI 1.4 to 2.5) for women were found in regard to daily smoking, but odd ratios of only 0.7 (95% CI 0.4 to 1.2) for men and 1.3 (95% CI 0.7 to 2.4) for women were found in regard to intermittent smoking. A decrease in the daily smoking odds ratios was found when social participation was introduced in the model, while the odds ratios regarding intermittent smoking were unaffected.

CONCLUSIONS

There were no socioeconomic differences in intermittent smoking and no association with social participation, a result that contrasts sharply with the patterns of daily smoking. These findings have important implications for the discussion concerning social capital and preventive measures.

Smoking cessation: integrating recent advances into clinical practice

Smoking remains a prevalent habit with serious consequences for public health. There are now effective treatments for nicotine addiction and, in the UK, specialist services for the treatment of smoking cessation are becoming available in all areas. This paper reviews the role of treatments for nicotine addiction in the management of smoking cessation. Recommendations are made for the judicious use of these therapies and also for the rational use of the new UK smoking cessation services.

Smoking cessation: integrating recent advances into clinical practice

Smoking remains a prevalent habit with serious consequences for public health. There are now effective treatments for nicotine addiction and, in the UK, specialist services for the treatment of smoking cessation are becoming available in all areas. This paper reviews the role of treatments for nicotine addiction in the management of smoking cessation. Recommendations are made for the judicious use of these therapies and also for the rational use of the new UK smoking cessation services.

Using content analysis of video-recorded consultations to identify smokers' "readiness" and "resistance" towards stopping smoking

Although physicians' brief advice against smoking is effective in helping smokers to stop, very little is known about the process of counseling smokers. We describe the development of a coding system for describing smokers' motivation to stop smoking as judged by their behaviour when discussing smoking with their family physician. We analysed video-recordings of consultations between 47 self-reported smokers and 29 family physicians where smoking was discussed. By a process of observing recordings, reading transcripts and discussion, we developed a coding system for describing smokers' levels of motivation to stop smoking. This consists of four behaviours thought to indicate "readiness" (higher motivation to stop) and four "resistance" (lower motivation to stop). Interobserver reliability between two observers was good (Kappa = 0.71 for readiness, 0.73 for resistance behaviours). We discuss the relevance of our descriptions for clinicians and the possibility of developing this work further to enable systematic research into doctor-patient interactions where smokers are counseled to stop.

Advising parents of asthmatic children on passive smoking: randomised controlled trial

OBJECTIVE

To investigate whether parents of asthmatic children would stop smoking or alter their smoking habits to protect their children from environmental tobacco smoke.

DESIGN

Randomised controlled trial.

SETTING

Tayside and Fife, Scotland.

PARTICIPANTS

501 families with an asthmatic child aged 2-12 years living with a parent who smoked.

INTERVENTION

Parents were told about the impact of passive smoking on asthma and were advised to stop smoking or change their smoking habits to protect their child's health.

MAIN OUTCOME MEASURES

Salivary cotinine concentrations in children, and changes in reported smoking habits of the parents 1 year after the intervention.

RESULTS

At the second visit, about 1 year after the baseline visit, a small decrease in salivary cotinine concentrations was found in both groups of children: the mean decrease in the intervention group (0.70 ng/ml) was slightly smaller than that of the control group (0.88 ng/ml), but the net difference of 0.19 ng/ml had a wide 95% confidence interval (-0.86 to 0.48). Overall, 98% of parents in both groups still smoked at follow up. However, there was a non-significant tendency for parents in the intervention group to report smoking more at follow up and to having a reduced desire to stop smoking.

CONCLUSIONS

A brief intervention to advise parents of asthmatic children about the risks from passive smoking was ineffective in reducing their children's exposure to environmental tobacco smoke. The intervention may have made some parents less inclined to stop smoking. If a clinician believes that a child's health is being affected by parental smoking, the parent's smoking needs to be addressed as a separate issue from the child's health.

Tobacco control activities of Iowa dental hygienists

The purpose of this study was to determine the type and extent of tobacco control activities provided to dental patients by Iowa dental hygienists. Surveys were mailed to 1056 dental hygienists who had active Iowa dental hygiene licenses. Forty-one were returned by the post office and 138 did not meet all of the criteria for the survey. Of the remaining pool of 877-340 were completed and returned for a response rate of 38.8%. Only 4.6% of the hygienists routinely asked their patients about their tobacco use. Thirty-five percent routinely advised smokers to stop and 57% routinely advised smokeless tobacco users to stop. Thirteen percent routinely assisted smokers to stop and 20% routinely assisted smokeless tobacco users in stopping. None of the hygienists routinely engaged in follow-up to tobacco cessation activities. Cessation practice activities and amounts varied by several categorical variables. The majority of Iowa dental hygienists who responded to this survey did not routinely ask, advise, assist or arrange for or about their patients' tobacco use or cessation. Recommendations are given on how to improve tobacco prevention and cessation programs in dental offices.