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Lindson N, Pritchard G, Hong B, Fanshawe TR, Pipe A, Papadakis S. Strategies to improve smoking cessation rates in primary care. Cochrane Database Syst Rev 2021; 9:CD011556. [PMID: 34693994 PMCID: PMC8543670 DOI: 10.1002/14651858.cd011556.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials). OBJECTIVES To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020. SELECTION CRITERIA We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). MAIN RESULTS We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.
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Affiliation(s)
- Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gillian Pritchard
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
- Canadian Public Health Association, Ottawa, Canada
| | - Bosun Hong
- Oral Surgery Department, Birmingham Dental Hospital, Birmingham, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Pipe
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
| | - Sophia Papadakis
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
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Reisinger SA, Kamel S, Seiber E, Klein EG, Paskett ED, Wewers ME. Cost-Effectiveness of Community-Based Tobacco Dependence Treatment Interventions: Initial Findings of a Systematic Review. Prev Chronic Dis 2019; 16:E161. [PMID: 31831106 PMCID: PMC6936666 DOI: 10.5888/pcd16.190232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction Scientific literature evaluating the cost-effectiveness of tobacco dependence treatment programs delivered in community-based settings is scant, which limits evidence-based tobacco control decisions. The aim of this review was to systematically assess the cost-effectiveness and quality of the economic evaluations of community-based tobacco dependence treatment interventions conducted as randomized controlled trials in the United States. Methods We searched 8 electronic databases and gray literature from their beginning to February 2018. Inclusion criteria were economic evaluations of community-based tobacco dependence treatments conducted as randomized controlled trials in the United States. Two independent researchers extracted data on study design and outcomes. Study quality was assessed by using Drummond and Jefferson’s economic evaluations checklist. Nine of 3,840 publications were eligible for inclusion. Heterogeneity precluded formal meta-analyses. We synthesized a qualitative narrative of outcomes. Results All 9 studies used cost-effectiveness analysis and a payer/provider/program perspective, but several study components, such as abstinence measures, were heterogeneous. Study participants were predominantly English speaking, middle aged, white, motivated to quit, and highly nicotine dependent. Overall, the economic evaluations met most of Drummond and Jefferson’s recommendations; however, some studies provided limited details. All studies had a cost per quit at or below $2,040 or an incremental cost-effectiveness ratio (ICER) at or below $3,781. When we considered biochemical verification, sensitivity analysis, and subgroups, the costs per quit were less than $2,050 or the ICERs were less than $6,800. Conclusion All community-based interventions included in this review were cost-effective. When economic evaluation results are extrapolated to future savings, the low cost per quit or ICER indicates that the cost-effectiveness of community-based tobacco dependence treatments is similar to the cost-effectiveness of clinic-based programs and that community-based interventions are a valuable approach to tobacco control. Additional research that more fully characterizes the cost-effectiveness of community-based tobacco dependence treatments is needed to inform future decisions in tobacco control policy.
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Affiliation(s)
- Sarah A Reisinger
- Division of Health Behavior and Health Promotion, College of Public Health, Ohio State University, Columbus, Ohio.,Comprehensive Cancer Center, Ohio State University, Columbus, Ohio.,420 W 12th Ave, Ste 390, Columbus, OH 43210.
| | - Sahar Kamel
- Comprehensive Cancer Center, Ohio State University, Columbus, Ohio
| | - Eric Seiber
- Division of Health Services Management and Policy, College of Public Health, Ohio State University, Columbus, Ohio
| | - Elizabeth G Klein
- Division of Health Behavior and Health Promotion, College of Public Health, Ohio State University, Columbus, Ohio
| | - Electra D Paskett
- Comprehensive Cancer Center, Ohio State University, Columbus, Ohio.,Division of Cancer Prevention and Control, College of Medicine, Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio
| | - Mary Ellen Wewers
- Division of Health Behavior and Health Promotion, College of Public Health, Ohio State University, Columbus, Ohio
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Livingstone‐Banks J, Ordóñez‐Mena JM, Hartmann‐Boyce J. Print-based self-help interventions for smoking cessation. Cochrane Database Syst Rev 2019; 1:CD001118. [PMID: 30623970 PMCID: PMC7112723 DOI: 10.1002/14651858.cd001118.pub4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Many smokers give up smoking on their own, but materials that provide a structured programme for smokers to follow may increase the number who quit successfully. OBJECTIVES The aims of this review were to determine the effectiveness of different forms of print-based self-help materials that provide a structured programme for smokers to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print-based self-help, such as computer-generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Trials Register, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The date of the most recent search was March 2018. SELECTION CRITERIA We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested print-based materials providing self-help compared with minimal print-based self-help (such as a short leaflet) or a lower-intensity control. We defined 'self-help' as structured programming for smokers trying to quit without intensive contact with a therapist. DATA COLLECTION AND ANALYSIS We extracted data in accordance with standard methodological procedures set out by Cochrane. The main outcome measure was abstinence from smoking after at least six months' follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each study and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a random-effects model. MAIN RESULTS We identified 75 studies that met our inclusion criteria. Many study reports did not include sufficient detail to allow judgement of risk of bias for some domains. We judged 30 studies (40%) to be at high risk of bias for one or more domains.Thirty-five studies evaluated the effects of standard, non-tailored self-help materials. Eleven studies compared self-help materials alone with no intervention and found a small effect in favour of the intervention (n = 13,241; risk ratio (RR) 1.19, 95% confidence interval (CI) 1.03 to 1.37; I² = 0%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for indirect relevance to populations in low- and middle-income countries because evidence for this comparison came from studies conducted solely in high-income countries and there is reason to believe the intervention might work differently in low- and middle-income countries. This analysis excluded two studies by the same author team with strongly positive outcomes that were clear outliers and introduced significant heterogeneity. Six further studies of structured self-help compared with brief leaflets did not show evidence of an effect of self-help materials on smoking cessation (n = 7023; RR 0.87, 95% CI 0.71 to 1.07; I² = 21%). We found evidence of benefit from standard self-help materials when there was brief contact that did not include smoking cessation advice (4 studies; n = 2822; RR 1.39, 95% CI 1.03 to 1.88; I² = 0%), but not when self-help was provided as an adjunct to face-to-face smoking cessation advice for all participants (11 studies; n = 5365; RR 0.99, 95% CI 0.76 to 1.28; I² = 32%).Thirty-two studies tested materials tailored for the characteristics of individual smokers, with controls receiving no materials, or stage-matched or non-tailored materials. Most of these studies used more than one mailing. Pooling studies that compared tailored self-help with no self-help, either on its own or compared with advice, or as an adjunct to advice, showed a benefit of providing tailored self-help interventions (12 studies; n = 19,190; RR 1.34, 95% CI 1.20 to 1.49; I² = 0%) with little evidence of difference between subgroups (10 studies compared tailored with no materials, n = 14,359; RR 1.34, 95% CI 1.19 to 1.51; I² = 0%; two studies compared tailored materials with brief advice, n = 2992; RR 1.13, 95% CI 0.86 to 1.49; I² = 0%; and two studies evaluated tailored materials as an adjunct to brief advice, n = 1839; RR 1.72, 95% CI 1.17 to 2.53; I² = 10%). When studies compared tailored self-help with non-tailored self-help, results favoured tailored interventions when the tailored interventions involved more mailings than the non-tailored interventions (9 studies; n = 14,166; RR 1.42, 95% CI 1.20 to 1.68; I² = 0%), but not when the two conditions were contact-matched (10 studies; n = 11,024; RR 1.07, 95% CI 0.89 to 1.30; I² = 50%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for risk of bias.Five studies evaluated self-help materials as an adjunct to nicotine replacement therapy; pooling three of these provided no evidence of additional benefit (n = 1769; RR 1.05, 95% CI 0.86 to 1.30; I² = 0%). Four studies evaluating additional written materials favoured the intervention, but the lower confidence interval crossed the line of no effect (RR 1.20, 95% CI 0.91 to 1.58; I² = 73%). A small number of other studies did not detect benefit from using targeted materials, or find differences between different self-help programmes. AUTHORS' CONCLUSIONS Moderate-certainty evidence shows that when no other support is available, written self-help materials help more people to stop smoking than no intervention. When people receive advice from a health professional or are using nicotine replacement therapy, there is no evidence that self-help materials add to their effect. However, small benefits cannot be excluded. Moderate-certainty evidence shows that self-help materials that use data from participants to tailor the nature of the advice or support given are more effective than no intervention. However, when tailored self-help materials, which typically involve repeated assessment and mailing, were compared with untailored materials delivered similarly, there was no evidence of benefit.Available evidence tested self-help interventions in high-income countries, where more intensive support is often available. Further research is needed to investigate effects of these interventions in low- and middle-income countries, where more intensive support may not be available.
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Effectiveness of Tailored Rehabilitation Education in Improving the Health Literacy and Health Status of Postoperative Patients With Breast Cancer. Cancer Nurs 2018; 43:E38-E46. [DOI: 10.1097/ncc.0000000000000665] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Andronis L, Goranitis I, Pirrie S, Pope A, Barton D, Collins S, Daunton A, McLaren D, O'Sullivan JM, Parker C, Porfiri E, Staffurth J, Stanley A, Wylie J, Beesley S, Birtle A, Brown JE, Chakraborti P, Hussain SA, Russell JM, Billingham LJ, James ND. Cost-effectiveness of zoledronic acid and strontium-89 as bone protecting treatments in addition to chemotherapy in patients with metastatic castrate-refractory prostate cancer: results from the TRAPEZE trial (ISRCTN 12808747). BJU Int 2017; 119:522-529. [PMID: 27256016 DOI: 10.1111/bju.13549] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of adding zoledronic acid or strontium-89 to standard docetaxel chemotherapy for patients with castrate-refractory prostate cancer (CRPC). PATIENTS AND METHODS Data on resource use and quality of life for 707 patients collected prospectively in the TRAPEZE 2 × 2 factorial randomised trial (ISRCTN 12808747) were used to assess the cost-effectiveness of i) zoledronic acid versus no zoledronic acid (ZA vs. no ZA), and ii) strontium-89 versus no strontium-89 (Sr89 vs. no Sr89). Costs were estimated from the perspective of the National Health Service in the UK and included expenditures for trial treatments, concomitant medications, and use of related hospital and primary care services. Quality-adjusted life-years (QALYs) were calculated according to patients' responses to the generic EuroQol EQ-5D-3L instrument, which evaluates health status. Results are expressed as incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves. RESULTS The per-patient cost for ZA was £12 667, £251 higher than the equivalent cost in the no ZA group. Patients in the ZA group had on average 0.03 QALYs more than their counterparts in no ZA group. The ICER for this comparison was £8 005. Sr89 was associated with a cost of £13 230, £1365 higher than no Sr89, and a gain of 0.08 QALYs compared to no Sr89. The ICER for Sr89 was £16 884. The probabilities of ZA and Sr89 being cost-effective were 0.64 and 0.60, respectively. CONCLUSIONS The addition of bone-targeting treatments to standard chemotherapy led to a small improvement in QALYs for a modest increase in cost (or cost-savings). ZA and Sr89 resulted in ICERs below conventional willingness-to-pay per QALY thresholds, suggesting that their addition to chemotherapy may represent a cost-effective use of resources.
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Affiliation(s)
| | - Ilias Goranitis
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Sarah Pirrie
- Cancer Research UK Clinical Trials Unit (CRCTU Birmingham), University of Birmingham, Birmingham, UK
| | - Ann Pope
- Cancer Research UK Clinical Trials Unit (CRCTU Birmingham), University of Birmingham, Birmingham, UK
| | - Darren Barton
- Cancer Research UK Clinical Trials Unit (CRCTU Birmingham), University of Birmingham, Birmingham, UK
| | - Stuart Collins
- Posthumously listed (previously CRCTU Birmingham), Birmingham, UK
| | - Adam Daunton
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | | - Emilio Porfiri
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Staffurth
- Institute of Cancer and Genetics, Cardiff University, UK
| | | | | | | | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, UK
| | | | | | | | | | - Lucinda J Billingham
- Cancer Research UK Clinical Trials Unit (CRCTU Birmingham), University of Birmingham, Birmingham, UK
| | - Nicholas D James
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Bully P, Sánchez Á, Zabaleta-del-Olmo E, Pombo H, Grandes G. Evidence from interventions based on theoretical models for lifestyle modification (physical activity, diet, alcohol and tobacco use) in primary care settings: A systematic review. Prev Med 2015; 76 Suppl:S76-93. [PMID: 25572619 DOI: 10.1016/j.ypmed.2014.12.020] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 12/19/2014] [Accepted: 12/26/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effectiveness of health promotion interventions based on theoretical models of behavioral change to modify the main lifestyle factors (physical activity, diet, alcohol and tobacco) in adults receiving primary health care (PHC). METHODS We searched the MEDLINE and Cochrane Database of Systematic Reviews from January 2000 to December 2012. Two reviewers independently performed the first screening of titles and abstracts, the methodological quality assessment using the lecturacritica.com tool, and the extraction of necessary data to systematize the available information. RESULTS Only few studies met the inclusion criteria (17 studies from 30 articles). Thirteen were randomized controlled trials, three systematic reviews, and one observational study. The transtheoretical model was the most frequent (13 studies), and obtained strong evidence of its effectiveness for dietary interventions in the short-term and for smoking cessation interventions in the long-term as compared to usual PHC practice. Limited evidence was found for smoking cessation interventions based in the social cognitive theory. CONCLUSION There are few studies that explicitly link intervention strategies and theories of behavioral change. A rigorous evaluation of the theoretical principles could help researchers and practitioners to understand how and why interventions succeed or fail.
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Affiliation(s)
- Paola Bully
- Primary Care Research Unit of Bizkaia, Basque Health Service-Osakidetza, Spain.
| | - Álvaro Sánchez
- Primary Care Research Unit of Bizkaia, Basque Health Service-Osakidetza, Spain
| | | | - Haizea Pombo
- Primary Care Research Unit of Bizkaia, Basque Health Service-Osakidetza, Spain
| | - Gonzalo Grandes
- Primary Care Research Unit of Bizkaia, Basque Health Service-Osakidetza, Spain
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Peckham S, Falconer J, Gillam S, Hann A, Kendall S, Nanchahal K, Ritchie B, Rogers R, Wallace A. The organisation and delivery of health improvement in general practice and primary care: a scoping study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03290] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThis project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.AimsThe aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.MethodsWe undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.FindingsMany of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.Future ResearchFuture research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Stephen Peckham
- Centre for Health Services Studies, University of Kent, Kent, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jane Falconer
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Steve Gillam
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alison Hann
- Public Health and Policy Studies, Swansea University, Swansea, UK
| | - Sally Kendall
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hertfordshire, UK
| | - Kiran Nanchahal
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Benjamin Ritchie
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Rebecca Rogers
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Social Policy, University of Lincoln, Lincoln, UK
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Abstract
BACKGROUND Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully. OBJECTIVES The aims of this review were to determine: the effectiveness of different forms of print-based self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to print-based self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search April 2014. SELECTION CRITERIA We included randomized trials of smoking cessation with follow-up of at least six months, where at least one arm tested a print-based self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist. DATA COLLECTION AND ANALYSIS We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model. MAIN RESULTS We identified 74 trials which met the inclusion criteria. Many study reports did not include sufficient detail to judge risk of bias for some domains. Twenty-eight studies (38%) were judged at high risk of bias for one or more domains but the overall risk of bias across all included studies was judged to be moderate, and unlikely to alter the conclusions.Thirty-four trials evaluated the effect of standard, non-tailored self-help materials. Pooling 11 of these trials in which there was no face-to-face contact and provision of structured self-help materials was compared to no intervention gave an estimate of benefit that just reached statistical significance (n = 13,241, risk ratio [RR] 1.19, 95% confidence interval [CI] 1.04 to 1.37). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Six further trials without face-to-face contact in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials (n = 7023, RR 0.88, 95% CI 0.74 to 1.04). When these two subgroups were pooled, there was no longer evidence for a benefit of standard structured materials (n = 20,264, RR 1.06, 95% CI 0.95 to 1.18). We failed to find evidence of benefit from providing standard self-help materials when there was brief contact with all participants (5 trials, n = 3866, RR 1.17, 95% CI 0.96 to 1.42), or face-to-face advice for all participants (11 trials, n = 5365, RR 0.97, 95% CI 0.80 to 1.18).Thirty-one trials offered materials tailored for the characteristics of individual smokers, with controls receiving either no materials, or stage matched or non-tailored materials. Most of the trials used more than one mailing. Pooling these showed a benefit of tailored materials (n = 40,890, RR 1.28, 95% CI 1.18 to 1.37) with moderate heterogeneity (I² = 32%). The evidence is strongest for the subgroup of nine trials in which tailored materials were compared to no intervention (n = 13,437, RR 1.35, 95% CI 1.19 to 1.53), but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data, since the subgroup of 10 trials where the number of contacts was matched did not detect an effect (n = 11,024, RR 1.06, 95% CI 0.94 to 1.20). In two trials including a direct comparison between tailored materials and brief advice from a health care provider, there was no evidence of a difference, but confidence intervals were wide (n = 2992, RR 1.13, 95% CI 0.86 to 1.49).Only four studies evaluated self-help materials as an adjunct to nicotine replacement therapy, with no evidence of additional benefit (n = 2291, RR 1.05, 95% CI 0.88 to 1.25). A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes. AUTHORS' CONCLUSIONS Standard, print-based self-help materials increase quit rates compared to no intervention, but the effect is likely to be small. We did not find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective than non-tailored materials, although the absolute size of effect is still small. Available evidence tested self-help interventions in high income countries; further research is needed to investigate their effect in contexts where more intensive support is not available.
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Affiliation(s)
- Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK, OX2 6GG
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Cost-Effectiveness of Computer-Tailored Smoking Cessation Advice in Primary Care: A Randomized Trial (ESCAPE). Nicotine Tob Res 2013; 16:270-8. [DOI: 10.1093/ntr/ntt136] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Gilbert HM, Leurent B, Sutton S, Alexis-Garsee C, Morris RW, Nazareth I. ESCAPE: a randomised controlled trial of computer-tailored smoking cessation advice in primary care. Addiction 2013; 108:811-9. [PMID: 23072513 DOI: 10.1111/add.12005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 09/14/2012] [Accepted: 10/10/2012] [Indexed: 11/27/2022]
Abstract
AIMS To evaluate the effectiveness of tailored cessation advice reports, including levels of reading ability, compared with a generic self-help booklet. DESIGN Participants were randomised to receive standard non-tailored information or to receive standard information plus a cessation advice report and a progress report, both tailored to individual characteristics. SETTING One hundred and twenty-three general practices located throughout the UK. PARTICIPANTS Questionnaires were mailed to 58 660 current cigarette smokers aged 18-65 years, identified from general practitioner records. Of the 6911 (11.8%) who completed the questionnaire, provided consent and were enrolled into the study, 6697 (11.4%) were included in the analysis. MEASUREMENTS Follow-up was by postal questionnaire sent six months after randomisation, or by telephone interview for participants failing to return the questionnaire. The primary outcome was self-reported prolonged abstinence for at least three months at the six-month follow-up. FINDINGS Quit rates on the primary outcome were not significantly different (3.2% versus 2.7%) (OR = 1.20, 95% CI [0.94, 1.54], P = 0.15). A significantly higher proportion of intervention group participants made a quit attempt during the follow-up period (32.3% versus 29.6%; OR = 1.13, 95% CI [1.01, 1.26], P = 0.026). CONCLUSION ESCAPE, a brief tailored smoking cessation intervention delivered by post and designed to reach a wide population of smokers, appears to increase the rate at which smokers try to stop, but if there is an effect on prolonged abstinence it is small.
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Affiliation(s)
- Hazel M Gilbert
- Research Department of Primary Care and Population Health, University College Medical School, London, UK
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Taggart J, Williams A, Dennis S, Newall A, Shortus T, Zwar N, Denney-Wilson E, Harris MF. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC FAMILY PRACTICE 2012; 13:49. [PMID: 22656188 PMCID: PMC3444864 DOI: 10.1186/1471-2296-13-49] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 04/02/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW). METHODS A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and <8; Low ≤ 3 points of contact hours) and setting (primary health, community or other).Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported. RESULTS 52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions. CONCLUSION Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.
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Affiliation(s)
- Jane Taggart
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, Australia
| | - Anna Williams
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, Australia
| | - Sarah Dennis
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, Australia
| | - Anthony Newall
- School of Public Health and Community Medicine, University of New South Wales, Sydney, 2052, Australia
| | - Tim Shortus
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, Australia
| | - Nicholas Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, 2052, Australia
| | - Elizabeth Denney-Wilson
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, Australia
| | - Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, 2052, Australia
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Dennis S, Williams A, Taggart J, Newall A, Denney-Wilson E, Zwar N, Shortus T, Harris MF. Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis. BMC FAMILY PRACTICE 2012; 13:44. [PMID: 22639799 PMCID: PMC3515410 DOI: 10.1186/1471-2296-13-44] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 04/12/2012] [Indexed: 01/27/2023]
Abstract
Background People with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes. Methods Studies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor. The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review. Results 52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity. Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients. Conclusion Capacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.
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Affiliation(s)
- Sarah Dennis
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.
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Gilbert H, Leurent B, Sutton S, Morris R, Alexis-Garsee C, Nazareth I. Factors predicting recruitment to a UK wide primary care smoking cessation study (the ESCAPE trial). Fam Pract 2012; 29:110-7. [PMID: 21624941 DOI: 10.1093/fampra/cmr030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recruiting smokers to smoking cessation trials is challenging and participation rates are often low. Consequently, the interventions evaluated may fail to reach a broad spectrum of the target population, thus compromising the generalizability of the findings. Brief interventions, using proactive recruitment, are likely to attract a broader and more representative proportion of the population. OBJECTIVE We explored the factors that influenced recruitment into a trial evaluating computer-tailored feedback reports that aimed to help smokers to quit [the ESCAPE (Effectiveness of computer-tailored Smoking Cessation Advice in Primary Care) study] in order to investigate the possibilities for increasing recruitment into smoking cessation trials. METHODS Current cigarette smokers, identified from GP records, were invited to participate in the study. The main outcome measure was the recruitment rate, i.e. the proportion of participants who responded and were randomized to one of the intervention groups. Predictor variables included geographical region, level of deprivation, practice characteristics and the number and timing of mailings of questionnaires. RESULTS The recruitment rate varied by practice (2.5-19.8%) and differed significantly between regions (from 16.3% in Scotland to 8.4% in London, P < 0.001). Recruitment decreased significantly by 1.1% between the lowest and highest quintiles of deprivation (P = 0.012), measured by Index of Multiple Deprivation scores, and decreased by 1.33% for every extra 10% smokers identified within a practice population (P = 0.010). Sending reminders increased recruitment by 7.5% (P < 0.001). Multivariable analysis showed region and length of time between mailings were the main predictors of recruitment. CONCLUSIONS Proactive recruitment methods can increase participation in smoking cessation trials and weighting the target sample in favour of more deprived areas will recruit a more representative sample. The number and timing of mailings to potential participants can also increase recruitment.
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Affiliation(s)
- Hazel Gilbert
- Research Department of Primary Care and Population Health, University College Medical School, London, UK.
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Wetter DW, McClure JB, Cofta-Woerpel L, Costello TJ, Reitzel LR, Businelle MS, Cinciripini PM. A randomized clinical trial of a palmtop computer-delivered treatment for smoking relapse prevention among women. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2011; 25:365-71. [PMID: 21500879 DOI: 10.1037/a0022797] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Relapse is the rule rather than the exception among smokers attempting to quit, and compared to men, women may have higher relapse rates. The current study was a randomized clinical trial testing a palmtop computer-delivered treatment (CDT) for smoking relapse prevention among women. The intervention was individualized based on key theoretical constructs that were measured using ecological momentary assessment (EMA). All participants (N = 302) received standard smoking cessation treatment consisting of nicotine replacement therapy and group counseling, and completed EMA procedures for one week after quitting. At the completion of the group counseling sessions and EMA procedures, participants were randomized to either CDT or no further computer-delivered treatment or assessment (EMA-Only). CDT participants received a palmtop computer-delivered relapse prevention treatment for one additional month. CDT did not improve abstinence rates relative to EMA-Only. Process analyses suggested that heavier smokers were more likely to use CDT and that greater use among CDT participants may be associated with more positive outcomes. The rapid pace of technological advances in mobile computer technology and the ubiquity of such devices provide a novel platform for developing new and potentially innovative treatments. However, the current study did not demonstrate the efficacy of such technology in improving treatment outcomes.
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Affiliation(s)
- David W Wetter
- Department of Health Disparities Research, The University of Texas, M. D. Anderson Cancer Center, Houston, TX 77230, USA.
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Fjalldal SB, Janson C, Benediktsdóttir B, Gudmundsson G, Burney P, Buist AS, Vollmer WM, Gíslason T. Smoking, stages of change and decisional balance in Iceland and Sweden. CLINICAL RESPIRATORY JOURNAL 2011; 5:76-83. [PMID: 21410899 DOI: 10.1111/j.1752-699x.2010.00201.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Smoking remains a significant health problem. Smoking interventions are important but selection of successful quitters can be difficult. OBJECTIVE To characterise smokers with emphasis on two constructs of the transtheoretical model, the stages of change and decisional balance. METHODS A random sample from adults aged 40 and over in Reykjavik, Iceland, and Uppsala, Sweden. Smokers were defined as being in the stage of pre-contemplation (not thinking of quitting within the next 6 months), contemplation (thinking of quitting within the next 6 months) or preparation (thinking of quitting within the next 30 days, having managed to quit for at least 24 h within the last 12 months). RESULTS A total of 226 participants were smokers: 72 (32%) were in the pre-contemplation stage, 126 (56%) in the contemplation stage and 28 (12%) in the preparation stage. A younger age, higher body mass index (BMI) and higher educational level were significantly related to being in a more advanced stage. A significant association was observed between decisional balance and stages of change such that decreased importance of the positive aspects of smoking and increased importance of the negative aspects of smoking were independently associated with an increased readiness to quit. CONCLUSION The motivated smoker is likely to be young and educated with an above average BMI. A smoker in the contemplation stage is likely to maintain the negative aspects of smoking at a high level. Decreasing the value of the pros of smoking may facilitate the shift towards the stage of preparation.
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Affiliation(s)
- Sigrídur B Fjalldal
- Department of Respiratory Medicine, Allergy and Sleep, Landspitali-University Hospital, Iceland
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Proactive recruitment of cancer patients' social networks into a smoking cessation trial. Contemp Clin Trials 2011; 32:498-504. [PMID: 21382509 DOI: 10.1016/j.cct.2011.03.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 02/03/2011] [Accepted: 03/01/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND This report describes the characteristics associated with successful enrollment of smokers in the social networks (i.e., family and close friends) of patients with lung cancer into a smoking cessation intervention. METHODS Lung cancer patients from four clinical sites were asked to complete a survey enumerating their family members and close friends who smoke, and provide permission to contact these potential participants. Family members and close friends identified as smokers were interviewed and offered participation in a smoking cessation intervention. Repeated measures logistic regression model examined characteristics associated with enrollment. RESULTS A total of 1062 eligible lung cancer patients were identified and 516 patients consented and completed the survey. These patients identified 1325 potentially eligible family and close friends. Of these, 496 consented and enrolled in the smoking cessation program. Network enrollment was highest among patients who were white and had late-stage disease. Social network members enrolled were most likely to be female, a birth family, immediate family, or close friend, and live in close geographic proximity to the patient. CONCLUSIONS Proactive recruitment of smokers in the social networks of lung cancer patients is challenging. In this study, the majority of family members and friends declined to participate. Enlisting immediate female family members and friends, who live close to the patient as agents to proactively recruit other network members into smoking cessation trials could be used to extend reach of cessation interventions to patients' social networks. Moreover, further consideration should be given to the appropriate timing of approaching network smokers to consider cessation.
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Abstract
BACKGROUND The transtheoretical model is the most widely known of several stage-based theories of behaviour. It proposes that smokers move through a discrete series of motivational stages before they quit successfully. These are precontemplation (no thoughts of quitting), contemplation (thinking about quitting), preparation (planning to quit in the next 30 days), action (quitting successfully for up to six months), and maintenance (no smoking for more than six months). According to this influential model, interventions which help people to stop smoking should be tailored to their stage of readiness to quit, and are designed to move them forward through subsequent stages to eventual success. People in the preparation and action stages of quitting would require different types of support from those in precontemplation or contemplation. OBJECTIVES Our primary objective was to test the effectiveness of stage-based interventions in helping smokers to quit. SEARCH STRATEGY We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('stage* of change', 'transtheoretical model*', 'trans-theoretical model*, 'precaution adoption model*', 'health action model', 'processes of change questionnaire*', 'readiness to change', 'tailor*') and 'smoking' in the title or abstract, or as keywords. The latest search was in August 2010. SELECTION CRITERIA We included randomized controlled trials, which compared stage-based interventions with non-stage-based controls, with 'usual care' or with assessment only. We excluded trials which did not report a minimum follow-up period of six months from start of treatment, and those which measured stage of change but did not modify their intervention in the light of it. DATA COLLECTION AND ANALYSIS We extracted data in duplicate on the participants, the dose and duration of intervention, the outcome measures, the randomization procedure, concealment of allocation, and completeness of follow up.The main outcome was abstinence from smoking for at least six months. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where reported. Where appropriate we performed meta-analysis to estimate a pooled risk ratio, using the Mantel-Haenszel fixed-effect model. MAIN RESULTS We found 41 trials (>33,000 participants) which met our inclusion criteria. Four trials, which directly compared the same intervention in stage-based and standard versions, found no clear advantage for the staging component. Stage-based versus standard self-help materials (two trials) gave a relative risk (RR) of 0.93 (95% CI 0.62 to 1.39). Stage-based versus standard counselling (two trials) gave a relative risk of 1.00 (95% CI 0.82 to 1.22). Six trials of stage-based self-help systems versus any standard self-help support demonstrated a benefit for the staged groups, with an RR of 1.27 (95% CI 1.01 to 1.59). Twelve trials comparing stage-based self help with 'usual care' or assessment-only gave an RR of 1.32 (95% CI 1.17 to 1.48). Thirteen trials of stage-based individual counselling versus any control condition gave an RR of 1.24 (95% CI 1.08 to 1.42). These findings are consistent with the proven effectiveness of these interventions in their non-stage-based versions. The evidence was unclear for telephone counselling, interactive computer programmes or training of doctors or lay supporters. This uncertainty may be due in part to smaller numbers of trials. AUTHORS' CONCLUSIONS Based on four trials using direct comparisons, stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents. Thirty-one trials of stage-based self help or counselling interventions versus any control condition demonstrated levels of effectiveness which were comparable with their non-stage-based counterparts. Providing these forms of practical support to those trying to quit appears to be more productive than not intervening. However, the additional value of adapting the intervention to the smoker's stage of change is uncertain. The evidence is not clear for other types of staged intervention, including telephone counselling, interactive computer programmes and training of physicians or lay supporters. The evidence does not support the restriction of quitting advice and encouragement only to those smokers perceived to be in the preparation and action stages.
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Affiliation(s)
- Kate Cahill
- Department of Primary Health Care, University of Oxford, Rosemary Rue Building, Old Road Campus, Oxford, UK, OX3 7LF
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Krebs P, Prochaska JO, Rossi JS. A meta-analysis of computer-tailored interventions for health behavior change. Prev Med 2010; 51:214-21. [PMID: 20558196 PMCID: PMC2939185 DOI: 10.1016/j.ypmed.2010.06.004] [Citation(s) in RCA: 509] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 06/04/2010] [Accepted: 06/05/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Computer-tailored interventions have become increasingly common for facilitating improvement in behaviors related to chronic disease and health promotion. A sufficient number of outcome studies from these interventions are now available to facilitate the quantitative analysis of effect sizes, permitting moderator analyses that were not possible with previous systematic reviews. METHOD The present study employs meta-analytic techniques to assess the mean effect for 88 computer-tailored interventions published between 1988 and 2009 focusing on four health behaviors: smoking cessation, physical activity, eating a healthy diet, and receiving regular mammography screening. Effect sizes were calculated using Hedges g. Study, tailoring, and demographic moderators were examined by analyzing between-group variance and meta-regression. RESULTS Clinically and statistically significant overall effect sizes were found across each of the four behaviors. While effect sizes decreased after intervention completion, dynamically tailored interventions were found to have increased efficacy over time as compared with tailored interventions based on one assessment only. Study effects did not differ across communication channels nor decline when up to three behaviors were identified for intervention simultaneously. CONCLUSION This study demonstrates that computer-tailored interventions have the potential to improve health behaviors and suggests strategies that may lead to greater effectiveness of these techniques.
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Affiliation(s)
- Paul Krebs
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
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Papadakis S, McDonald P, Mullen KA, Reid R, Skulsky K, Pipe A. Strategies to increase the delivery of smoking cessation treatments in primary care settings: a systematic review and meta-analysis. Prev Med 2010; 51:199-213. [PMID: 20600264 DOI: 10.1016/j.ypmed.2010.06.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Revised: 06/07/2010] [Accepted: 06/09/2010] [Indexed: 01/11/2023]
Abstract
OBJECTIVES A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics. METHODS The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for "5As" (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies. RESULTS Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing "5As" delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6-2.1] for "ask", 1.6 [95% CI 1.4-1.8] for "advice", 9.3 [95% CI 6.8-12.8] for "assist" (quit date) and 3.5 [95% CI 2.8-4.2] for "assist" (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5-2.0] and multi-component interventions [OR 2.2; 95% CI 1.7-2.8] were found to significantly increase smoking abstinence. CONCLUSION Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.
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Affiliation(s)
- Sophia Papadakis
- Department of Health Studies and Gerontology, Faculty of Applied Health Sciences, University of Waterloo, 200 University Ave. West, Waterloo, Ontario, Canada.
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Hoving C, Mudde AN, Dijk F, de Vries H. Effectiveness of a smoking cessation intervention in Dutch pharmacies and general practices. HEALTH EDUCATION 2010. [DOI: 10.1108/09654281011008726] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Haug S, Meyer C, Ulbricht S, Schorr G, Rüge J, Rumpf HJ, John U. Predictors and moderators of outcome in different brief interventions for smoking cessation in general medical practice. PATIENT EDUCATION AND COUNSELING 2010; 78:57-64. [PMID: 19660890 DOI: 10.1016/j.pec.2009.07.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 06/19/2009] [Accepted: 07/09/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To explore demographic-, health-, and smoking-related predictors and moderators of outcome in smokers who participated in two different brief smoking cessation interventions. METHODS Data were acquired using a quasi-randomized controlled trial that tested the efficacy of computer-generated tailored letters and physician-delivered brief advice against assessment only. Daily smokers (n=1499) were recruited from 34 general medical practices. We used Generalized Estimating Equation analyses to investigate the relationship between 6-month prolonged smoking abstinence assessed at 12-, 18-, and 24-month follow-ups and potential predictors and moderators. RESULTS Female gender (OR=1.49, 95% CI=1.01-2.19), higher level of education (OR=1.82, 95% CI=1.18-2.82), intention to quit smoking (OR=1.66, 95% CI=1.16-2.38), and smoking cessation self-efficacy (OR=1.30, 95% CI=1.03-1.64) were positively, nicotine dependence (OR=0.84, 95% CI=0.76-0.94) and the presence of a smoking partner (OR=0.60, 95% CI=0.42-0.85) were negatively associated with smoking abstinence. Compared to assessment only, physician advice was less effective for people without an intention to quit smoking and for unemployed. CONCLUSION Smoking cessation interventions might be improved by tailoring them to demographic- and smoking-related variables which were identified as predictors in this study. PRACTICE IMPLICATIONS The results suggest that tailored letters are a more universally applicable brief intervention in general medical practice than physician advice.
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Affiliation(s)
- Severin Haug
- Ernst-Moritz-Arndt-University Greifswald, Institute of Epidemiology and Social Medicine, Greifswald, Germany.
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Ritzwoller DP, Sukhanova A, Gaglio B, Glasgow RE. Costing behavioral interventions: a practical guide to enhance translation. Ann Behav Med 2009; 37:218-27. [PMID: 19291342 DOI: 10.1007/s12160-009-9088-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2007] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/PURPOSE Cost and cost effectiveness of behavioral interventions are critical parts of dissemination and implementation into non-academic settings. Due to the lack of indicative data and policy makers' increasing demands for both program effectiveness and efficiency, cost analyses can serve as valuable tools in the evaluation process. METHODS To stimulate and promote broader use of practical techniques that can be used to efficiently estimate the implementation costs of behavioral interventions, we propose a set of analytic steps that can be employed across a broad range of interventions. RESULTS/CONCLUSIONS Intervention costs must be distinguished from research, development, and recruitment costs. The inclusion of sensitivity analyses is recommended to understand the implications of implementation of the intervention into different settings using different intervention resources. To illustrate these procedures, we use data from a smoking reduction practical clinical trial to describe the techniques and methods used to estimate and evaluate the costs associated with the intervention. Estimated intervention costs per participant were $419, with a range of $276 to $703, depending on the number of participants.
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Affiliation(s)
- Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237-8066, USA.
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Aveyard P, Massey L, Parsons A, Manaseki S, Griffin C. The effect of Transtheoretical Model based interventions on smoking cessation. Soc Sci Med 2009; 68:397-403. [PMID: 19038483 DOI: 10.1016/j.socscimed.2008.10.036] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2007] [Indexed: 11/24/2022]
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Kahende JW, Loomis BR, Adhikari B, Marshall L. A review of economic evaluations of tobacco control programs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2008; 6:51-68. [PMID: 19440269 PMCID: PMC2672319 DOI: 10.3390/ijerph6010051] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Accepted: 12/23/2008] [Indexed: 11/16/2022]
Abstract
Each year, an estimated 443,000 people die of smoking-related diseases in the United States. Cigarette smoking results in more than $193 billion in medical costs and productivity losses annually. In an effort to reduce this burden, many states, the federal government, and several national organizations fund tobacco control programs and policies. For this report we reviewed existing literature on economic evaluations of tobacco control interventions. We found that smoking cessation therapies, including nicotine replacement therapy (NRT) and self-help are most commonly studied. There are far fewer studies on other important interventions, such as price and tax increases, media campaigns, smoke free air laws and workplace smoking interventions, quitlines, youth access enforcement, school-based programs, and community-based programs. Although there are obvious gaps in the literature, the existing studies show in almost every case that tobacco control programs and policies are either cost-saving or highly cost-effective.
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Affiliation(s)
- Jennifer W. Kahende
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 4770 Buford Highway, NE., MS-K50, Atlanta, GA 30341, USA; E-mails:
(B. A.);
(L. T. M.)
- * Author to whom correspondence should be addressed; E-Mail:
; Tel.: +1-770-488-5279
| | - Brett R. Loomis
- Research Triangle International, Public Health Policy Research Program, Hobbs Building, Rm 139, 3040 Cornwallis Rd, Research Triangle Park, NC 27709, USA; E-Mail:
| | - Bishwa Adhikari
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 4770 Buford Highway, NE., MS-K50, Atlanta, GA 30341, USA; E-mails:
(B. A.);
(L. T. M.)
| | - LaTisha Marshall
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 4770 Buford Highway, NE., MS-K50, Atlanta, GA 30341, USA; E-mails:
(B. A.);
(L. T. M.)
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Murray RL, Coleman T, Antoniak M, Stocks J, Fergus A, Britton J, Lewis SA. The effect of proactively identifying smokers and offering smoking cessation support in primary care populations: a cluster-randomized trial. Addiction 2008; 103:998-1006; discussion 1007-8. [PMID: 18422823 DOI: 10.1111/j.1360-0443.2008.02206.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To establish whether proactively identifying all smokers in primary care populations and offering smoking cessation support is effective in increasing long-term abstinence from smoking. DESIGN Cluster randomized controlled trial. SETTING Twenty-four general practices in Nottinghamshire, randomized by practice to active or control intervention. PARTICIPANTS All adult patients registered with the practices who returned a questionnaire confirming that they were current smokers (n = 6856). INTERVENTION Participants were offered smoking cessation support by letter and those interested in receiving it were contacted and referred into National Health Service (NHS) stop smoking services if required. MEASUREMENTS Validated abstinence from smoking, use of smoking cessation services and number of quit attempts in continuing smokers at 6 months. FINDINGS Smokers in the intervention group were more likely than controls to report that they had used local cessation services during the study period [16.6% and 8.9%, respectively, adjusted odds ratio (OR) 2.09, 95% confidence interval (CI) 1.57-2.78], and continuing smokers (in the intervention group) were more likely to have made a quit attempt in the last 6 months (37.4% and 33.3%, respectively, adjusted OR 1.23, 95% CI 1.01-1.51). Validated point prevalence abstinence from smoking at 6 months was higher in the intervention than the control groups (3.5% and 2.5%, respectively) but the difference was not statistically significant (adjusted OR controlling for covariates: 1.64, 95% CI 0.92-2.89). CONCLUSIONS Proactively identifying smokers who want to quit in primary care populations, and referring them to a cessation service, increased contacts with cessation services and the number of quit attempts. We were unable to detect a significant effect on long-term cessation rates, but the study was not powered to detect the kind of difference that might be expected.
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Affiliation(s)
- Rachael L Murray
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK.
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Gilbert H, Nazareth I, Sutton S, Morris R, Godfrey C. Effectiveness of computer-tailored Smoking Cessation Advice in Primary Care (ESCAPE): a randomised trial. Trials 2008; 9:23. [PMID: 18445279 PMCID: PMC2409293 DOI: 10.1186/1745-6215-9-23] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 04/29/2008] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Smoking remains a major public health problem; developing effective interventions to encourage more quit attempts, and to improve the success rate of self-quit attempts, is essential to reduce the numbers of people who smoke. Interventions for smoking cessation can be characterised in two extremes: the intensive face-to face therapy of the clinical approach, and large-scale, public health interventions and policy initiatives. Computer-based systems offer a method for generating highly tailored behavioural feedback letters, and can bridge the gap between these two extremes. Proactive mailing and recruitment can also serve as a prompt to motivate smokers to make quit attempts or to seek more intensive help. The aim of this study is to evaluate the effect of personally tailored feedback reports, sent to smokers identified from general practitioners lists on quit rates and quitting activity. The trial uses a modified version of a computer-based system developed by two of the authors to generate individually tailored feedback reports. METHOD A random sample of cigarette smokers, aged between 18 and 65, identified from GP records at a representative selection of practices registered with the GPRF are sent a questionnaire. Smokers returning the questionnaire are randomly allocated to a control group to receive usual care and standard information, or to an intervention group to receive usual care and standard information plus tailored feedback reports. Smoking status and cognitive change will be assessed by postal questionnaire at 6-months. DISCUSSION Computer tailored personal feedback, adapted to reading levels and motivation to quit, is a simple and inexpensive intervention which could be widely replicated and delivered cost effectively to a large proportion of the smoking population. Given its recruitment potential, a modest success rate could have a large effect on public health. The intervention also fits into the broader scope of tobacco control, by prompting more quit attempts, and increasing referrals to specialised services. The provision of this option to smokers in primary care can complement existing services, and work synergistically with other measures to produce more quitters and reduce the prevalence of smoking in the UK. TRIAL REGISTRATION Current Controlled Trials ISRCTN05385712.
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Affiliation(s)
- Hazel Gilbert
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK
- GP Principal, The Keats Group Practice, 1b Downshire Hill, London, UK
| | - Stephen Sutton
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Richard Morris
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK
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Meyer C, Ulbricht S, Baumeister SE, Schumann A, Rüge J, Bischof G, Rumpf HJ, John U. Proactive interventions for smoking cessation in general medical practice: a quasi-randomized controlled trial to examine the efficacy of computer-tailored letters and physician-delivered brief advice. Addiction 2008; 103:294-304. [PMID: 17995993 PMCID: PMC2253708 DOI: 10.1111/j.1360-0443.2007.02031.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To test the efficacy of (i) computer-generated tailored letters and (ii) practitioner-delivered brief advice for smoking cessation against an assessment-only condition; and to compare both interventions directly. DESIGN Quasi-randomized controlled trial. SETTING A total of 34 randomly selected general practices from a German region (participation rate 87%). PARTICIPANTS A total of 1499 consecutive patients aged 18-70 years with daily cigarette smoking (participation rate 80%). INTERVENTIONS The tailored letters intervention group received up to three individualized personal letters. Brief advice was delivered during routine consultation by the practitioner after an onsite training session. Both interventions were based on the Transtheoretical Model of behaviour change. MEASUREMENTS Self-reported point prevalence and prolonged abstinence at 6-, 12-, 18- and 24-month follow-ups. FINDINGS Among participants completing the last follow-up, 6-month prolonged abstinence was 18.3% in the tailored letters intervention group, 14.8% in the brief advice intervention group and 10.5% in the assessment-only control group. Assuming those lost to follow-up to be smokers, the rates were 10.2%, 9.7% and 6.7%, respectively. Analyses including all follow-ups confirmed statistically significant effects of both interventions compared to assessment only. Using complete case analysis, the tailored letters intervention was significantly more effective than brief advice for 24-hour [odds ratio (OR) = 1.4; P = 0.047] but not for 7-day point prevalence abstinence (OR = 1.4; P = 0.068) for prolonged abstinence, or for alternative assumptions about participants lost to follow-up. CONCLUSIONS The study demonstrated long-term efficacy of low-cost interventions for smoking cessation in general practice. The interventions are suitable to reach entire populations of general practices and smoking patients. Computer-generated letters are a promising option to overcome barriers to provide smoking cessation counselling routinely.
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Affiliation(s)
- Christian Meyer
- Department of Epidemiology and Social Medicine, University of Greifswald, Greifswald, Germany.
| | - Sabina Ulbricht
- University of Greifswald, Department of Epidemiology and Social MedicineGreifswald, Germany
| | - Sebastian E Baumeister
- University of Greifswald, Department of Epidemiology and Social MedicineGreifswald, Germany
| | - Anja Schumann
- Bremen Institute for Prevention Research and Social MedicineBremen, Germany
| | - Jeannette Rüge
- University of Greifswald, Department of Epidemiology and Social MedicineGreifswald, Germany
| | - Gallus Bischof
- University of Lübeck, Department of Psychiatry and Psychotherapy, Research Group S:TEP (Substance Abuse: Treatment, Epidemiology and Prevention)Lübeck, Germany
| | - Hans-Jürgen Rumpf
- University of Lübeck, Department of Psychiatry and Psychotherapy, Research Group S:TEP (Substance Abuse: Treatment, Epidemiology and Prevention)Lübeck, Germany
| | - Ulrich John
- University of Greifswald, Department of Epidemiology and Social MedicineGreifswald, Germany
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Schumann A, John U, Rumpf HJ, Hapke U, Meyer C. Changes in the "stages of change" as outcome measures of a smoking cessation intervention: a randomized controlled trial. Prev Med 2006; 43:101-6. [PMID: 16709427 DOI: 10.1016/j.ypmed.2006.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Revised: 03/30/2006] [Accepted: 04/01/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Employing changes in the "stages of change" as alternative outcome measures of a smoking cessation intervention. METHOD RCT carried out between 2002 and 2004 in Germany with 485 daily cigarette smokers recruited from a general population survey. The intervention was conceptually based on the transtheoretical model, involving individualized feedback letters generated by computerized expert-system technology. RESULTS Latent transition analysis was applied to test models for patterns of change, to evaluate stage of change distributions and transitions over time, and to compare the intervention and control group. The patterns of change across three time points could best be described by a model including stability, one-stage regressions, and one-to-four-stage progressions. There were no significant differences between the intervention and control group in the stage of change distributions at each time point or in the amount of stage transitions over time. CONCLUSION The efficacy of the intervention could not be demonstrated. Reasons may include oversampling of smokers who are interested in health-related topics but do not intend to quit, and power problems due to substantial attrition.
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Affiliation(s)
- Anja Schumann
- Ernst-Moritz-Arndt-University Greifswald, Institute of Epidemiology and Social Medicine, Germany
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Solberg LI, Maciosek MV, Edwards NM, Khanchandani HS, Goodman MJ. Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness. Am J Prev Med 2006; 31:62-71. [PMID: 16777544 DOI: 10.1016/j.amepre.2006.03.013] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Revised: 03/15/2006] [Accepted: 03/17/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND This report updates 2001 estimates of disease burden prevented and cost effectiveness of tobacco-use screening and brief intervention relative to that of other clinical preventive services. It also addresses repeated counseling because the literature has focused on single episodes of treatment, while in reality that is neither desirable nor likely. METHODS Literature searches led to four models for calculating the clinically preventable burden of deaths and morbidity from smoking as well as the cost effectiveness of providing the service annually over time. The same methods were used in similar calculations for other preventive services to facilitate comparison. RESULTS Using methods consistent with existing literature for this service, an estimated 190,000 undiscounted quality-adjusted life years (QALYs) are saved at a cost of $1100 per QALY saved (discounted). These estimates exclude financial savings from smoking-attributable disease prevented and use the average 12-month quit rate in clinical practice for tobacco screening and brief cessation counseling with cessation medications (5.0%) and without (2.4%). Including the savings of prevented smoking-attributable disease and using the effectiveness of repeated interventions over the lifetime of smokers (23.1%), 2.47 million QALYs are saved at a cost savings of $500 per smoker who receives the service. CONCLUSIONS This analysis makes repeated clinical tobacco-cessation counseling one of the three most important and cost-effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low levels of performance.
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Affiliation(s)
- Leif I Solberg
- HealthPartners Research Foundation, Bloomington, Minnesota 55425, USA.
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Walters ST, Wright JA, Shegog R. A review of computer and Internet-based interventions for smoking behavior. Addict Behav 2006; 31:264-77. [PMID: 15950392 DOI: 10.1016/j.addbeh.2005.05.002] [Citation(s) in RCA: 153] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Accepted: 05/04/2005] [Indexed: 11/27/2022]
Abstract
This article reviews studies of computer and Internet-based interventions for smoking behavior, published between 1995 and August 2004. Following electronic and manual searches of the literature, 19 studies were identified that used automated systems for smoking prevention or cessation, and measured outcomes related to smoking behavior. Studies varied widely in methodology, intervention delivery, participant characteristics, follow-up period, and measurement of cessation. Of eligible studies, nine (47%) reported statistically significant or improved outcomes at the longest follow-up, relative to a comparison group. Few patterns emerged in terms of subject, design or intervention characteristics that led to positive outcomes. The "first generation" format, where participants were mailed computer-generated feedback reports, was the modal intervention format and the one most consistently associated with improved outcomes. Future studies will need to identify whether certain patients are more likely to benefit from such interventions, and which pharmacological and behavioral adjuncts can best promote cessation.
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Affiliation(s)
- Scott T Walters
- University of Texas School of Public Health, 5323 Harry Hines Blvd, V8.112, Dallas, TX 75390-9128, United States.
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Berlin A, Sorani M, Sim I. A taxonomic description of computer-based clinical decision support systems. J Biomed Inform 2006; 39:656-67. [PMID: 16442854 DOI: 10.1016/j.jbi.2005.12.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Revised: 11/30/2005] [Accepted: 12/04/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Computer-based clinical decision support systems (CDSSs) vary greatly in design and function. Using a taxonomy that we had previously developed, we describe the characteristics of CDSSs reported in the literature. METHODS We searched PubMed and the Cochrane Library for randomized controlled trials (RCTs) published in English between 1998 and 2003 that evaluated CDSSs. We coded each CDSS using our taxonomy. RESULTS 58 studies met our inclusion criteria. The 74 reported CDSSs varied greatly in context of use, knowledge and data sources, nature of decision support offered, information delivery, and workflow impact. Two distinct subsets of CDSSs were seen: patient-directed systems that provided decision support for preventive care or health-related behaviors via mail or phone (38% of systems), and inpatient systems targeting clinicians with online decision support and direct online execution of the recommendations (18%). 84% of the CDSSs required extra staffing for handling CDSS-related input or output. CONCLUSION Reported CDSSs are heterogeneous along many dimensions. Caution should be taken in generalizing the results of CDSS RCTs to different clinical or workflow settings.
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Affiliation(s)
- Amy Berlin
- Department of Psychiatry, University of California, San Francisco, CA, USA
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Faulkner MA, Lenz TL, Stading JA. Cost-effectiveness of smoking cessation and the implications for COPD. Int J Chron Obstruct Pulmon Dis 2006; 1:279-87. [PMID: 18046865 PMCID: PMC2707159 DOI: 10.2147/copd.2006.1.3.279] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The cost burden of COPD is substantial for patients and families, payers, and society as a whole. Smoking has been known for decades to be the leading cause of the disease. Numerous studies have been completed to address the cost-effectiveness of programs created to aid smokers in their efforts to quit. Because several assumptions must be made in order to conduct such a study, and because differences in study design are numerous, comparison of data is difficult. However, studies have consistently shown that regardless of the perspective from which the study was completed, or the methods used to help smokers abstain, the interventions are cost-effective. Although no study has been conducted specifically to assess the cost-effectiveness of smoking cessation interventions as they relate directly to patients with COPD, based on current data it can be concluded that smoking cessation programs are cost-effective for this population.
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Affiliation(s)
- Michele A Faulkner
- Creighton University School of Pharmacy and Health Professions, 2500 California Plaza, Omaha, NE 68178, USA.
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Abstract
BACKGROUND Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully. OBJECTIVES The aims of this review were to determine the effectiveness of different forms of self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials. SEARCH STRATEGY We searched the Cochrane Tobacco Addiction Group trials register using the terms 'self-help', 'manual*' or 'booklet*'. Date of the most recent search April 2005. SELECTION CRITERIA We included randomized trials of smoking cessation with follow up of at least six months, where at least one arm tested a self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist. DATA COLLECTION AND ANALYSIS We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model. MAIN RESULTS We identified sixty trials. Thirty-three compared self-help materials to no intervention or tested materials used in addition to advice. In 11 trials in which self help was compared to no intervention there was a pooled effect that just reached statistical significance (N = 13,733; odds ratio [OR] 1.24, 95% confidence interval [CI] 1.07 to 1.45). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Four further trials in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials. We failed to find evidence of benefit from adding self-help materials to face-to-face advice, or to nicotine replacement therapy. There were seventeen trials using materials tailored for the characteristics of individual smokers, where meta-analysis supported a small benefit of tailored materials (N = 20,414; OR 1.42, 95% CI 1.26 to 1.61). The evidence is strongest for tailored materials compared to no intervention, but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data. A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes. AUTHORS' CONCLUSIONS Standard self-help materials may increase quit rates compared to no intervention, but the effect is likely to be small. We failed to find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are effective, and are more effective than untailored materials, although the absolute size of effect is still small.
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Affiliation(s)
- T Lancaster
- Department of Primary Health Care, Oxford University, Old Road Campus, Headington, Oxford, UK, OX3 7LF.
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Webb MS, Simmons VN, Brandon TH. Tailored interventions for motivating smoking cessation: using placebo tailoring to examine the influence of expectancies and personalization. Health Psychol 2005; 24:179-88. [PMID: 15755232 DOI: 10.1037/0278-6133.24.2.179] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The present study examined mechanisms underlying the effectiveness of tailored interventions for motivating smoking cessation. The study used a placebo-tailoring design to test whether the efficacy of tailoring was due, in part, to personalized features in addition to the theoretically based content. Two hundred forty adult smokers were randomized to 1 of 3 conditions: standard booklet, minimally personalized booklet, or extensively personalized booklet. The interventions varied in their degree of ostensible tailoring, yet the actual smoking-related content of the booklets was identical. A dose-response relationship was hypothesized, with the greatest apparent tailoring producing the most positive outcomes. This pattern was found for evaluation of the booklets, with trends for readiness to change and self-efficacy increases. Moreover, as hypothesized, the effect of the interventions on readiness was moderated by participants' expectancies about tailoring.
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Affiliation(s)
- Monica S Webb
- Department of Psychology, University of South Florida, and Tobacco Research and Intervention Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 36617, USA
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Crilly M, Esmail A. Randomised controlled trial of a hypothyroid educational booklet to improve thyroxine adherence. Br J Gen Pract 2005; 55:362-8. [PMID: 15904555 PMCID: PMC1463159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Non-adherence with medication prescribed for chronic disease is ubiquitous and undermines the benefits of effective therapy. AIM To evaluate the influence of an educational booklet on thyroxine adherence and health in patients with primary hypothyroidism. DESIGN OF STUDY Unblinded randomised clinical trial of individual patients (by stratified permutated blocks) to receive an 'educational booklet' or 'usual care'. SETTING Three general practices in the north-west of England serving 497 adults with primary hypothyroidism (prevalence 1.5%). METHOD A total of 332 adults who had been prescribed thyroxine for hypothyroidism were allocated to either a group that was posted a hypothyroid booklet addressing lay health beliefs or to a group that received usual care. Outcomes were mean within-subject change over 3 months in thyroid stimulating hormone (TSH), the SF-36 domains of vitality and general health, and a hypothyroid symptoms index. All results were concealed until the end of the trial. RESULTS A total of 332 randomised patients were analysed by 'intention to treat' (TSH available for 330 patients). Groups were comparable at baseline, although 'undetectable TSH' was higher in the intervention than the control group (20% versus 13%). Mean change in TSH was -0.11 mIU/L (intervention) and -0.12 mIU/L (control). An absolute difference of 0.01 mIU/L (95% confidence interval [CI] -0.93 to 0.94 mIU/L). Analysis adjusted (ANCOVA) for baseline TSH produced a difference of -0.12 mIU/L (95% CI = -1.97 to 1.95). Changes in SF-36 and hypothyroid index were minimal. Trial participants were younger than non-participants and more likely to have a previous TSH in the normal range. CONCLUSION Brief intervention with an educational booklet has no influence on thyroxine adherence or health in patients with primary hypothyroidism. These findings do not support the routine distribution of health educational materials to improve medication adherence.
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Affiliation(s)
- Mike Crilly
- Department of Public Health, University of Aberdeen Medical School, Aberdeen.
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Stoop AP, van't Riet A, Berg M. Using information technology for patient education: realizing surplus value? PATIENT EDUCATION AND COUNSELING 2004; 54:187-195. [PMID: 15288913 DOI: 10.1016/s0738-3991(03)00211-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2003] [Revised: 06/30/2003] [Accepted: 07/06/2003] [Indexed: 05/24/2023]
Abstract
Computer-based patient information systems are introduced to replace traditional forms of patient education like brochures, leaflets, videotapes and, to a certain extent, face-to-face communication. In this paper, we claim that though computer-based patient information systems potentially have many advantages compared to traditional means, the surplus value of these systems is much harder to realize than often expected. By reporting on two computer-based patient information systems, both found to be unsuccessful, we will show that building computer-based patient information systems for patient education requires a thorough analysis of the advantages and limitations of IT compared to traditional forms of patient education. When this condition is fulfilled, however, these systems have the potential to improve health status and to be a valuable supplement to (rather than a substitute for) traditional means of patient education.
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Affiliation(s)
- Arjen P Stoop
- Department of Health Policy and Management, Erasmus Medical Center Rotterdam, L-building, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
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van Sluijs EMF, van Poppel MNM, van Mechelen W. Stage-based lifestyle interventions in primary care: are they effective? Am J Prev Med 2004; 26:330-43. [PMID: 15110061 DOI: 10.1016/j.amepre.2003.12.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To systematically review the literature concerning the effect of stages-of-change-based interventions in primary care on smoking, physical activity, and dietary behavior. METHODS An extensive search (until July 2002) was performed using the following inclusion criteria: (1) (randomized) controlled trial (RCT/CT), (2) intervention initiated in primary care, (3) and intervention aimed at changing smoking, physical activity, or dietary behavior, and stages-of-change-based outcomes, and (4) behavioral outcomes. Methodologic quality was assessed, and conclusions on the effectiveness at short-, medium-, and long-term follow-up were based on a rating system of five levels of evidence. Odds ratios were calculated when methodologically appropriate. RESULTS A total of 29 trials were selected for inclusion. Thirteen studies included a physical activity intervention, 14 aimed at smoking cessation, and five included a dietary intervention. Overall methodologic quality was good. No evidence was found for an effect on stages of change and actual levels of physical activity. Based on the strength of the evidence, limited to no evidence was found for an effect on stages of change for smoking and smoking quit rates. Odds ratios for quitting smoking showed a positive trend. Strong evidence was found for an effect on fat intake at short- and long-term follow-up. Limited evidence was found for an effect on stages of change for fat intake at short-term follow-up. CONCLUSIONS The scientific evidence for the effect of stages-of-change-based lifestyle interventions in primary care is limited. Limiting aspects in the stages-of-change concept with respect to complex behaviors as physical activity and dietary behavior are discussed.
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Affiliation(s)
- Esther M F van Sluijs
- Department of Social Medicine, Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands
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Miller SM, Bowen DJ, Campbell MK, Diefenbach MA, Gritz ER, Jacobsen PB, Stefanek M, Fang CY, Lazovich D, Sherman KA, Wang C. Current Research Promises and Challenges in Behavioral Oncology. Cancer Epidemiol Biomarkers Prev 2004; 13:171-80. [PMID: 14973109 DOI: 10.1158/1055-9965.epi-463-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Behavioral Oncology Interest Group of the American Society of Preventive Oncology held a Roundtable session on March 10, 2002, at the American Society of Preventive Oncology annual meeting in Bethesda, Maryland, to discuss the current state-of-the-science in behavioral approaches to cancer prevention and control and to delineate priorities for additional research. Four key areas were considered: (a) behavioral approaches to cancer genetic risk assessment and testing; (b) biological mechanisms of psychosocial effects on cancer; (c) the role of risk perceptions in cancer screening adherence; and (d) the impact of tailored and targeted interventions on cancer prevention and control research. The evidence reviewed indicates that behavioral approaches have made significant contributions to cancer prevention and control research. At the same time, there is a need to more closely link future investigations to the underlying base of behavioral science principles and paradigms that guide them. To successfully bridge the gap between the availability of effective new cancer prevention and control technologies and the participants they are meant to serve will require the development of more integrative conceptual models, the incorporation of more rigorous methodological designs, and more precise identification of the individual and group characteristics of the groups under study.
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Musich S, Faruzzi SD, Lu C, McDonald T, Hirschland D, Edington DW. Pattern of medical charges after quitting smoking among those with and without arthritis, allergies, or back pain. Am J Health Promot 2003; 18:133-42. [PMID: 14621408 DOI: 10.4278/0890-1171-18.2.133] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine the time frame of changes in medical charges after smoking cessation among (1) those with arthritis, allergies, or back pain and (2) those with none of these chronic conditions. DESIGN Cross-sectional study using smoking status determined in 1996 and 4-year average medical charges measured from 1996 to 1999. SETTING Nationwide manufacturing corporation (General Motors Corporation). SUBJECTS A total of 20,332 employees and spouses who completed a health risk appraisal in 1996 were younger than 64 years, were enrolled in indemnity or preferred provider organization health insurance plans during 1996 to 1999, and self-reported no preexisting primary diseases. MEASURES Participants were categorized according to 1996 self-reported smoking status into six subgroups: current smokers, former smokers by years since cessation (0-4, 5-9, 10-14, and > or = 15 years), and never smokers. Average annual medical charges (1996-1999) among those with chronic conditions (arthritis, allergies, or back pain; N = 11,921) or without chronic conditions (N = 8411) were examined independently. Never smokers in each group were compared to respective smoker and former smoker subgroups. RESULTS Current smokers and former smokers without chronic conditions who quit fewer than 5 years earlier had higher medical charges compared with never smokers ($2613 and $3356 vs. $2203, respectively). Among those with chronic conditions, current smokers, former smokers who quit 0 to 4 years ago, and former smokers who quit 5 to 9 years ago had higher medical charges than never smokers ($4208, $4027, and $4050 vs. $3108, respectively). CONCLUSIONS It took approximately 5 years for former smokers without chronic conditions and nearly 10 years for former smokers with chronic conditions to reduce their medical charges to levels close to their respective never smokers. Health promotion practitioners and other decision makers should consider the impact of chronic conditions on the course of medical savings when implementing smoking cessation programs at the worksite.
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Affiliation(s)
- Shirley Musich
- Health Management Research Center, University of Michigan, 1027 E Huron St, Ann Arbor, MI 48104-1688, USA
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Reiter E, Robertson R, Osman LM. Lessons from a failure: Generating tailored smoking cessation letters. ARTIF INTELL 2003. [DOI: 10.1016/s0004-3702(02)00370-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Aveyard P, Griffin C, Lawrence T, Cheng KK. A controlled trial of an expert system and self-help manual intervention based on the stages of change versus standard self-help materials in smoking cessation. Addiction 2003; 98:345-54. [PMID: 12603234 DOI: 10.1046/j.1360-0443.2003.00302.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM To examine the population impact and effectiveness of the Pro-Change smoking cessation course based on the Transtheoretical Model (TTM) compared to standard self-help smoking cessation literature. DESIGN Randomized controlled trial. SETTING Sixty-five West Midlands general practices. PARTICIPANTS Randomly sampled patients recorded as smokers by their general practitioners received an invitation letter and 2471 current smokers agreed. INTERVENTIONS Responders were randomized to one of four interventions. The control group received standard self-help literature. In the Manual intervention group, participants received the Pro-Change system, a self-help workbook and three questionnaires at 3-monthly intervals, which generated individually tailored feedback. In the Phone intervention group, participants received the Manual intervention plus three telephone calls. In the Nurse intervention group, participants received the Manual intervention plus three visits to the practice nurse. MEASUREMENTS Biochemically confirmed point prevalence of being quit and 6-month sustained abstinence, 12 months after study commencement. FINDINGS A total of 9.1% of registered current smokers participated, of whom 83.0% were not ready to quit. Less than half of participants returned questionnaires to generate second and third individualized feedback. Telephone calls reached 75% of those scheduled, but few participants visited the nurse. There were small differences between the three Pro-Change arms. The odds ratio (95% confidence intervals) for all Pro-Change arms combined versus the control arm were 1.50 (0.85-2.67) and 1.53 (0.76-3.10), for point prevalence and 6-month abstinence, respectively. This constitutes 2.1% of the TTM group versus 1.4% of the control group achieving confirmed 6-month sustained abstinence. CONCLUSIONS There was no statistically significant benefit of the intervention apparent in this trial and the high relapse of quitters means that any population impact is small.
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Affiliation(s)
- Paul Aveyard
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK.
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Hopper JA, Gallagher RE. Tobacco cessation: new challenges, new opportunities. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2003; 18:128-133. [PMID: 14512260 DOI: 10.1207/s15430154jce1803_05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Throughout the 1990's tobacco use has continued to expand in the developing world, and patterns of use have begun to shift in developed countries. During this same period, our knowledge of effective tobacco cessation methods has dramatically increased. In this paper, we review global trends in tobacco use, and current strategies for tobacco cessation. Evolving work in genetics, pharmacology, counseling, cessation aides, training, systems approaches, and regulation all have the potential to deliver more effective interventions to more tobacco users. Reducing the worldwide tobacco burden will require complementary efforts to reduce initiation and promote cessation. Until effective tobacco cessation methods are widely disseminated and readily available, the tobacco death toll will continue to rise.
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Affiliation(s)
- John A Hopper
- Wayne State University Department of Medicine, Detroit, Michigan 48201, USA.
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McClune T, Burton AK, Waddell G. Whiplash associated disorders: a review of the literature to guide patient information and advice. Emerg Med J 2002; 19:499-506. [PMID: 12421771 PMCID: PMC1756324 DOI: 10.1136/emj.19.6.499] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To review the literature and provide an evidence based framework for patient centred information and advice on whiplash associated disorders. METHODS A systematic literature search was conducted, which included both clinical and non-clinical articles to encompass the wide range of patients' informational needs. From the studies and previous reviews retrieved, 163 were selected for detailed review. The review process considered the quantity, consistency, and relevance of all selected articles. These were categorised under a grading system to reflect the quality of the evidence, and then linked to derived evidence statements. RESULTS The main messages that emerged were: physical serious injury is rare; reassurance about good prognosis is important; over-medicalisation is detrimental; recovery is improved by early return to normal pre-accident activities, self exercise, and manual therapy; positive attitudes and beliefs are helpful in regaining activity levels; collars, rest, and negative attitudes and beliefs delay recovery and contribute to chronicity. These findings were synthesised into patient centred messages with the potential to reduce the risk of chronicity. CONCLUSIONS The scientific evidence on whiplash associated disorders is of variable quality, but sufficiently robust and consistent for the purpose of guiding patient information and advice. While the delivery of appropriate messages can be both oral and written, consistency is imperative, so an innovative patient educational booklet, The Whiplash Book, has been developed and published.
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Affiliation(s)
- T McClune
- Spinal Research Unit, University of Huddersfield, UK.
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Abstract
Smoking remains a widespread intractable behaviour and is a significant cause of morbidity and mortality worldwide. Effective approaches to smoking cessation include behavioural intervention and pharmacotherapy, in particular nicotine replacement therapy (NRT) and sustained-release bupropion (bupropion SR). Pharmacotherapy remains a popular choice of smoking cessation intervention for many smokers, and both NRT and bupropion SR, combined with behavioural interventions, achieve 1.5- to >2-fold increases in smoking cessation rates. Various national and international smoking cessation guidelines have been published recommending effective implementation of smoking cessation strategies. Recommendations include the systematic identification of smokers, assessment of their willingness to quit smoking, provision of advice promoting a cessation attempt, and administration of approved first-line therapies.
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Affiliation(s)
- Gay Sutherland
- Tobacco Research Unit, Institute of Psychiatry, National Addiction Centre, Kings College, 4 Windsor Walk, London SE5 8AF, UK.
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Abstract
BACKGROUND Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully. OBJECTIVES The aims of this review were to determine the effectiveness of different forms of self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to self-help, such as computer generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials. SEARCH STRATEGY We searched the Cochrane Tobacco Addiction Group trials register using the terms 'self-help', 'manual*' or 'booklet*'. Date of the most recent search March 2002. SELECTION CRITERIA We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested a self-help intervention. We defined self-help as structured programming for smokers trying to quit without intensive contact with a therapist. DATA COLLECTION AND ANALYSIS We extracted data in duplicate on the type of subjects, the nature of the self-help materials, the amount of face to face contact given to subjects and to controls, outcome measures, method of randomisation, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed effects model. MAIN RESULTS We identified fifty-one trials. Thirty two compared self-help materials to no intervention or tested materials used in addition to advice. In eleven trials in which self-help was compared to no intervention there was a pooled effect that just reached statistical significance (odds ratio 1.24, 95% confidence interval 1.07 to 1.45) This analysis excluded one trial with a strongly positive outcome that introduced significant heterogeneity. Four further trials in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials. We failed to find evidence of benefit from adding self-help materials to face to face advice, or to nicotine replacement therapy. There was evidence from fourteen trials using materials tailored for the characteristics of individual smokers that such personalised materials were more effective than standard manuals (ten trials, odds ratio 1.36, 95% confidence interval 1.13 to 1.64) or no materials (three trials, odds ratio 1.80, 95% confidence interval 1.46 to 2.23). A small numbers of trials failed to detect benefit from using additional materials or targetted materials. REVIEWER'S CONCLUSIONS Standard self-help materials may increase quit rates compared to no intervention, but the effect is likely to be small. We failed to find evidence that they have an additional benefit when used alongside other interventions such as advice from a health care professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective.
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Affiliation(s)
- T Lancaster
- ICRF General Practice Research Group, Division of Public Health and Primary Health Care, Institute of Health Sciences, Old Road, Headington, Oxford, UK, OX3 7LF.
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