Methodologic issues in evaluating stop smoking programs

Factors associated with smoking abstinence among smokers and recent-quitters with lung and head and neck cancer

INTRODUCTION

Smoking cessation among cancer patients is critical for improving outcomes. Understanding factors associated with smoking abstinence after the diagnosis of cancer can provide direction to develop and test interventions to enhance cessation rates. The purpose of this study was to identify determinants of smoking outcomes among cancer patients.

METHODS

Standardized questionnaires were used to collect data from 163 smokers or recent-quitters (quit≤6 months) at study entry of which 132 and 121 had data collected at 3 and 6 months. Biochemical verification was conducted with urinary cotinine and carbon monoxide. Descriptive statistics, Cronbach alpha coefficients, Pearson correlations, Fisher's exact test, and multivariable logistic regression were used for analyses.

RESULTS

Seven-day-point-prevalence-abstinence (PPA) rates were 90/132 (68%) at 3 months; 46/71 (65%) among lung and 44/61 (72%) among head and neck cancer patients, whereas 7-day-PPA rates were 74/121 (61%) at 6 months; 31/58 (53%) among lung and 43/63 (68%) among head and neck cancer patients. Continuous abstinence rates were 63/89 (71%) at 3 months; 32/45 (71%) among lung and 31/44 (70%) among head and neck cancer patients, whereas continuous abstinence rates were 46/89 (52%) at 6 months; 18/45 (40%) among lung and 28/44 (64%) among head and neck cancer patients. Lower cancer-related, psychological and nicotine withdrawal symptoms were associated with increased 7-D-PPA abstinence rates at 3 and 6 months in univariate models. In multivariable models, however, decreased craving was significantly related with 7-day-PPA at 3 months and decreased craving and increased self-efficacy were associated with 7-D-PPA at 6 months. Decreased craving was the only factor associated with continuous abstinence at 6 months.

CONCLUSIONS

Smoking outcomes among lung and head and neck cancer patients appear to have remained the same over the last two decades despite the availability of an increased number of pharmacotherapy options to treat tobacco dependence. Decreased craving and increased self-efficacy were the most consistent factors associated with improved smoking outcomes but symptom control may also play a role in optimal management. Use of combined, and/or higher doses of pharmacotherapy along with behavioral interventions that increase self-efficacy and manage symptoms may promote enhanced cessation rates.

ACTION live: using process evaluation to describe implementation of a worksite wellness program

OBJECTIVES

Process evaluation is a necessary component of randomized controlled field trials. This is a descriptive article that reviews process evaluation for the ACTION Wellness Program for Elementary School Personnel.

METHODS

: Methods included self-report by participants, documentation by program staff, and school administrator report. Variables evaluated were program dose, fidelity and reach, exposure to materials and activities, and school factors that could influence program implementation and outcomes.

RESULTS

Dose and exposure were high across intervention schools and intervention years. Reach was variable across schools and activities. Schools on the East Bank of the Mississippi River generally had slightly better reach than schools on the West Bank. Some nutrition activities had higher levels of participation than physical activities.

CONCLUSIONS

High program dose reflected good effort and cooperation by program staff and schools. A disconnect between exposure and reach showed that high exposure did not always translate to high participation.

A school-based environmental intervention to reduce smoking among high school students: the Acadiana Coalition of Teens against Tobacco (ACTT)

A school-based environmental program to reduce adolescent smoking was conducted in 20 schools (10 intervention; 10 control) in south central Louisiana. The 9th grade cohort (n = 4,763; mean age = 15.4 yrs; 51% female; 61% Caucasian; 30-day smoking prevalence at baseline = 25%) was followed over four years for 30-day smoking prevalence with the school as the unit of analysis. Although prevalence decreased in intervention schools and increased in control schools in Year 2 the significant difference between the two groups at baseline was not overcome by the intervention and increases in prevalence were observed in both groups in Years 3 and 4. The higher the percentage of white students in a school the higher the prevalence rates regardless of intervention/control status. Boys' and girls' smoking rates were similar. These outcome data, student feedback and process evaluation provide a basis for continuing to create more innovative adolescent tobacco control programs.

The use and impact of incentives in population-based smoking cessation programs: a review

PURPOSE

This review discusses current published literature on population-based smoking cessation interventions that involve incentives and examines whether such interventions are effective in reducing the prevalence of smoking.

SEARCH METHOD

Studies published between 1975 and Spring 1997 were identified through a computerized search of four electronic databases (MEDLINE, HEALTH, CINAHL, and PSYCINFO) and reference lists of key articles using the following key words: (smoking cessation OR quit smoking) AND (contest OR competition OR incentive OR lottery OR quit and win). This search yielded 79 articles. To be included, studies had to be published in English and had to have presented either quit rates or participation rates for an incentive-based program that used population-based recruitment. Of the 79 articles, 17 met these criteria.

FINDINGS

Population-based interventions generally attract 1 to 2% of the target population, but these participation rates can potentially be increased through the use of innovative recruitment techniques. No specific type of recruitment strategy was shown to be consistently more effective than others. There is no evidence that particular types of incentives are able to influence participation or quit rates, but the size of an incentive does appear to be important, with larger incentives viewed as more effectively motivating smokers to quit and stay smoke free than smaller ones. Estimates of the cost per quitter have ranged from less than $20 to over $400. There are some indications that the costs of such programs compare favorably with smoking cessation classes or clinic-based approaches.

CONCLUSION

Incentive-based smoking cessation programs that target an entire community have the advantage of reaching a large and diverse group of smokers. They may, however, attract only smokers who are already motivated to quit. Realistically, incentive-based programs aimed at the general population can expect 1% of all their smokers to quit smoking. Quit rates among participants may initially be high (i.e., mean quit rate of 34% at 1-month follow-up) but decrease over time (i.e., mean rate of 23% at 1 year). The results of this review suggest a continued need to establish standard and valid criteria for the evaluation of smoking cessation interventions. Methodological differences among existing studies make them difficult to compare and interpret.

Predictors of smoking cessation following physicians' counseling

BACKGROUND

The purpose of this study was, to identify predictors of quitting following general practitioners' (GP) anti-smoking counseling.

METHODS

We studied determinants (characterized following the Precede framework) of successful quitting (1 year sustained abstinence, biochemically confirmed at 6- and 12-month follow-up) among 861 smokers randomized to the intervention groups based on repeated counseling (RC), RC + spirometric testing, and RC + nicotine gum, in a smoking cessation trial carried out in Turin, Italy.

RESULTS

GPs' intervention worked best for male (OR = 2.30; 95% CI, 1.13-4.52) and married (OR = 3.63; 95% CI, 1.37-9.59) smokers, for smokers who had maintained abstinence for at least 1 month in the past (OR = 6.78; 95% CI, 1.56-29.52) or at their first quit attempt (OR = 10.91; 95% CI, 2.37-50.13), and for those who spontaneously reduced their coffee consumption (OR = 3.30; 95% CI, 1.59-6.82); heavy smokers (> = 20 cig/day OR = 0.48; 95% CI, 0.24-0.93) and those living with other smokers (> = 1 smokers in the household: OR = 0.44; 95% CI, 0.22-0.90) were less likely to give up. Previous antismoking advice by the GP represented a strong barrier to success for healthy smokers (OR = 0.19; 95% CI, 0.07-0.52), but not for those reporting symptoms of shortness of breath (OR = 0.63; 95% CI, 0.39-9.20). There were no interactions between predictors and treatment conditions.

CONCLUSIONS

Assessment of factors influencing quitting would allow GPs to tailor their message to address existing barriers and to help patients utilize their resources for change.

The impact of incentives and competitions on participation and quit rates in worksite smoking cessation programs

PURPOSE

The purpose of this review is to determine whether incentive-based programs conducted at worksites increase participation and long-term smoking cessation rates.

METHODS

Published studies of workplace smoking cessation programs involving incentives and competition were identified through all available years up to winter of 1992 in MEDLINE (1966-1992), Psychlit (1967-1992), Smoking and Health (1960-1992), and Combined Health Information (1973-1992) computer databases and article reference lists. Programs were considered incentive programs when they involved either cash or other prizes paid to the participant for quitting smoking. Incentive competition programs typically involve groups contesting for prizes by having the greatest smoking cessation rates. Thirty studies were found, out of which 15 quasi-experimental and experimental studies are reviewed. The 15 studies that did not have comparison groups were excluded from this report.

RESULTS

Only eight studies had a comparison group in which the effects of incentives and competition were separated from the effects of other interventions. Only one study separated the effects of competition from incentives. Five of these studies evaluated smoking rates after six months, and three after 12 months from the program start. Three of these studies showed that incentives increased participation rates, and five enhanced smoking reduction. No study showed, however, that incentives and/or competition enhanced smoking cessation past six months.

CONCLUSIONS

It appears that incentives/competition may be useful for increasing participation and smoking reduction. Further research needs to be conducted to determine whether incentives and/or competition enhance long-term quit rates, and what are the most effective types of incentive procedures.

Effect of cost on the self-administration and efficacy of nicotine gum: a preliminary study

METHODS. One hundred six smokers seen in a family practice received brief physician advice and a prescription for nicotine gum. Smokers were randomly assigned to pay $20, $6, or $0/box of nicotine gum and followed for 6 months. RESULTS. Decreased cost increased the incidence of obtaining gum, the amount of gum used, and the incidence of long-term use (P less than 0.05). Decreased cost also increased cessation attempts and 1-week cessation (P less than 0.05) and appeared to increase abstinence at 6-month follow-up (19% vs 6% vs 8%, P less than 0.10). Cost-benefit estimates suggest that an insurance plan, HMO, etc., would recoup any costs in subsidizing nicotine gum and perhaps incur a net financial gain.

Drug use, depression, and adolescents

This article reviews use and depression in adolescents and explores the thesis that depressed mood and deviant actions represent deviant modes of coping and are the result of failed efforts to handle different and sometimes overlapping constitutional and social risk factors. Theories of drug use and depression and various studies in support of the theoretical framework are examined. Implications are suggested for public health interventions and clinical management as derived from the theoretic background and empiric evidence. Also provided are guidelines for assessment and intervention that can be useful for primary care physicians and other professionals working with troubled teenagers.

Maintaining smoking abstinence after myocardial infarction

Maintaining smoking abstinence after a myocardial infarction (MI) greatly reduces risks of recurrent disease morbidity and of mortality. Although post-MI patients appear to have better long-term rates of smoking abstinence compared with healthy groups, studies employing biochemical verification of smoking status generally indicate that only about one third of previously smoking post-MI patients remain abstinent at follow-up. Factors which may accompany the occurrence of a MI and which may be associated with maintenance of smoking abstinence include environmental changes aiding cessation (e.g., decreased exposure to smoking cues), increased social support from family, and stronger belief in the harmful effects of continued smoking. The usefulness of these factors in developing new treatments for maintaining abstinence in post-MI patients is discussed, and commonalities between efforts to maintain smoking abstinence in post-MI patients and avoidance of substance abuse in other groups at risk for serious health consequences are briefly noted.

Smoking cessation studies: a methodological comparison

A wide variety in outcome criteria hinders comparison of results between smoking cessation studies. Three important methodological issues are discussed: analysis of data of participants who drop out of therapy, treatment of missing data, and repeated use of significance tests. These issues determine to a great extent the results of evaluation studies. In general, they are of interest to all researchers of addiction who study the effects of interventions. Several ways to decide on these issues and the consequences of these decisions are considered. Little consensus exists about the criterion for dropout. It is concluded that a dropout criterion is a burden rather than a help. A better criterion would be the number of sessions present. Few satisfying techniques exist to handle the problem of missing data. Evaluation studies need to set a priori standards to counter the increased risk of a Type I error, caused by the repeated use of significance tests. Reviewers need to be aware of the variety in data treatment before comparing results.