Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for tobacco cessation

Cigarette Smoke and Cancer Health Among Incarcerated Men in U.S. Northeastern Prison Facilities

Incarcerated men, an understudied population, have not been the focus of cancer prevention studies. The Cancer Risk in Incarcerated Men Study was developed to examine smoking behaviors and cancer health among 236 incarcerated men. The participants were between 19 and 86 years of age. Only 30.5% of the sample reported receiving a cancer screening test and less than 5% reported being diagnosed with cancer. In terms of the cancer screening test provided, 43.6% reported having had a prostate-specific antigen test, 19.2% a fecal occult blood test, and 11.4% a sigmoidoscopy or a colonoscopy. Age was the only significant predictor of having a cancer screening procedure (B = .10, p < .001). This study demonstrates the need to promote cancer prevention studies among incarcerated populations.

Perception of health professions students of their role model status in Toombak cessation: A cross-sectional study from Sudan

Introduction

Health professionals are to play an essential and effective role in tobacco control. Toombak is a popular form of smokeless tobacco, locally made and used among Sudanese. It is associated with oral and systemic health hazards, particularly oral cancer. This study was set out to assess health professions students’ perception of their status as future role models for their patients and the public regarding Toombak use cessation and to explore socio-cognitive covariates of perceived role model status.

Materials and methods

A cross-sectional study was conducted in 2013–2014 using a self-administered questionnaire among health professions students enrolled in Medicine, Pharmacy, Dentistry and Nursing colleges in Khartoum state, Sudan. A total of 1530 participants were recruited from colleges using a cluster stratified sampling procedure.

Results

The majority of the participants (88.2%) were 19–22 year old, females showed predominance (66.1%). Most of the participants (69.7%) scored good knowledge of Toombak-related therapies. The majority (97%) had a positive attitude towards banning Toombak use in public. Half of the participants (50.4%) confirmed availability of Toombak control policy in their college, while 66% reported receiving training in Toombak cessation. Only 9.2% of the participants reported that they have ever used Toombak; among them, 69.5% were current daily users. Less than half (47.8%) reported a positive perception of their status as a role model. Logistic regression model revealed that tobacco cessation training, availability of college policy and positive attitudes towards banning Toombak use in public were strong predictors of with a positive perception of role model status.

Conclusion

Imposing Toombak control policies within colleges combined with formal training in cessation methods, would reinforce the positive perception of health professions students as a role model, particularly the students themselves seem to be ready for such systematic training.

Direct-to-Member Household or Targeted Mailings: Incentivizing Medicaid Calls for Quitline Services

INTRODUCTION

Innovative methods are needed to promote tobacco cessation services. The Medi-Cal Incentives to Quit Smoking project (2012-2015) promoted modest financial and medication incentives to encourage Medi-Cal smokers to utilize the California Smokers' Helpline (Helpline). This article describes the implementation and impact of two different direct-to-member mailing approaches.

METHODS

Medi-Cal Incentives to Quit Smoking promotional materials were mailed directly to members using two approaches: (1) household mailings: households identified through centralized membership divisions and (2) individually targeted mailings: smokers identified by medical codes from Medi-Cal managed care plans. Mailings included messaging on incentives, such as gift cards or nicotine patches. Number of calls per month, calls per unit mailed, and associated printing costs per call were compared during and 1 month after mailings. Activated caller response was based on reporting a household mailing promotional code or based on requesting financial incentives for individually targeted mailings. Analyses were conducted in 2018.

RESULTS

Direct-to-member mailings, particularly with incentive messaging, demonstrated an increase in call volumes during and 1 month after mailing, and increased Medi-Cal calls to the Helpline per unit mailed. Mailings with only counseling messages had the lowest percentage of activated calls per unit mailed, whereas the incentive messaging mailings were consistently higher. Although household mailings demonstrated lower printing costs per call, individually targeted mailings had a higher percentage of activated calls per unit mailed.

CONCLUSIONS

Household and individually targeted mailings are feasible approaches to increase Medi-Cal calls to the Helpline, particularly with incentive messaging. Choosing an approach and messaging depends on available resources, timing, and purpose.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Building and Scaling-up California Quits: Supporting Health Systems Change for Tobacco Treatment

The California Tobacco Control Program is the longest standing, publicly funded tobacco control program in the U.S. California's adult smoking rate declined from 23.7% (1989) to 11% (2016) but California still has more than 3 million smokers dispersed over 58 counties, requiring a coordinated approach to further tobacco control. Early California Tobacco Control Program success is rooted in public health policy strategies and a statewide media campaign that shifted social norms. In 2009, concepts for a coordinated approach were introduced by the California Tobacco Control Program in the state's first tobacco quit plan. The state quit plan called for public health's tobacco control programs to engage healthcare systems and insurers to work more directly with the California Smoker's Helpline (Helpline). With California's Medicaid (Medi-Cal) program expansion and the implementation of electronic medical record systems, health care plans and providers received additional support for system changes. Simultaneous with these changes, coordinated tobacco control efforts began, including California's Medi-Cal Incentives to Quit Smoking project (2012-2015). In the Medi-Cal Incentives to Quit Smoking project, safety-net providers and Medi-Cal plans were outreached and engaged to promote incentives for Medi-Cal members to utilize Helpline services. In another effort, UC Quits (2013-2015), the five University of California health systems used electronic medical record tools to promote tobacco treatments and electronic referrals to the Helpline. Now, as tobacco prevention is increasingly prioritized for quality improvement, California Tobacco Control Program is funding CA Quits, a statewide tobacco-cessation learning collaborative and technical assistance resource to promote integration of tobacco treatment services and quality improvement activities into safety-net health systems. CA Quits, in coordination with the Helpline, will connect public health departments, Medi-Cal plans, and safety-net providers to accelerate health systems change for tobacco-cessation treatment throughout the state. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Tobacco Cessation Interventions in Tertiary Hospitals in Nigeria: An Audit of Patient Records

Background

Patient medical records are an objective tool for the systematic identification and treatment of tobacco users. The aim of this study was to assess brief intervention tobacco cessation activities documented by physicians in some select tertiary hospitals in Nigeria.

Methods

We conducted a cross-sectional descriptive study using information obtained from 1588 randomly selected patient records in six teaching hospitals participating in a study to capacitate physicians to deliver brief advice. Trained data collectors collected data using a uniform checklist prior to the training of the physicians in these hospitals.

Results

Of the audited health records, 33.1% of patients had documentation of physicians' inquiry of their tobacco use mostly during out-patient clinics (37%) and by a resident doctor/medical officer (42.9%). Among identified tobacco users, it was documented that 12.9% were offered some form of tobacco cessation advice; readiness to quit was recorded in 2.6%; assistance with quitting was documented for 1.5% of tobacco users, while only 0.8% showed documentation of patient follow-up. Males and patients admitted to the hospital were 1.86 times and 2.14 times respectively more likely to have records of physicians' inquiry of their tobacco use. Patients who had tobacco-related morbidities and the unemployed were also more likely to have records of inquiry of their tobacco use.

Conclusions

There was poor documentation of tobacco use by physicians in these hospitals and many opportunities for brief intervention activities were missed. Efforts to educate the physicians on the importance of documenting tobacco use in clinical notes are recommended.

Implications

This study provides empirical evidence showing that there is poor documentation of tobacco use inquiry and brief intervention among physicians in tertiary hospitals in Nigeria. Records showing implementation of the 5A's were abysmally low and opportunities for brief intervention may have been missed. In line with the World Health Organization recommendations of Article 14 of the Framework Convention on Tobacco Control, efforts to promote brief intervention among physicians in tertiary hospitals in Nigeria should include an emphasis on appropriate documentation of tobacco control interventions in patient clinical notes.

The relationship between type of telephone service and smoking cessation among rural smokers enrolled in quitline tobacco dependence treatment

Quitlines are successful tools for smoking cessation, but no known study has examined whether type of phone service (cell phone only (CPO) vs. landline (LL)) impacts quitline utilization, quit attempts, and sustained cessation. This report details an observational study examining the association between phone service and quitline utilization and cessation among Ohio Appalachian adults willing to quit smoking and enrolled in a cessation trial from 2010 to 2014. A secondary analysis was conducted with data obtained from smokers enrolled in the Ohio Tobacco Quitline arm of a group randomized trial (n = 345). The intermediate outcome variables included number of calls, cumulative total call length, average call length, verified shipments of NRT, and 24-hour quit attempt. The primary outcome measure was biologically confirmed 7-day point prevalence abstinence from tobacco at 3, 6, and 12 months post treatment. Participants with LL service, on average, made almost one more call to the quitline and spoke 17.2 min longer over the course of treatment than those with CPO service. Those with LL service were more likely to receive a second 4-week supply of NRT. Phone service status was not associated with average quitline call length, receiving at least one NRT shipment, having made one quit attempt at the end of treatment, or biochemically confirmed abstinence at 3, 6, or 12-month follow-up. Participants with LL services completed more counseling calls, accrued a longer cumulative length, and received more NRT when compared with CPO service participants. However, type of phone service did not deter abstinence outcomes.

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More calls for those with landline (LL) compared to cell only (CPO) phone access

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Cumulative treatment call time higher for those with LL compared to CPO access

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Receipt of 2nd 4-wk NRT supply more likely for those with LL compared to CPO access

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Average quitline call length was not related to LL vs. CPO phone service access.

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Abstinence 3, 6, and 12 months post-baseline were similar by LL vs. CPO phone access.

The Influence of Health Messaging Source and Frequency on Maternal Smoking and Child Exposure among Low-Income Mothers

Addressing maternal smoking and child tobacco smoke exposure (TSE) remains a public health priority, particularly in low-income, underserved populations which are known to experience the highest TSE rates and tobacco-related morbidity/mortality. Little is known about the types of TSE messaging received in high-risk populations, and which communication channels are influential in promoting smokers' efforts to protect children from TSE. The purpose of this study was to examine associations between reported sources and frequency of TSE-reduction health messages maternal smokers received and the effects of the messaging on smoking-and TSE-reduction related behaviors. Maternal smokers from low-income communities in Philadelphia, Pennsylvania who were enrolled at baseline in the Family Rules for Establishing Smokefree Homes (FRESH) trial (N=359) were included in this study. Each participant completed a 60-minute in-home baseline interview, which included questions about their smoking history, current smoking patterns, children's TSE, and the TSE-related health messaging they had received prior to enrollment. Multivariable analyses were conducted to determine the effect of source messaging on mothers' knowledge, behavior, and intention regarding their baby's TSE. Results suggest that different sources of messaging may differentially impact smoking behavior and intention to change. For example, messaging from healthcare and dental providers may influence efforts to protect children from TSE whereas friends and family may influence intention to quit. Future studies could examine the value of multilevel health communication strategies, utilizing advice from healthcare providers that is augmented by family and peers to help promote smoking behavior change in this high-risk group of underserved postpartum smokers.

Ethnic Disparities in the Use of Nicotine Replacement Therapy for Smoking Cessation in an Equal Access Health Care System

Purpose.

To examine ethnic variations in the use of nicotine replacement therapy (NRT) in an equal access health care system.

Design.

Cross-sectional survey.

Setting.

Eighteen Veterans Affairs medical and ambulatory care centers.

Subjects.

A cohort of male current smokers (n = 1606).

Measures.

Use of NRT (nicotine patch or nicotine gum), ethnicity, sociodemographics, health status, smoking-related history, and facility prescribing policy.

Results.

Overall, only 34% of African-American and 26% of Hispanic smokers have ever used NRT as a cessation aid compared with 50% of white smokers. In the past year, African-American smokers were most likely to have attempted quitting. During a serious past-year quit attempt, however, African-American and Hispanic smokers reported lower rates of NRT use than white smokers (20% vs. 22% vs. 34%, respectively, p = .001). In multivariate analyses, ethnicity was independently associated with NRT use during a past-year quit attempt. Compared with white smokers, African-American (adjusted odds ratio, .53; 95% confidence interval, .34–.83) and Hispanic (adjusted odds ratio, .55; 95% confidence interval, .28–1.08) smokers were less likely to use NRT.

Conclusions.

Assessment of variations in use of NRT demonstrates that African-American and Hispanic smokers are less likely to use NRT during quit attempts. Future research is needed on the relative contributions of patient, physician, and system features to gaps in guideline implementation to provide treatment for ethnic minority smokers.

Comparative effectiveness of adding weight control simultaneously or sequentially to smoking cessation quitlines: study protocol of a randomized controlled trial

Background

Prevalence of multiple health risk behaviors is growing, and obesity and smoking are costly. Weight gain associated with quitting smoking is common and can interfere with quit success. Efficacy of adding weight management to tobacco cessation treatment has been tested with women in group sessions over an extended period of time, but has never been tested in real-world settings with men and women seeking help to quit. This paper describes the Best Quit study which tests the effectiveness of delivering tobacco and weight control interventions via existing quitline infrastructures.

Methods

Eligible and consenting smokers (n = 2550) who call a telephone quitline will be randomized to one of three groups; the standard quitline or standard quitline plus a weight management program added either simultaneously or sequentially to the tobacco program. The study aims to test: 1) the effectiveness of the combined intervention on smoking cessation and weight, 2) the cost-effectiveness of the combined intervention on cessation and weight and 3) theoretically pre-specified mediators of treatment effects on cessation: reduced weight concerns, increased outcome expectancies about quitting and improved self-efficacy about quitting without weight gain.

Baseline, 6 month and 12 month data will be analyzed using multivariate statistical analyses and groups will be compared on treatment adherence, quit rates and change in weight among abstinent participants. To determine if the association between group assignment and primary outcomes (30-day abstinence and change in weight at 6 months) is moderated by pre-determined baseline and process measures, interaction terms will be included in the regression models and their significance assessed.

Discussion

This study will generate information to inform whether adding weight management to a tobacco cessation intervention delivered by phone, mail and web for smokers seeking help to quit will help or harm quit rates and whether a simultaneous or sequential approach is better at increasing abstinence and reducing weight gain post quit. If proven effective, the combined intervention could be disseminated across the U.S. through quitlines and could encourage additional smokers who have not sought cessation treatment for fear of gaining weight to make quit attempts.

Trial registration

Clinicaltrials.gov NCT01867983. Registered: May 30, 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3231-6) contains supplementary material, which is available to authorized users.

Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial

BACKGROUND

Early in medical education, physicians must develop competencies needed for tobacco dependence treatment.

OBJECTIVE

To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students' counseling skills.

DESIGN

A group-randomized controlled trial (2010-2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE).

SETTING/PARTICIPANTS

Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N = 1345) completed objective structured clinical examinations (OSCEs), and 50 % (N = 660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N = 1096) from the class of 2014 completed an OSCE and 69.7 % (N = 1047) completed pre and post surveys.

INTERVENTIONS

The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students.

MEASUREMENTS

The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling.

RESULTS

Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean 8.0 [SE 0.6], p = 0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p < 0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p < 0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps ≤0.05).

LIMITATIONS

Inclusion of only ten schools limits generalizability.

CONCLUSIONS

Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools. NIH Trial Registry Number: NCT01905618.

Implementing tobacco use treatment guidelines in community health centers in Vietnam

Background

Vietnam has a smoking prevalence that is the second highest among Southeast Asian countries (SEACs). According to the World Health Organization (WHO), most reductions in mortality from tobacco use in the near future will be achieved through helping current users quit. Yet, largely due to a lack of research on strategies for implementing WHO-endorsed treatment guidelines in primary care settings, services to treat tobacco dependence are not readily available to smokers in low middle-income countries (LMICs) like Vietnam. The objective of this study is to conduct a cluster randomized controlled trial that compares the effectiveness of two system-level strategies for implementing evidence-based guidelines for the treatment of tobacco use in 26 public community health centers (CHCs) in Vietnam.

Methods/Design

The current study will use a cluster-randomized design and multiple data sources (patient exit interviews, provider and village health worker (VHW) surveys, and semi-structured provider/VHW interviews) to study the process of adapting and implementing clinical practice guidelines in Vietnam and theory-driven mechanisms hypothesized to explain the comparative effectiveness of the two strategies for implementation. CHCs will be randomly assigned to either of the following: (1) training plus clinical reminder system (TC) or (2) TC + referral to a VHW (TCR) for three in person counseling sessions. The primary outcome is provider adherence to tobacco use treatment guidelines. The secondary outcome is 6-month biochemically verified smoking abstinence.

Discussion

The proposed implementation strategies draw on evidence-based approaches and a growing literature that supports the effectiveness of integrating community health workers as members of the health care team to improve access to preventive services. We hypothesize that the value of these implementation strategies is additive and that incorporating a referral resource that allows providers to delegate the task of offering counseling (TCR) will be superior to TC alone in improving delivery of cessation assistance to smokers. The findings of this research have potential to guide large-scale adoption of promising strategies for implementing and disseminating tobacco use treatment guidelines throughout the public health system in Vietnam and will serve as a model for similar action in other LMICs.

Trial registration

NCT01967654

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0328-8) contains supplementary material, which is available to authorized users.

Demographic, psychological and smoking characteristics of users of an on-line smoking cessation programme in the Spanish language

OBJECTIVE

To determine the characteristics of users of a smoking cessation programme run by the Open University of Spain (Universidad Nacional de Educación a Distancia [UNED]).

METHODS

We examined the demographic, psychological and smoking characteristics of 23,763 smokers who participated in the on-line smoking cessation program of the UNED. The programme was open to any smoker, free of charge, and was fully automated and with direct access.

RESULTS

A total of 93.5% of the users were Spaniards, with an equal percentage of participation among men and women. The mean age was 39 years. Somewhat less than half were married and had a university education. The participants smoked a mean of 19.3 cigarettes per day, showing a mid-range level of nicotine dependence according to the Heaviness of Smoking Index. The results of the Anxiety and Depression subscales of the Symptom Checklist-90-Revised (SCL-90-R) and Perceived Stress Scale were not clinically significant. In a secondary analysis of the data, we found gender differences in all the variables measured.

CONCLUSIONS

The results of this study confirm the digital divide, with lower participation among people with a lower educational level. No association was observed between stress, anxiety or depression and cigarette consumption.

Tobacco counseling experience prior to starting medical school, tobacco treatment self-efficacy and knowledge among first-year medical students in the United States

OBJECTIVE

To explore students' tobacco dependence counseling experiences prior to medical school and their associations with tobacco counseling self-efficacy, and familiarity with and perceived effectiveness of tobacco dependence treatment among first-year medical students in the United States.

METHOD

In 2010, 1266 first-year medical students from 10 US medical schools completed a survey reporting their clinical experiences with specific tobacco counseling skills (e.g., 5As) prior to medical school. The survey also included questions on tobacco counseling self-efficacy, perceived physician impact on smokers, and familiarity and effectiveness of tobacco-related treatments.

RESULTS

Half (50.4%) reported some tobacco counseling experiences prior to medical school (i.e. at least one 5A). Students with prior counseling experiences were more likely to have higher tobacco counseling self-efficacy, and greater familiarity with medication treatment, nicotine replacement treatment, and behavioral counseling for smoking cessation, compared to those with no prior experiences. Perceived physician impact on patient smoking outcomes did not differ by prior tobacco counseling experiences.

CONCLUSIONS

Many first-year medical students may already be primed to learn tobacco dependence counseling skills. Enhancing early exposure to learning these skills in medical school is likely to be beneficial to the skillset of our future physicians.

Using ecological measures of smoking trigger exposure to predict smoking cessation milestones

This study used ecological momentary assessment data from adult daily smokers attempting to quit smoking to assess relations between exposure to contextual risk factors and cessation failure, latency to a first smoking lapse, or progression from lapse to relapse (smoking 7 days in a row). Participants were adult, daily smokers enrolled in a randomized controlled clinical trial of bupropion SR and individual counseling who were followed to 1 year postquit. Participants reported exposure to high-risk contexts and behaviors, including being where cigarettes were available or smoking was permitted, being around others smoking in prospective, real-time assessment for 2 weeks pre- and 4 weeks postquit. Results showed that greater exposure to contextual risk factors during the prequit did not predict cessation failure. However, Cox regression survival analyses revealed that spending a greater proportion of time where cigarettes were easily available following at least 1 day of abstinence predicted shorter latency to a first lapse, even after controlling for baseline risk factors such as gender, nicotine dependence, depressive symptoms, and living with a smoker. Greater cigarette availability following a lapse was not associated with progression from lapse to relapse with or without baseline risk factors in the model. This suggests that postquit environmental risk factors, such as cigarette availability, increase lapse risk, and stable risk factors, such as living with smokers and higher baseline carbon monoxide level or depressive symptoms, remain potent predictors of progression to relapse. Real-time contextual risk assessments postquit predict lapse above and beyond stable, baseline risk factors. (PsycINFO Database Record

Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students

OBJECTIVE

Physicians play a critical role in addressing tobacco dependence, yet report limited training. Tobacco dependence treatment curricula for medical students could improve performance in this area. This study identified student and medical school tobacco treatment curricula characteristics associated with intentions and use of the 5As for tobacco treatment among 3rd year U.S. medical students.

METHODS

Third year medical students (N=1065, 49.3% male) from 10 U.S. medical schools completed a survey in 2009-2010 assessing student characteristics, including demographics, tobacco treatment knowledge, and self-efficacy. Tobacco curricula characteristics assessed included amount and type of classroom instruction, frequency of tobacco treatment observation, instruction, and perception of preceptors as role models.

RESULTS

Greater tobacco treatment knowledge, self-efficacy, and curriculum-specific variables were associated with 5A intentions, while younger age, tobacco treatment self-efficacy, intentions, and each curriculum-specific variable were associated with greater 5A behaviors. When controlling for important student variables, greater frequency of receiving 5A instruction (OR=1.07; 95%CI 1.01-1.12) and perception of preceptors as excellent role models in tobacco treatment (OR=1.35; 95%CI 1.04-1.75) were significant curriculum predictors of 5A intentions. Greater 5A instruction (B=.06 (.03); p<.05) and observation of tobacco treatment (B=.35 (.02); p<.001) were significant curriculum predictors of greater 5A behaviors.

CONCLUSIONS

Greater exposure to tobacco treatment teaching during medical school is associated with both greater intentions to use and practice tobacco 5As. Clerkship preceptors, or those physicians who provide training to medical students, may be particularly influential when they personally model and instruct students in tobacco dependence treatment.

Educating Physical Therapist Students in Tobacco Cessation Counseling: Feasibility and Preliminary Outcomes

BACKGROUND

Smoking is the leading preventable cause of chronic disease and premature morbidity. People with physical disabilities experience elevated smoking prevalence when compared with their non-disabled peers. The physical therapy profession is dedicated to meeting needs of people with physical disabilities, yet most physical therapists (PT) do not typically provide tobacco cessation interventions. Similar deficits exist among other health professions, creating a demand for improved services to address smoking-related health burdens. Within other health professions, insufficient tobacco cessation counseling (TCC) education has been linked to a lack of interventions and may account for similar deficits in physical therapy practice.

STUDY PURPOSE

Goals were to assess feasibility, implementation, and results of a tailored TCC educational program for entry-level physical therapist (PT) students.

SUBJECTS

Two cohorts of entry-level physical therapist (PT) students (n = 12 and n = 17).

METHODS

Educational objectives were established based on prior review of the literature, a survey of national PT education programs, and clinical guidelines for TCC established by the United States Public Health Service (USPHS). Based on these objectives, the team designed a 3-hour workshop involving didactic content and problem-based skills practice. A pre- and post-test survey was used to measure 6 dimensions: knowledge, perceived barriers, perceived facilitators, self-efficacy, outcome expectations, and self-rated skill in TCC. Within each cohort, changes in score were compared using a paired t test. The ability to apply clinical guidelines for TCC was assessed using case scenarios and structured observation. These outcomes were selected based on the Theory of Reasoned Action, which states that future behavior is determined by intention to act. Intention to act is a product of knowledge, a positive balance between perceived barriers and facilitators, strong self-efficacy, favorable outcome expectations, and necessary skills. Student satisfaction with training was assessed through anonymous written feedback. Feasibility was based on cost analysis, including material resources, as well as faculty time and effort.

RESULTS

Following participation, both cohorts improved in knowledge, perceived facilitators, outcome expectations, and self-rated skill. Cohort 2 also showed an increase in self-efficacy (P < .01). Structured observation revealed competencies in application of clinical guidelines for case-based scenarios. Mean student satisfaction ratings for the educational experience were 5/5, and cost-estimate for delivery of the 3-hour educational intervention was approximately $32 per student.

CONCLUSIONS

This research study demonstrated feasibility and impact of an evidence-based curricular model designed to increase likelihood of TCC by future PTs by enhancing factors known to promote TCC behaviors. The program was well-received by students, and objectives were achieved through efficient use of faculty time and resources. Subsequent research should examine the effects of training on the provision of TCC within clinical settings, as well as the impact of TCC on smoking quit rates for patients who have received this intervention as a component of their physical therapy plan of care.

Life course transitions and racial and ethnic differences in smoking prevalence

This study aims to: (1) describe trajectories in the likelihood of smoking by racial or ethnic group across the transition to adulthood, (2) identify the influence of achieved socioeconomic status (SES) and the nature and timing of adult role transitions, and (3) determine the extent to which achieved SES and adult roles mediate the effects of race and ethnicity on smoking. The analyses use U.S. longitudinal data from the National Longitudinal Study of Adolescent Health (Add Health), which follows a representative national sample over four waves and from ages 11-17 in 1994/95 to 26-34 in 2007/08. Growth curve models compare trajectories of smoking likelihood for white, black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native individuals. While whites have higher rates of smoking than blacks and Hispanics during their teen years and 20s, blacks and Hispanics lose their advantage relative to whites as they approach and enter their 30s. American Indian/Alaska Natives show high rates of smoking at earlier ages and an increasing likelihood to smoke. Although life course transitions are influential for smoking prevalence in the overall U.S. population, SES and the nature and timing of adult role transitions account for little of the gap between whites and black, Hispanic, and American Indian/Alaska Native individuals. Racial and ethnic disparities in adult smoking are independent of SES and life transitions, pointing to explanations such as culturally specific normative environments or experiences of discrimination.

Tobacco cessation counseling training in US entry-level physical therapist education curricula: prevalence, content, and associated factors

BACKGROUND

The US Public Health Service (USPHS) recommends tobacco cessation counseling (TCC) training for all health care professionals. Within physical therapist practice, smoking can have adverse effects on treatment outcomes in all body systems. In addition, people with physical disabilities have a higher smoking prevalence than the general population, creating a strong need for tobacco cessation among physical therapy clientele. Therefore, TCC training is an important component of entry-level physical therapist education.

OBJECTIVE

The aims of this study were: (1) to determine need for TCC training within entry-level physical therapist education and (2) to identify potential barriers to implementation of USPHS guidelines in the academic environment.

DESIGN

A descriptive cross-sectional survey was conducted.

METHODS

Directors or academic coordinators of clinical education from entry-level physical therapist programs (N=204) were surveyed using an online instrument designed specifically for this study. Data regarding program and faculty characteristics, tobacco-related training content, and faculty opinions toward TCC in both physical therapist practice and education were analyzed descriptively.

RESULTS

The response rate was 71%. A majority (60%) of programs indicated inclusion of tobacco-related training, most commonly 1 to 2 hours in duration, and of these programs, 40% trained students in the implementation of USPHS clinical guidelines for TCC.

LIMITATIONS

Data analyses were constrained by limited or missing data in some areas. A single faculty member completed the survey for each program.

CONCLUSIONS

There is a need for TCC training in entry-level physical therapist education. Inclusion may be facilitated by addressing perceived barriers toward TCC as a component of physical therapist practice and promoting the relevance of TCC as it relates to intended outcomes of physical therapy interventions.

Usage and effectiveness of a fully automated, open-access, Spanish Web-based smoking cessation program: randomized controlled trial

BACKGROUND

The Internet is an optimal setting to provide massive access to tobacco treatments. To evaluate open-access Web-based smoking cessation programs in a real-world setting, adherence and retention data should be taken into account as much as abstinence rate.

OBJECTIVE

The objective was to analyze the usage and effectiveness of a fully automated, open-access, Web-based smoking cessation program by comparing interactive versus noninteractive versions.

METHODS

Participants were randomly assigned either to the interactive or noninteractive version of the program, both with identical content divided into 4 interdependent modules. At baseline, we collected demographic, psychological, and smoking characteristics of the smokers self-enrolled in the Web-based program of Universidad Nacional de Educación a Distancia (National Distance Education University; UNED) in Madrid, Spain. The following questionnaires were administered: the anxiety and depression subscales from the Symptom Checklist-90-Revised, the 4-item Perceived Stress Scale, and the Heaviness of Smoking Index. At 3 months, we analyzed dropout rates, module completion, user satisfaction, follow-up response rate, and self-assessed smoking abstinence.

RESULTS

A total of 23,213 smokers were registered, 50.06% (11,620/23,213) women and 49.94% (11,593/23,213) men, with a mean age of 39.5 years (SD 10.3). Of these, 46.10% (10,701/23,213) were married and 34.43% (7992/23,213) were single, 46.03% (10,686/23,213) had university education, and 78.73% (18,275/23,213) were employed. Participants smoked an average of 19.4 cigarettes per day (SD 10.3). Of the 11,861 smokers randomly assigned to the interactive version, 2720 (22.93%) completed the first module, 1052 (8.87%) the second, 624 (5.26%) the third, and 355 (2.99%) the fourth. Completion data was not available for the noninteractive version (no way to record it automatically). The 3-month follow-up questionnaire was completed by 1085 of 23,213 enrolled smokers (4.67%). Among them, 406 (37.42%) self-reported not smoking. No difference between groups was found. Assuming missing respondents continued to smoke, the abstinence rate was 1.74% (406/23,213), in which 22,678 were missing respondents. Among follow-up respondents, completing the 4 modules of the intervention increased the chances of smoking cessation (OR 1.95, 95% CI 1.27-2.97, P<.001), as did smoking 30 minutes (OR 1.58, 95% CI 1.04-2.39, P=.003) or 1 hour after waking (OR 1.93, 95% CI 1.27-2.93, P<.001) compared to smoking within the first 5 minutes after waking.

CONCLUSIONS

The findings suggest that the UNED Web-based smoking cessation program was very accessible, but a high level of attrition was confirmed. This could be related to the ease of enrollment, its free character, and the absence of direct contact with professionals. It is concluded that, in practice, the greater the accessibility to the program, the lower the adherence and retention. Professional support from health services and the payment of a reimbursable fee could prevent high rates of attrition.

Teaching tobacco dependence treatment and counseling skills during medical school: rationale and design of the Medical Students helping patients Quit tobacco (MSQuit) group randomized controlled trial

INTRODUCTION

Physician-delivered tobacco treatment using the 5As is clinically recommended, yet its use has been limited. Lack of adequate training and confidence to provide tobacco treatment is cited as leading reasons for limited 5A use. Tobacco dependence treatment training while in medical school is recommended, but is minimally provided. The MSQuit trial (Medical Students helping patients Quit tobacco) aims to determine if a multi-modal and theoretically-guided tobacco educational intervention will improve tobacco dependence treatment skills (i.e. 5As) among medical students.

METHODS/DESIGN

10 U.S. medical schools were pair-matched and randomized in a group-randomized controlled trial to evaluate whether a multi-modal educational (MME) intervention compared to traditional education (TE) will improve observed tobacco treatment skills. MME is primarily composed of TE approaches (i.e. didactics) plus a 1st year web-based course and preceptor-facilitated training during a 3rd year clerkship rotation. The primary outcome measure is an objective score on an Objective Structured Clinical Examination (OSCE) tobacco-counseling smoking case among 3rd year medical students from schools who implemented the MME or TE.

DISCUSSION

MSQuit is the first randomized to evaluate whether a tobacco treatment educational intervention implemented during medical school will improve medical students' tobacco treatment skills. We hypothesize that the MME intervention will better prepare students in tobacco dependence treatment as measured by the OSCE. If a comprehensive tobacco treatment educational learning approach is effective, while also feasible and acceptable to implement, then medical schools may substantially influence skill development and use of the 5As among future physicians.

Financial versus health motivation to quit smoking: a randomized field study

OBJECTIVE

Smoking is the most preventable cause of death, thus justifying efforts to effectively motivate quitting. We compared the effectiveness of financial versus health messages to motivate smoking cessation. Low-income individuals disproportionately smoke and, given their greater income constraints, we hypothesized that making financial costs of smoking more salient would encourage more smokers to try quitting. Further, we predicted that financial messages would be stronger in financial settings where pecuniary constraints are most salient.

METHODS

We conducted a field study in low-income areas of New Haven, Connecticut using brochures with separate health vs. financial messages to motivate smoking cessation. Displays were rotated among community settings-check-cashing, health clinics, and grocery stores. We randomized brochure displays with gain-framed cessation messages across locations.

RESULTS

Our predictions were confirmed. Financial messages attracted significantly more attention than health messages, especially in financial settings.

CONCLUSIONS

These findings suggest that greater emphasis on the financial gains to quitting and use of financial settings to provide cessation messages may be more effective in motivating quitting. Importantly, use of financial settings could open new, non-medical venues for encouraging cessation. Encouraging quitting could improve health, enhance spending power of low-income smokers, and reduce health disparities in both health and purchasing power.

Smoking-cessation e-referrals: a national dental practice-based research network randomized controlled trial

BACKGROUND

Tobacco use is still the leading preventable cause of death and morbidity in the U.S. Web-assisted tobacco interventions are an effective but underutilized tool in assisting smokers with quitting. The dental visit is an excellent opportunity to assist smokers in quitting by referring them to these tobacco-cessation online programs.

PURPOSE

The study purpose was to test two patient referral methods-paper referrals (information prescriptions) versus paper plus e-referrals-to a web-assisted smoking-cessation induction system.

DESIGN

RCT that used implementation research methods.

PARTICIPANTS/SETTING

A total of 100 community-based dental practices were enrolled and 1814 smokers were referred to the web-assisted tobacco induction system.

INTERVENTION

The study intervention was a proactive e-referral of smokers to a web-assisted tobacco induction system called Decide2Quit.org, and the control group used paper referrals (information prescriptions) to refer smokers to the Decide2Quit.org.

MAIN OUTCOME MEASUREMENTS

The outcome measurements were the referral numbers, Decide2Quit registration numbers, and the smokers' quit rate. Data were collected in 2010-2011 and analyses were completed in 2012.

RESULTS

Although total referrals from intervention practices was lower than control, subsequent proportions of registrations among smokers referred to Decide2Quit.org were nearly fourfold higher (adjusted mean percentages: 29.5% vs 7.6%, p<0.01) in intervention compared with control practices. Subsequent rates of cessation among referred smokers were threefold higher (adjusted mean percentages: 3.0% vs 0.8%, p=0.03) in intervention practices as compared with control.

CONCLUSIONS

Intervention practices using the e-referral system had higher smoker registration numbers and higher quit smoking rates than the control practices. This study finds that e-referrals are effective in getting smokers to the web-assisted smoking-cessation induction system and in assisting with quitting that more than compensates for any additional effort that e-referrals require on the part of the practitioner.

CLINICAL TRIAL REGISTRATION

DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation (HiQuit); NCT01108432.

Implementing point of care "e-referrals" in 137 clinics to increase access to a quit smoking internet system: the Quit-Primo and National Dental PBRN HI-QUIT Studies

Integrating electronic referral systems into clinical practices may increase use of web-accessible tobacco interventions. We report on our feasibility evaluation of using theory-driven implementation science techniques to translate an e-referral system (ReferASmoker.org) into the workflow of 137 community-based medical and dental practices, including system use, patient registration, implementation costs, and lessons learned. After 6 months, 2,376 smokers were e-referred (medical, 1,625; dental, 751). Eighty-six percent of the medical practices [75/87, mean referral = 18.7 (SD = 17.9), range 0-105] and dental practices [43/50, mean referral = 15.0 (SD = 10.5), range 0-38] had e-referred. Of those smokers e-referred, 25.3 registered [mean smoker registration rate-medical 4.9 (SD = 7.6, range 0-59), dental 3.6 (SD = 3.0, range 0-10)]. Estimated mean implementation costs are medical practices, US$429.00 (SD = 85.3); and dental practices, US$238.75 (SD = 13.6). High performing practices reported specific strategies to integrate ReferASmoker.org; low performers reported lack of smokers and patient disinterest in the study. Thus, a majority of practices e-referred and 25.3 % of referred smokers registered demonstrating e-referral feasibility. However, further examination of the identified implementation barriers is important as of the estimated 90,000 to 140,000 smokers seen in the 87 medical practices in 6 months, only 1,625 were e-referred.

Crowdsourced peer- versus expert-written smoking-cessation messages

BACKGROUND

Tailored, web-assisted interventions can reach many smokers. Content from other smokers (peers) through crowdsourcing could enhance relevance.

PURPOSE

To evaluate whether peers can generate tailored messages encouraging other smokers to use a web-assisted tobacco intervention (Decide2Quit.org).

METHODS

Phase 1: In 2009, smokers wrote messages in response to scenarios for peer advice. These smoker-to-smoker (S2S) messages were coded to identify themes. Phase 2: resulting S2S messages, and comparison expert messages, were then e-mailed to newly registered smokers. In 2012, subsequent Decide2Quit.org visits following S2S or expert-written e-mails were compared.

RESULTS

Phase 1: a total of 39 smokers produced 2886 messages (message themes: attitudes and expectations, improvements in quality of life, seeking help, and behavioral strategies). For not-ready-to-quit scenarios, S2S messages focused more on expectations around a quit attempt and how quitting would change an individual's quality of life. In contrast, for ready-to-quit scenarios, S2S messages focused on behavioral strategies for quitting. Phase 2: In multivariable analysis, S2S messages were more likely to generate a return visit (OR=2.03, 95% CI=1.74, 2.35), compared to expert messages. A significant effect modification of this association was found, by time-from-registration and message codes (both interaction terms p<0.01). In stratified analyses, S2S codes that were related more to "social" and "real-life" aspects of smoking were driving the main association of S2S and increased return visits.

CONCLUSIONS

S2S peer messages that increased longitudinal engagement in a web-assisted tobacco intervention were successfully collected and delivered. S2S messages expanded beyond the biomedical model to enhance relevance of messages.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT00797628 (web-delivered provider intervention for tobacco control [QUIT-PRIMO]) and NCT01108432 (DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation [HiQuit]).

Anti-smoking environment: a perspective from Murray's psychogenic needs theory

Smoking emerged as a social problem in many nations. Smoking is inflicting injuries to society including addiction, diseases, health damage, and loss of productivity. Individuals, institutions and governments are working to contain the menace of smoking. Many policies, programs and activities are being designed and implemented. To extend a helping hand to fight against smoking this study brought to light the amalgamation of Murray’s psychogenic needs theory with anti-smoking activities to create an effective anti-smoking environment. Conceptual methodology is adopted and five propositions were drafted. This study conclude that anti-smoking activities general education, campaigning, counseling, social welfare, and medical camps when moderated by Murray’s psychogenic needs power, affiliation and achievement can create an effective anti-smoking environment further leading to quitting or reduction in the smoking.

Share2Quit: Web-Based Peer-Driven Referrals for Smoking Cessation

Background

Smoking is the number one preventable cause of death in the United States. Effective Web-assisted tobacco interventions are often underutilized and require new and innovative engagement approaches. Web-based peer-driven chain referrals successfully used outside health care have the potential for increasing the reach of Internet interventions.

Objective

The objective of our study was to describe the protocol for the development and testing of proactive Web-based chain-referral tools for increasing the access to Decide2Quit.org, a Web-assisted tobacco intervention system.

Methods

We will build and refine proactive chain-referral tools, including email and Facebook referrals. In addition, we will implement respondent-driven sampling (RDS), a controlled chain-referral sampling technique designed to remove inherent biases in chain referrals and obtain a representative sample. We will begin our chain referrals with an initial recruitment of former and current smokers as seeds (initial participants) who will be trained to refer current smokers from their social network using the developed tools. In turn, these newly referred smokers will also be provided the tools to refer other smokers from their social networks. We will model predictors of referral success using sample weights from the RDS to estimate the success of the system in the targeted population.

Results

This protocol describes the evaluation of proactive Web-based chain-referral tools, which can be used in tobacco interventions to increase the access to hard-to-reach populations, for promoting smoking cessation.

Conclusions

Share2Quit represents an innovative advancement by capitalizing on naturally occurring technology trends to recruit smokers to Web-assisted tobacco interventions.

Tobacco dependence treatment teaching by medical school clerkship preceptors: survey responses from more than 1,000 US medical students

OBJECTIVE

To determine factors associated with tobacco cessation counseling in medical school clerkships.

METHODS

Third-year medical students at 10 medical schools across the United States completed a 100-item survey, measuring the frequency with which they experienced their preceptors providing clinical teaching components: clear instruction, feedback, modeling behavior, setting clear objectives, and responding to questions about tobacco dependence counseling as well as frequency of use of tobacco prompts and office systems. Our primary dependent measure was student self-reported skill level for items of tobacco dependence treatment (e.g. "5As").

RESULTS

Surveys were completed by 1213 students. For both family medicine and internal medicine clerkships, modeling and providing clear instruction on ways to provide tobacco counseling were reported most commonly. In contrast, providing feedback and clear objectives for tobacco dependence treatment lagged behind. Overall, students who reported preceptors' provision of optimal clinical teaching components and office system prompts in both family medicine and internal medicine clerkships had higher self-reported skill (P<0.001) than students with no exposure or exposure during only one of the clerkships.

CONCLUSIONS

Future educational interventions intended to help students adopt effective tobacco dependence treatment techniques should be engineered to facilitate these critical precepting components.

Who participates in Web-assisted tobacco interventions? The QUIT-PRIMO and National Dental Practice-Based Research Network Hi-Quit studies

INTRODUCTION

Smoking is the most preventable cause of death. Although effective, Web-assisted tobacco interventions are underutilized and recruitment is challenging. Understanding who participates in Web-assisted tobacco interventions may help in improving recruitment.

OBJECTIVES

To understand characteristics of smokers participating in a Web-assisted tobacco intervention (Decide2Quit.org).

METHODS

In addition to the typical Google advertisements, we expanded Decide2Quit.org recruitment to include referrals from medical and dental providers. We assessed how the expanded recruitment of smokers changed the users' characteristics, including comparison with a population-based sample of smokers from the national Behavioral Risk Factors Surveillance Survey (BRFSS). Using a negative binomial regression, we compared demographic and smoking characteristics by recruitment source, in particular readiness to quit and association with subsequent Decide2Quit.org use.

RESULTS

The Decide2Quit.org cohort included 605 smokers; the 2010 BRFSS dataset included 69,992. Compared to BRFSS smokers, a higher proportion of Decide2Quit.org smokers were female (65.2% vs 45.7%, P=.001), over age 35 (80.8% vs 67.0%, P=.001), and had some college or were college graduates (65.7% vs 45.9%, P=.001). Demographic and smoking characteristics varied by recruitment; for example, a lower proportion of medical- (22.1%) and dental-referred (18.9%) smokers had set a quit date or had already quit than Google smokers (40.1%, P<.001). Medical- and dental-referred smokers were less likely to use Decide2Quit.org functions; in adjusted analysis, Google smokers (predicted count 17.04, 95% CI 14.97-19.11) had higher predicted counts of Web page visits than medical-referred (predicted count 12.73, 95% CI 11.42-14.04) and dental-referred (predicted count 11.97, 95% CI 10.13-13.82) smokers, and were more likely to contact tobacco treatment specialists.

CONCLUSIONS

Recruitment from clinical practices complimented Google recruitment attracting smokers less motivated to quit and less experienced with Web-assisted tobacco interventions.

Radon, smoking, and lung cancer: the need to refocus radon control policy

Exposure to radon is the second leading cause of lung cancer, and the risk is significantly higher for smokers than for nonsmokers. More than 85% of radon-induced lung cancer deaths are among smokers. The most powerful approach for reducing the public health burden of radon is shaped by 2 overarching principles: public communication efforts that promote residential radon testing and remediation will be the most cost effective if they are primarily directed at current and former smokers; and focusing on smoking prevention and cessation is the optimal strategy for reducing radon-induced lung cancer in terms of both public health gains and economic efficiency. Tobacco control policy is the most promising route to the public health goals of radon control policy.

Web-based peer-driven chain referrals for smoking cessation

BACKGROUND

We are testing web-based respondent-driven sampling (RDS) chain referrals to recruit smokers to the Decide2Quit.org (D2Q) web-assisted tobacco intervention.

METHODS

Using an online survey of smokers, we assessed the potential of recruiting 1200 smokers in 9 months using RDS chain referrals. RDS is a complex sample design, and many factors can influence its success. We conducted simulations to determine the design of optimal RDS chains.

RESULTS

Smokers (n=48) were mostly female (72%) and between ages 30-60 (82%). Estimation of smokers in their network: 1-5 (40%), 6-10 (24%), and 10-20 (22%), with mean number of intimate family (2.2, SD=2.1) and close friend smokers (3.7, SD=3.8). Most smokers (82%) were willing to refer to D2Q and thought their friends (mean=5.0, SD=4.4, range=0-20) would be open to referral. Simulations suggested that with a quota of 3 and 10 seeds, 99.9% of the sample would be achieved in 107 days if the acceptance probability was 0.5. Acceptance probability of 25% would necessitate an increased quota.

CONCLUSIONS

Our study suggests that it is possible to recruit smokers using RDS.

Current status of tobacco policy and control

Behaviors pertaining to tobacco use have changed significantly over the past century. Compared with 1964, smoking prevalence rates have halved from 40% to 20%, and as a result there has been a slow but steady decline in the rates of tobacco-induced diseases such as heart disease and cancer. Growing awareness of the health risks of smoking was aided by the US Surgeon Reports that were issued on a nearly annual basis starting from 1964. Concerns about the hazards of breathing in second-hand smoke further contributed to the declining social acceptance of smoking, which evolved into regulatory actions restricting smoking on buses, planes, retail outlets, restaurants, and bars. Today, 23 states and 493 localities have comprehensive laws restricting indoor smoking. This paper examines public policies that have made a significant impact on smoking and lung cancer rates and discusses potential future research directions to further reduce the diseases caused by smoking.

Sensation-seeking predicts initiation of daily smoking behavior among American Indian high school students

PURPOSE

American Indian (AI) youth have a high risk of smoking initiation. Sensation-seeking, defined as the tendency to seek novel and thrilling experiences, has been associated with smoking initiation in other groups but has never been examined in AI youth.

METHODS

Data were from the Voices of Indian Teens Project (VOICES), a longitudinal study of AI youth from seven high schools in four AI communities in the western United States. Participants completed annual surveys in school over a three-year period. Our sample comprised 764 students who were non-smokers at baseline. Smoking initiation was defined as endorsement of daily smoking after baseline. We used binary logistic regression to evaluate the association of baseline sensation-seeking with odds of daily smoking initiation, stratified by gender.

RESULTS

Participants were 353 males and 411 females aged 13 to 21years at baseline. After adjusting for covariates, baseline sensation-seeking correlated with smoking initiation differently in males and females. Sensation-seeking did not predict daily smoking in males. Among females, however, higher sensation-seeking scores at baseline predicted daily smoking in both the unadjusted (odds ratio=1.4; 95% CI=1.1-1.8; p=0.005) and covariate-adjusted (odds ratio=1.3; 95% CI=1.0-1.6; p=0.04) models.

CONCLUSION

Gender-specific prevention programs may be warranted in addressing different risk-factor profiles in this high-risk population.

The unintended consequences of disclosure: effect of manipulating sponsor identification on the perceived credibility and effectiveness of smoking cessation advertisements

One reason that tobacco-sponsored smoking cessation ads are less effective than those sponsored by public health agencies may be that the persuasive arguments in tobacco-sponsored ads are inherently weaker than arguments made in public health ads. An alternate explanation is that sponsorship disclosure on the face of the ad activates resistance, partly because of credibility judgments directed toward tobacco companies. The authors test hypotheses in a 3 (sponsor identification) × 2 (ad content) randomized factorial experiment (N = 270). Results indicate that judgments of sponsor credibility play a mediating role in perceptions of ad effectiveness, with identification of a tobacco company as the sponsor of cessation ads undermining perceived credibility compared with the same ads without the tobacco company identified. However, the reduction in credibility resulting from tobacco sponsorship can be partially overcome when the sponsor is placed on more direct ad content (public health ads). The effects of credibility on perceived effectiveness were stronger for more ambiguous ad content and driven by participants with lower levels of involvement (nonsmokers). Credibility judgments are not as important when the ad content is more direct about the health consequences of smoking. Implications of study results for theory and public policy are explored.

Interventions for tobacco use prevention in Indigenous youth

BACKGROUND

Tobacco use in Indigenous populations (people who have inhabited a country for thousands of years) is often double that in the non-Indigenous population. Addiction to nicotine usually begins during early adolescence and young people who reach the age of 18 as non-smokers are unlikely to become smokers thereafter. Indigenous youth in particular commence smoking at an early age, and a disproportionate burden of substance-related morbidity and mortality exists as a result.

OBJECTIVES

To evaluate the effectiveness of intervention programmes to prevent tobacco use initiation or progression to regular smoking amongst young Indigenous populations and to summarise these approaches for future prevention programmes and research.

SEARCH METHODS

The Cochrane Tobacco Addiction Group Specialised Register was searched in November 2011, with additional searches run in MEDLINE. Online clinical trial databases and publication references were also searched for potential studies.

SELECTION CRITERIA

We included randomized and non-randomized controlled trials aiming to prevent tobacco use initiation or progression from experimentation to regular tobacco use in Indigenous youth. Interventions could include school-based initiatives, mass media, multi-component community level interventions, family-based programmes or public policy.

DATA COLLECTION AND ANALYSIS

Data pertaining to methodology, participants, interventions and outcomes were extracted by one reviewer and checked by a second, whilst information on risk of bias was extracted independently by a combination of two reviewers. Studies were assessed by qualitative narrative synthesis, as insufficient data were available to conduct a meta-analysis. The review process was examined by an Indigenous (Aboriginal) Australian for applicability, acceptability and content.

MAIN RESULTS

Two studies met all of the eligibility criteria for inclusion within the review and a third was identified as ongoing. The two included studies employed multi-component community-based interventions tailored to the specific cultural aspects of the population and were based in Native American populations (1505 subjects in total). No difference was observed in weekly smoking at 42 months follow-up in the one study assessing this outcome (skills-community group versus control: risk ratio [RR] 0.95, 95% CI 0.78 to 1.14; skills-only group versus control: RR 0.86, 95% CI 0.71 to 1.05). For smokeless tobacco use, no difference was found between the skills-community arm and the control group at 42 weeks (RR 0.93, 95% CI 0.67 to 1.30), though a significant difference was observed between the skills-only arm and the control group (RR 0.57, 95% CI 0.39 to 0.85). Whilst the second study found positive changes for tobacco use in the intervention arm at post test (p < 0.05), this was not maintained at six month follow-up (change score -0.11 for intervention and 0.07 for control). Both studies were rated as high or unclear risk of bias in seven or more domains (out of a total of 10).

AUTHORS' CONCLUSIONS

Based on the available evidence, a conclusion cannot be drawn as to the efficacy of tobacco prevention initiatives tailored for Indigenous youth. This review highlights the paucity of data and the need for more research in this area. Smoking prevalence in Indigenous youth is twice that of the non-Indigenous population, with tobacco experimentation commencing at an early age. As such, a significant health disparity exists where Indigenous populations, a minority, are over-represented in the burden of smoking-related morbidity and mortality. Methodologically rigorous trials are needed to investigate interventions aimed at preventing the uptake of tobacco use amongst Indigenous youth and to assist in bridging the gap between tobacco-related health disparities in Indigenous and non-Indigenous populations.

Healthy Behavior Trajectories between Adolescence and Young Adulthood

Healthy behaviors including adequate exercise and sleep, eating breakfast, maintaining a healthy weight, and not smoking or binge drinking inhibit chronic disease. However, little is known about how these behaviors change across life course stages, or the social factors that shape healthy behaviors over time. I use multilevel growth models and waves I-III of the National Longitudinal Study of Adolescent Health (N=10,775) to evaluate relationships between adolescents' psychosocial resources, social support, and family of origin characteristics during adolescence and healthy behavior trajectories through young adulthood (ages 13-24). I find that healthy behaviors decline dramatically during the transition to young adulthood. Social support resources, such as school connectedness and support from parents, as well as living with non-smoking parents, are associated with higher levels of healthy behaviors across adolescence and adulthood. Social support from friends is associated with lower engagement in these behaviors, as is living in a single parent family or with a smoking parent during adolescence. Findings indicate that psychosocial, social support, and family of origin resources during adolescence exert a persistent, though generally not cumulative, influence on healthy behavior trajectories through young adulthood.

Nicotine receptor partial agonists for smoking cessation

BACKGROUND

Nicotine receptor partial agonists may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist).

OBJECTIVES

The primary objective of this review is to assess the efficacy and tolerability of nicotine receptor partial agonists, including cytisine, dianicline and varenicline for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('cytisine' or 'Tabex' or 'dianicline' or 'varenicline' or 'nicotine receptor partial agonist') in the title or abstract, or as keywords. The register is compiled from searches of MEDLINE, EMBASE, PsycINFO and Web of Science using MeSH terms and free text to identify controlled trials of interventions for smoking cessation and prevention. We contacted authors of trial reports for additional information where necessary. The latest update of the specialised register was in December 2011. We also searched online clinical trials registers.

SELECTION CRITERIA

We included randomized controlled trials which compared the treatment drug with placebo. We also included comparisons with bupropion and nicotine patches where available. We excluded trials which did not report a minimum follow-up period of six months from start of treatment.

DATA COLLECTION AND ANALYSIS

We extracted data on the type of participants, the dose and duration of treatment, the outcome measures, the randomization procedure, concealment of allocation, and completeness of follow-up.The main outcome measured was abstinence from smoking at longest follow-up. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where they were reported. Where appropriate we pooled risk ratios (RRs), using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Two recent cytisine trials (937 people) found that more participants taking cytisine stopped smoking compared with placebo at longest follow-up, with a pooled RR of 3.98 (95% confidence interval (CI) 2.01 to 7.87). One trial of dianicline (602 people) failed to find evidence that it was effective (RR 1.20, 95% CI 0.82 to 1.75). Fifteen trials compared varenicline with placebo for smoking cessation; three of these also included a bupropion treatment arm. We also found one open-label trial comparing varenicline plus counselling with counselling alone. We found one relapse prevention trial, comparing varenicline with placebo, and two open-label trials comparing varenicline with nicotine replacement therapy (NRT). We also include one trial in which all the participants were given varenicline, but received behavioural support either online or by phone calls, or by both methods. This trial is not included in the analyses, but contributes to the data on safety and tolerability. The included studies covered 12,223 participants, 8100 of whom used varenicline.The pooled RR for continuous or sustained abstinence at six months or longer for varenicline at standard dosage versus placebo was 2.27 (95% CI 2.02 to 2.55; 14 trials, 6166 people, excluding one trial evaluating long term safety). Varenicline at lower or variable doses was also shown to be effective, with an RR of 2.09 (95% CI 1.56 to 2.78; 4 trials, 1272 people). The pooled RR for varenicline versus bupropion at one year was 1.52 (95% CI 1.22 to 1.88; 3 trials, 1622 people). The RR for varenicline versus NRT for point prevalence abstinence at 24 weeks was 1.13 (95% CI 0.94 to 1.35; 2 trials, 778 people). The two trials which tested the use of varenicline beyond the 12-week standard regimen found the drug to be well-tolerated during long-term use. The main adverse effect of varenicline was nausea, which was mostly at mild to moderate levels and usually subsided over time. A meta-analysis of reported serious adverse events occurring during or after active treatment and not necessarily considered attributable to treatment suggests there may be a one-third increase in the chance of severe adverse effects among people using varenicline (RR 1.36; 95% CI 1.04 to 1.79; 17 trials, 7725 people), but this finding needs to be tested further. Post-marketing safety data have raised questions about a possible association between varenicline and depressed mood, agitation, and suicidal behaviour or ideation. The labelling of varenicline was amended in 2008, and the manufacturers produced a Medication Guide. Thus far, surveillance reports and secondary analyses of trial data are inconclusive, but the possibility of a link between varenicline and serious psychiatric or cardiovascular events cannot be ruled out.

AUTHORS' CONCLUSIONS

Cytisine increases the chances of quitting, although absolute quit rates were modest in two recent trials. Varenicline at standard dose increased the chances of successful long-term smoking cessation between two- and threefold compared with pharmacologically unassisted quit attempts. Lower dose regimens also conferred benefits for cessation, while reducing the incidence of adverse events. More participants quit successfully with varenicline than with bupropion. Two open-label trials of varenicline versus NRT suggested a modest benefit of varenicline but confidence intervals did not rule out equivalence. Limited evidence suggests that varenicline may have a role to play in relapse prevention. The main adverse effect of varenicline is nausea, but mostly at mild to moderate levels and tending to subside over time. Possible links with serious adverse events, including serious psychiatric or cardiovascular events, cannot be ruled out.Future trials of cytisine may test extended regimens and more intensive behavioural support. There is a need for further trials of the efficacy of varenicline treatment extended beyond 12 weeks.

Can Acceptance & Commitment Therapy be delivered with fidelity as a brief telephone-intervention?

This study examined therapist adherence and competence of the first telephone-based Acceptance & Commitment Therapy (ACT) intervention for smoking cessation. An independent rater assessed 100% (n=54 sessions) of the recorded phone sessions for adherence and competence on a 1 (never addressed) to 5 (addressed extensively) scale. A separate 20% random sample was rated by both the same independent rater and a second independent rater. The two coders were in perfect agreement (kappa of 1.0). Overall adherence (x=4.61, SD=0.63) and competence (x=4.81, SD=0.39) was high. Except self-as-context, benchmark ratings (i.e., 4 or more) were between 93% and 100%. Results suggest ACT therapy can be delivered competently over the telephone, opening many options for future research on the potential uses of telephone-based ACT for smoking and other behaviors.

Population-based tobacco treatment: study design of a randomized controlled trial

Background

Most smokers do not receive comprehensive, evidence-based treatment for tobacco use that includes intensive behavioral counseling along with pharmacotherapy. Further, the use of proven, tobacco treatments is lower among minorities than among Whites. The primary objectives of this study are to: (1) Assess the effect of a proactive care intervention (PRO) on population-level smoking abstinence rates (i.e., abstinence among all smokers including those who use and do not utilize treatment) and on utilization of tobacco treatment compared to reactive/usual care (UC) among a diverse population of smokers, (2) Compare the effect of PRO on population-level smoking abstinence rates and utilization of tobacco treatments between African American and White smokers, and (3) Determine the cost-effectiveness of the proactive care intervention.

Methods/Design

This prospective randomized controlled trial identifies a population-based sample of current smokers from the Department of Veterans Affairs (VA) electronic medical record health factor dataset. The proactive care intervention combines: (1) proactive outreach and (2) offer of choice of smoking cessation services (telephone or face-to-face). Proactive outreach includes mailed invitation materials followed by an outreach call that encourages smokers to seek treatment with choice of services. Proactive care participants who choose telephone care receive VA telephone counseling and access to pharmacotherapy. Proactive care participants who choose face-to-face care are referred to their VA facility's smoking cessation clinic. Usual care participants have access to standard smoking cessation services from their VA facility (e.g., pharmacotherapy, smoking cessation clinic) and from their state telephone quitline. Baseline data is collected from VA administrative databases and participant surveys. Outcomes from both groups are collected 12 months post-randomization from participant surveys and from VA administrative databases. The primary outcome is self-reported smoking abstinence, which is assessed at the population-level (i.e., among those who utilize and those who do not utilize tobacco treatment). Primary analyses will follow intention-to-treat methodology.

Discussion

This randomized trial is testing proactive outreach strategies offering choice of smoking cessation services, an innovation that if proven effective and cost-effective, will transform the way tobacco treatment is delivered. National dissemination of proactive treatment strategies could dramatically reduce tobacco-related morbidity, mortality, and health care costs.

Clinical trials registration

ClinicalTrials.gov: NCT00608426.

Systematic review of the cost-effectiveness of varenicline vs. bupropion for smoking cessation

The purpose of this systematic review was to review the cost-effectiveness of first-line non-nicotine therapies (varenicline and bupropion SR) for smoking cessation, identify differences in the models used and their conclusions of cost-effectiveness, and to determine which variables, if any, impact conclusions of cost-effectiveness. A systematic literature search was conducted in MEDLINE, PsychINFO, the National Health Service Economic Evaluation Database, the Health Technology Database and the Tufts Cost-effectiveness Analysis Registry from the earliest possible date through May 2011. To be included, studies had to compare cost-effectiveness of varenicline to bupropion using either a Markov model or discrete event simulation and be published as a full text manuscript in English or Spanish. Study selection and data extraction were done in duplicate with disagreement resolved through discussion. Data regarding the model characteristics, results and conclusions were extracted as were details to assess the quality of the study. Model characteristics and cost-effectiveness results were compared across studies and summarised qualitatively. Ten unique studies were included, all of which were Markov models. Eight studies used the Benefits of Smoking Cessation on Outcomes (BENESCO) model and all found varenicline to dominate bupropion. The two non-BENESCO models found varenicline to be cost-effective. Conclusions regarding the cost-effectives were changed upon sensitivity analysis with the following variables: time horizon, cost of bupropion, efficacy of either drug, age and the incidence of smoking related disease. Varenicline dominated bupropion in most cost-effectiveness models. However, applicability of models to clinical practice and variables which changed conclusion of cost-effectiveness should be considered in the interpretation of results.

Network formation, governance, and evolution in public health: the North American Quitline Consortium case

BACKGROUND

Collaborative networks of health organizations have received a great deal of attention in recent years as a way of enhancing the flow of information and coordination of services. However, relatively little is known about how such networks are formed and evolve, especially outside a local, community-based setting. This article is an in-depth discussion of the evolution of the North American Quitline Consortium (NAQC). The NAQC is a network of U.S. and Canadian organizations that provide telephone-based counseling and related services to people trying to quit smoking.

METHODOLOGY

The research draws on data from interviews, documents, and a survey of NAQC members to assess how the network emerged, became formalized, and effectively governed.

FINDINGS

The findings provide an understanding of how multiregional public health networks evolve, while building on and extending the broader literature on organizational networks in other sectors and settings. Specifically, we found that the network form that ultimately emerged was a product of the back-and-forth interplay between the internal needs and goals of those organizations that would ultimately become network members, in this case, state-, and provincial-level tobacco quitline organizations. We also found that network formation, and then governance through a network administrative organization, was driven by important events and shifts in the external environment, including the impact and influence of major national organizations.

PRACTICE IMPLICATIONS

The results of the study provide health care leaders and policy officials an understanding of how the activities of a large number of organizations having a common health goal, but spanning multiple states and countries, might be coordinated and integrated through the establishment of a formal network.

Relationship between smokers' modes of entry into quitlines and treatment outcomes

OBJECTIVES

To assess the relationship between the mode of entry into a quitline service and subsequent tobacco use treatment outcomes.

METHODS

A retrospective study using logistic regression analysis of 11,040 Arizona Smokers' Helpline (ASHLine) clients was conducted to determine whether self- or medical referrals were related to 7- and 30-day point prevalence tobacco treatment outcomes at 7 months postquit.

RESULTS

Smokers referred to the ASHLine by a health care provider were more likely to quit smoking than were those who self-referred.

CONCLUSIONS

Mode of entry into a quitline service for smoking cessation is related to treatment outcomes. Reasons for this outcome are uncertain and require additional research.

Fax referrals, academic detailing, and tobacco quitline use: a randomized trial

BACKGROUND

Fax referral programs quickly and economically can link smokers' visiting primary care clinics to state-based telephone quitlines. Yet, it is unclear how to optimize use of this strategy.

PURPOSE

To evaluate the potential of enhanced academic detailing in clinics (i.e., on-site training, technical assistance, and performance feedback) to boost utilization of a fax referral program called Fax to Quit.

DESIGN

Participants were randomized to one of two intervention conditions.

SETTING/PARTICIPANTS

Participants were drawn from 49 primary care clinics in southeastern Wisconsin. The sample size was based on a power analysis in which the control intervention condition was estimated to generate 0.5 referrals/clinic/month and the experimental condition 2.0 referrals/clinic/month.

INTERVENTIONS

One of two fax referral program interventions was administered: the control condition Fax to Quit-Only (F2Q-Only) or the experimental condition Fax to Quit plus Enhanced Academic Detailing (F2Q+EAD).

MAIN OUTCOME MEASURES

Clinic- and clinician-specific referral and quality referral rates (those resulting in quitline enrollment) were measured for 13 months post-intervention, starting in March 2009.

RESULTS

Mean number of post-intervention referrals/clinician to the Wisconsin Tobacco Quitline was 5.6 times greater for F2Q+EAD (8.5, SD=7.0) compared to F2Q-Only (1.6, SD=3.6, p<0.001). The F2Q+EAD (4.8, SD=4.1) condition produced a greater mean number of quality referrals/clinician than did the F2Q-Only (0.86, SD=1.8, p<0.001) condition. Data were analyzed in 2010.

CONCLUSIONS

Enhanced academic detailing, which included on-site training, technical assistance, and performance feedback, increased the number of referrals more than fivefold over a fax referral program implemented without such enhanced academic detailing.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov NCT00989755.

Health care provider tobacco cessation counseling among current African American tobacco users

Tobacco use is the leading cause of preventable mortality and morbidity in the United States. Patients advised to quit use of tobacco products by their health care providers are more likely to quit, yet it has been documented that patients are not receiving this advice. The aim of this study was to investigate whether or not current African American tobacco users were receiving provider-initiated advice to quit. A cross-sectional survey identified 245 self-reported African American tobacco users residing in Maryland. Study variables collected included sociodemographics, access to care, smoking status, and assessed if tobacco cessation counseling was ever provided. Among those surveyed, only 42% reported ever being counseled to quit tobacco use and, of those who had a recent clinical encounter (within the past year), only 20% reported being counseled. Multivariate logistic regression identified that having a regular source of health care, living in an urban setting, and being female increased chances of being advised to quit tobacco use. Overall, findings indicate that African Americans are not being screened or receiving cessation counseling as recommended by leading health agencies. Health care provider training to promote better integration of tobacco screening and tobacco cessation counseling during the patient encounter is needed.

Development of an interactive, Web-delivered system to increase provider-patient engagement in smoking cessation

BACKGROUND

Patient self-management interventions for smoking cessation are effective but underused. Health care providers do not routinely refer smokers to these interventions.

OBJECTIVE

The objective of our study was to uncover barriers and facilitators to the use of an e-referral system that will be evaluated in a community-based randomized trial. The e-referral system will allow providers to refer smokers to an online smoking intervention during routine clinical care.

METHODS

We devised a four-step development and pilot testing process: (1) system conceptualization using Delphi to identify key functionalities that would overcome barriers in provider referrals for smoking cessation, (2) Web system programming using agile software development and best programming practices with usability refinement using think-aloud testing, (3) implementation planning using the nominal group technique for the effective integration of the system into the workflow of practices, and (4) pilot testing to identify practice recruitment and system-use barriers in real-world settings.

RESULTS

Our Delphi process (step 1) conceptualized three key e-referral functions: (1) Refer Your Smokers, allowing providers to e-refer patients at the point of care by entering their emails directly into the system, (2) practice reports, providing feedback regarding referrals and impact of smoking-cessation counseling, and (3) secure messaging, facilitating provider-patient communication. Usability testing (step 2) suggested the system was easy to use, but implementation planning (step 3) suggested several important approaches to encourage use (eg, proactive email cues to encourage practices to participate). Pilot testing (step 4) in 5 practices had limited success, with only 2 patients referred; we uncovered important recruitment and system-use barriers (eg, lack of study champion, training, and motivation, registration difficulties, and forgetting to refer).

CONCLUSIONS

Implementing a system to be used in a clinical setting is complex, as several issues can affect system use. In our ongoing large randomized trial, preliminary analysis with the first 50 practices using the system for 3 months demonstrated that our rigorous preimplementation evaluation helped us successfully identify and overcome these barriers before the main trial.

TRIAL

Clinicaltrials.gov NCT00797628; http://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/61feCfjCy).

A cross-sectional survey on the inclusion of tobacco prevention/cessation, nutrition/ diet, and exercise physiology/fitness education in medical school curricula

Chronic diseases are currently the major cause of death and disability worldwide. Addressing the main causes of chronic diseases from a preventive perspective is imperative for half ing a continual increase in premature deaths. Physicians occupy a unique position to assist individuals with chronic disease prevention. Hence, medical school is an opportunity to prepare physicians for preventive interventions with patients at risk for developing chronic diseases. This study asserts that education on chronic disease prevention that targets tobacco cessation/prevention, nutrition/ diet, and exercise physiology/fitness is a key aspect of medical school curricula. However, many US medical schools do not include all 3 components in their curricula. This study investigates the extent to which medical school curricula include the above 3 areas. Two methods were utilized for the study: (1) a cross-sectional survey was given to the associate dean of academic affairs of 129 US medical schools and (2) relevant data were retrieved from the Association of American Medical Colleges. Findings support the notion that medical schools are in need of increased curricula covering tobacco prevention/cessation, nutrition/diet, and exercise physiology/fitness. Results indicate that exercise physiology/fitness was the area receiving the least attention in medical schools. Ultimately, this study's purpose was to provide a basis for determining whether inclusion of these 3 subjects in medical school curricula has any significant effect on training future doctors to meet the needs of growing numbers of individuals with chronic disease.