Nurse-assisted counseling for smokers in primary care

Prevalence of smoking habits, attitudes and knowledge on counteractive strategies among a sample of healthcare employees: results of the smoking-free health environments project in the province of Palermo, Italy

Introduction

Tobacco use is responsible for over 7 million deaths annually, making smoking the leading cause of preventable mortality globally. Over the last two decades in Italy, the prevalence of smoking among physicians has consistently decreased, while it remains higher and is gradually decreasing among non-physician healthcare workers. The aim of this study was to investigate the Prevalence of smoking habits, attitudes, and knowledge on counteractive strategies among employees in the Primary Healthcare Facilities in the Province of Palermo, Italy.

Methods

A cross-sectional survey was conducted between June 2020 and December 2020 through a previously validated anonymous questionnaire structured in four sections including 34 items. Data were analyzed using Stata/MP 12.1 statistical software.

Results

Overall, 2,645 participants answered the questionnaire. The prevalence of either current or former smokers was 18.6%. Based on the multivariable analysis conducted, a significantly higher frequency of current smokers was observed among male participants (AdjOR: 1.29; CI95%: 1.02-1.64) and those belonging to the Surgical Unit (AdjOR: 1.92; CI95%: 1.27-2.90). Conversely, the prevalence of current smokers was significantly lower among those with at least one child (AdjOR: 0.67; CI95%: 0.49-0.91), with an educational qualification equal to or greater than a graduation degree (AdjOR: 0.56; CI95%: 0.43-0.73), those who considered second-hand smoke harmful (AdjOR: 0.06; CI95%: 0.008-0.60), those who had observed smoking or detected the smell of smoke in their workplace (AdjOR: 0.64; CI95%: 0.45-0.91). Furthermore, the prevalence of current smokers was significantly lower among participants who believed that healthcare professionals could play a crucial role in influencing their patients' lifestyles (AdjOR: 0.67; CI95%: 0.50-0.90) and among those who recommend their patients to quit smoking (AdjOR: 0.35; CI95%: 0.24-0.51).

Discussion

The results of the current research demonstrate that, despite the decline in smoking prevalence among physicians, the rate of smokers among healthcare facility employees remains unacceptably high. This underscores the need to re-evaluate current anti-tobacco strategies in the workplace.

A smoking cessation induction intervention via virtual reality headset during a dental cleaning: protocol for a randomized controlled trial

BACKGROUND

Effective smoking cessation programs exist but are underutilized by smokers, especially by disadvantaged smokers. Cessation interventions in dental settings have been shown to be effective, but are not consistently delivered due to provider burden and lack of training, especially on how to counsel smokers who are not motivated to quit.

METHODS

This study is a 2-arm, phase III longitudinal randomized controlled efficacy trial to motivate utilization of evidenced based treatments (EBTs) for smoking cessation (e.g., state quitline, clinic-based counseling, the National Cancer Institute's text message program, and pharmacotherapy). Patients attending an urban dental clinic (n = 376) will be randomized to an intervention group (INT; smoking cessation induction video delivered via VR headset during their teeth cleaning, brochure about EBTs, and a 4-week text message program) or control group (CTRL; relaxation video delivered via VR headset during teeth cleaning, the same brochure as INT, and assessment-only text messages). Assessments will occur at baseline, immediately after the clinic appointment, one-month post-appointment and 3-and 6 months later. We hypothesize INT will be more likely to contact EBTs vs CTRL and have greater utilization rates of EBTs. Secondary objectives are to test the efficacy of INT on point-prevalence smoking abstinence, quit smoking attempts, and motivation to quit vs. CTRL.

DISCUSSION

Incorporating smoking cessation into a dental clinic visit and targeting all smokers, regardless of motivation to quit, provides proactive reach to cigarette smokers who otherwise may not seek treatment for smoking.

TRIAL REGISTRATION

NCT04524533 Registered August 24, 2020.

Strategies to improve smoking cessation rates in primary care

BACKGROUND

Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials).

OBJECTIVES

To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.

Efficacy of a short-term residential smoking cessation therapy versus standard outpatient group therapy ('START-Study'): study protocol of a randomized controlled trial

BACKGROUND

In Germany, evidence-based outpatient smoking cessation therapies are widely available. Long-term abstinence rates, however, are limited. Studies suggest that short-term residential therapy enables a higher level of environmental control, more intense contact and greater support among patients and from therapists, which could result in higher abstinence rates. The aim of the current START-study is to investigate the long-term efficacy of a short-term residential therapy exclusively for smoking cessation, conducted by a mobile team of expert therapists.

METHODS

A randomized controlled trial (RCT) is conducted to examine the efficacy of residential behavior therapeutic smoking cessation therapy compared to standard outpatient behavior therapeutic smoking cessation group therapy. Adult smokers consuming 10 or more cigarettes per day, who are willing to stop smoking, are randomized in a ratio of 1:1 between therapy groups. The primary endpoint is sustained abstinence for 6-month and 12-month periods. Secondary endpoints include smoking status after therapy, 7-day point abstinence after the 6-month and 12-month follow-ups, level of physical dependence, cost-effectiveness, use of nicotine replacement products, health-related quality of life, self-efficacy expectation for tobacco abstinence, motivational and volitional determinants of behavior change, self-reported depressive symptom severity, adverse events and possible side effects. Assessments will take place at baseline, post-therapy, and at 6-month and 12-month intervals after smoking cessation.

DISCUSSION

There is a high demand for long-term effective smoking cessation therapies. This study represents the first prospective RCT to examine the long-term efficacy of a residential smoking cessation therapy program compared to standard outpatient group therapy as an active control condition. The residential therapeutic concept may serve as a new model to substantially enhance future cessation therapies and improve the understanding of therapeutic impact factors on tobacco abstinence. Utilizing a mobile team, the model could be applied efficiently to medical centers that do not have permanent and trained personnel for smoking cessation at their disposal.

TRIAL REGISTRATION

German Register for Clinical Trials (Deutsches Register für Klinische Studien), DRKS00013466. Retrospectively registered on 1 April 2019. https://www.drks.de/drks_web/navigate.do?navigationId=start.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials that provide a structured programme for smokers to follow may increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of print-based self-help materials that provide a structured programme for smokers to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print-based self-help, such as computer-generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The date of the most recent search was March 2018.

SELECTION CRITERIA

We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested print-based materials providing self-help compared with minimal print-based self-help (such as a short leaflet) or a lower-intensity control. We defined 'self-help' as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in accordance with standard methodological procedures set out by Cochrane. The main outcome measure was abstinence from smoking after at least six months' follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each study and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

We identified 75 studies that met our inclusion criteria. Many study reports did not include sufficient detail to allow judgement of risk of bias for some domains. We judged 30 studies (40%) to be at high risk of bias for one or more domains.Thirty-five studies evaluated the effects of standard, non-tailored self-help materials. Eleven studies compared self-help materials alone with no intervention and found a small effect in favour of the intervention (n = 13,241; risk ratio (RR) 1.19, 95% confidence interval (CI) 1.03 to 1.37; I² = 0%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for indirect relevance to populations in low- and middle-income countries because evidence for this comparison came from studies conducted solely in high-income countries and there is reason to believe the intervention might work differently in low- and middle-income countries. This analysis excluded two studies by the same author team with strongly positive outcomes that were clear outliers and introduced significant heterogeneity. Six further studies of structured self-help compared with brief leaflets did not show evidence of an effect of self-help materials on smoking cessation (n = 7023; RR 0.87, 95% CI 0.71 to 1.07; I² = 21%). We found evidence of benefit from standard self-help materials when there was brief contact that did not include smoking cessation advice (4 studies; n = 2822; RR 1.39, 95% CI 1.03 to 1.88; I² = 0%), but not when self-help was provided as an adjunct to face-to-face smoking cessation advice for all participants (11 studies; n = 5365; RR 0.99, 95% CI 0.76 to 1.28; I² = 32%).Thirty-two studies tested materials tailored for the characteristics of individual smokers, with controls receiving no materials, or stage-matched or non-tailored materials. Most of these studies used more than one mailing. Pooling studies that compared tailored self-help with no self-help, either on its own or compared with advice, or as an adjunct to advice, showed a benefit of providing tailored self-help interventions (12 studies; n = 19,190; RR 1.34, 95% CI 1.20 to 1.49; I² = 0%) with little evidence of difference between subgroups (10 studies compared tailored with no materials, n = 14,359; RR 1.34, 95% CI 1.19 to 1.51; I² = 0%; two studies compared tailored materials with brief advice, n = 2992; RR 1.13, 95% CI 0.86 to 1.49; I² = 0%; and two studies evaluated tailored materials as an adjunct to brief advice, n = 1839; RR 1.72, 95% CI 1.17 to 2.53; I² = 10%). When studies compared tailored self-help with non-tailored self-help, results favoured tailored interventions when the tailored interventions involved more mailings than the non-tailored interventions (9 studies; n = 14,166; RR 1.42, 95% CI 1.20 to 1.68; I² = 0%), but not when the two conditions were contact-matched (10 studies; n = 11,024; RR 1.07, 95% CI 0.89 to 1.30; I² = 50%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for risk of bias.Five studies evaluated self-help materials as an adjunct to nicotine replacement therapy; pooling three of these provided no evidence of additional benefit (n = 1769; RR 1.05, 95% CI 0.86 to 1.30; I² = 0%). Four studies evaluating additional written materials favoured the intervention, but the lower confidence interval crossed the line of no effect (RR 1.20, 95% CI 0.91 to 1.58; I² = 73%). A small number of other studies did not detect benefit from using targeted materials, or find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that when no other support is available, written self-help materials help more people to stop smoking than no intervention. When people receive advice from a health professional or are using nicotine replacement therapy, there is no evidence that self-help materials add to their effect. However, small benefits cannot be excluded. Moderate-certainty evidence shows that self-help materials that use data from participants to tailor the nature of the advice or support given are more effective than no intervention. However, when tailored self-help materials, which typically involve repeated assessment and mailing, were compared with untailored materials delivered similarly, there was no evidence of benefit.Available evidence tested self-help interventions in high-income countries, where more intensive support is often available. Further research is needed to investigate effects of these interventions in low- and middle-income countries, where more intensive support may not be available.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions in adults. To establish whether nursing-delivered smoking cessation interventions are more effective than no intervention; are more effective if the intervention is more intensive; differ in effectiveness with health state and setting of the participants; are more effective if they include follow-ups; are more effective if they include aids that demonstrate the pathophysiological effect of smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register and CINAHL in January 2017.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Fifty-eight studies met the inclusion criteria, nine of which are new for this update. Pooling 44 studies (over 20,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention increased the likelihood of quitting (RR 1.29, 95% CI 1.21 to 1.38); however, statistical heterogeneity was moderate (I² = 50%) and not explained by subgroup analysis. Because of this, we judged the quality of evidence to be moderate. Despite most studies being at unclear risk of bias in at least one domain, we did not downgrade the quality of evidence further, as restricting the main analysis to only those studies at low risk of bias did not significantly alter the effect estimate. Subgroup analyses found no evidence that high-intensity interventions, interventions with additional follow-up or interventions including aids that demonstrate the pathophysiological effect of smoking are more effective than lower intensity interventions, or interventions without additional follow-up or aids. There was no evidence that the effect of support differed by patient group or across healthcare settings.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that behavioural support to motivate and sustain smoking cessation delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is insufficient evidence to assess whether more intensive interventions, those incorporating additional follow-up, or those incorporating pathophysiological feedback are more effective than one-off support. There was no evidence that the effect of support differed by patient group or across healthcare settings.

Varenicline versus nicotine patch with brief advice for smokers with substance use disorders with or without depression: effects on smoking, substance use and depressive symptoms

AIMS

Varenicline was compared with transdermal nicotine (NRT) for smokers with current substance use disorders (SUD) for effects on 3-month smoking abstinence (primary outcome) and, secondarily, on 3- and 6 month abstinence while adjusting for medication adherence, and on additional smoking and substance use outcomes. Moderation by major depressive disorder history (MDD) and adherence were investigated.

DESIGN

Double-blind double-placebo-controlled randomized design, stratifying by MDD, gender and nicotine dependence, with 3 and 6 months follow-up.

SETTING

University offices in Rhode Island, USA.

PARTICIPANTS

Adult smokers (n = 137), in SUD treatment, substance abstinent <12 months (n = 77 varenicline, 60 NRT).

INTERVENTION AND COMPARATOR

Twelve weeks of varenicline (2 mg/day, after 1-week dose run-up) or NRT (21 mg/day decreasing to 7 mg/day).

MEASUREMENTS

Primary: point-prevalence smoking abstinence (7-day, confirmed) at 3 months. Secondary: point-prevalence abstinence at 6 months, quantity and frequency of smoking and substance use at 3 and 6 months, and within-treatment abstinence, medication adherence and depressive symptoms. Smoking outcome analyses were repeated controlling for adherence and investigating adherence as a moderator.

FINDINGS

Effects on 3-month abstinence were P < 0.065 without a covariate (Bayes factor 3.35, supporting the effect strongly) and differed significantly when controlling for baseline smoking [varenicline: 13%, NRT: 3%; odds ratio (OR) = 4.81, 95% confidence interval (CI) 1.00, 23.13, P < 0.05]. The threefold difference at 6 months was not significant. Medication effect on abstinence across time was significant (P < 0.05) covarying adherence and baseline smoking (OR = 6.40, 95% CI = 1.00, 40.93). Medication differences in 3-month abstinence occurred among participants with ≥ 77% adherence (P < 0.02). No significant medication effects on heavy drinking, drug use or depressive symptoms were found.

CONCLUSIONS

Varenicline appears to improve the chances of achieving at least 3 months of smoking abstinence in smokers with substance use disorders trying to stop, compared with transdermal nicotine patches, the effect being independent of history of depressive disorder.

Prevalence, habits and personal attitudes towards smoking among health care professionals

BACKGROUND

Tobacco use is the second major cause of morbidity and the 4th most common health risk factor in the world. Medical professionals have a critical role in the process of smoking cessation both as advisers and behavioural models for the citizens. The aim of this study was to investigate the prevalence of smoking among health care professionals, their smoking habits and personal attitudes toward smoking, role and the responsibility of health care professionals in the prevention of smoking.

RESULTS

Out of the total number of examinees, 175 (35,1%) are active smokers, 29 (5,8%) are former smokers, and 295 (59,1%) are non-smokers. Nurses with secondary education disagree the most with the claim that passive smoking is more harmful to health (χ2 test, p = .008), also with the claim that the introduced Smoking Act is fair to smokers (χ2 test, p = .021). More nurses with secondary education disagree completely or partially that one should pay attention to smoking in the presence of non-smokers (χ2 test, p = .012).

CONCLUSION

Training programs for health care workers are needed to improve their ability in smoking cessation techniques to provide active support to their patients.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

To determine the effect of group-delivered behavioural interventions in achieving long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, using the terms 'behavior therapy', 'cognitive therapy', 'psychotherapy' or 'group therapy', in May 2016.

SELECTION CRITERIA

Randomized trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting-list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in participants smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. We analysed participants lost to follow-up as continuing smokers. We expressed effects as a risk ratio for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study and comparison, using the Cochrane 'Risk of bias' tool and GRADE criteria.

MAIN RESULTS

Sixty-six trials met our inclusion criteria for one or more of the comparisons in the review. Thirteen trials compared a group programme with a self-help programme; there was an increase in cessation with the use of a group programme (N = 4395, risk ratio (RR) 1.88, 95% confidence interval (CI) 1.52 to 2.33, I² = 0%). We judged the GRADE quality of evidence to be moderate, downgraded due to there being few studies at low risk of bias. Fourteen trials compared a group programme with brief support from a health care provider. There was a small increase in cessation (N = 7286, RR 1.22, 95% CI 1.03 to 1.43, I² = 59%). We judged the GRADE quality of evidence to be low, downgraded due to inconsistency in addition to risk of bias. There was also low quality evidence of benefit of a group programme compared to no-intervention controls, (9 trials, N = 1098, RR 2.60, 95% CI 1.80 to 3.76 I² = 55%). We did not detect evidence that group therapy was more effective than a similar intensity of individual counselling (6 trials, N = 980, RR 0.99, 95% CI 0.76 to 1.28, I² = 9%). Programmes which included components for increasing cognitive and behavioural skills were not shown to be more effective than same-length or shorter programmes without these components.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self-help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

Development of a Tobacco Cessation Clinical Decision Support System for Pediatric Emergency Nurses

Almost 50% of children who visit the pediatric emergency department are exposed to tobacco smoke. However, pediatric emergency nurses do not routinely address this issue. The incorporation of a clinical decision support system into the electronic health record may improve the rates of tobacco exposure screening and interventions. We used a mixed-methods design to develop, refine, and implement an evidence-based clinical decision support system to help nurses screen, educate, and assist caregivers to quit smoking. We included an advisory panel of emergency department experts and leaders and focus and user groups of nurses. The prompts include the following: (1) "Ask" about child smoke exposure and caregiver smoking; (2) "Advise" caregivers to reduce their child's smoke exposure by quitting smoking; (3) "Assess" interest; and (4) "Assist" caregivers to quit. The clinical decision support system was created to reflect nurses' suggestions and was implemented in five busy urgent care settings with 38 nurses. The nurses reported that the system was easy to use and helped them to address caregiver smoking. The use of this innovative tool may create a sustainable and disseminable model for prompting nurses to provide evidence-based tobacco cessation treatment.

Treating Smokers in Substance Treatment With Contingent Vouchers, Nicotine Replacement and Brief Advice Adapted for Sobriety Settings

Treatment for substance use disorders (SUD) provides an opportunity to use voucher-based treatment for smoking. Nicotine replacement (NRT) could improve outcomes previously observed with vouchers without NRT.

METHODS

A randomized controlled trial compared contingent vouchers (CV) for smoking abstinence to noncontingent vouchers (NV), when all received counseling and NRT. Smokers who had not sought smoking treatment (n=340) in residential SUD treatment were provided 14days of vouchers for complete smoking abstinence per exhaled carbon monoxide (CO) after a 5-day smoking reduction period, or vouchers only for breath samples, plus brief advice (four sessions) and 8weeks of NRT.

RESULTS

Within treatment, 20% had complete abstinence with CV, 5% with NV (p<.001), and participants showed 50% of days abstinent in CV compared to 22% in NV (p<.001). Across 1, 3, 6 and 12months after randomization, CV resulted in significantly fewer cigarettes per day (p<.01) and fewer days smoking (p<.01), but with small effects. Point-prevalence abstinence differences across follow-up (e.g., 4% CV, 2% in NV at 6 and 12months) were not significant. No differences in substance use were seen.

CONCLUSIONS

Within-treatment effects on abstinence are stronger than in a prior study of the same CV with BA but without NRT, but NRT does not improve abstinence after vouchers end. Implications for voucher-based treatment include investigating effects when combined with stronger smoking medications and using motivational interviewing. Smoking treatment does not harm SUD recovery.

Material deprivation and health: a longitudinal study

Background

Does material deprivation affect the consequences of ill health? Answering this question requires that we move beyond the effects of income. Longitudinal data on material deprivation, longstanding illness and limiting longstanding illness enables investigations of the effects of material deprivation on risk of limiting longstanding illness. This study investigates whether a shift from affording to not affording a car predicts the probability of limiting longstanding ill (LLSI).

Methods

The 2008–2011 longitudinal panel of Statistics on Income, Social Inclusion and Living Conditions (EU-SILC) is utilised. Longitudinal fixed effects logit models are applied, using LLSI as dependent variable. Transition from affording a car to not affording a car is used as a proxy for material deprivation. All models are controlled for whether the person becomes longstanding ill (LSI) as well as other time-variant covariates that could affect the results.

Results

The analysis shows a statistically significant increased odds ratio of LLSI when individuals no longer can afford a car, after controlling for confounders and LSI in the previous year (1.129, CI = 1.022–1.248). However, when restricting the sample to observations where respondents report longstanding illness the results are no longer significant (1.032, CI = 0.910–1.171).

Conclusion

The results indicate an individual level effect of material deprivation on LLSI, suggesting that material resources can affect the consequences of ill health.

The Patients' Perspective on the Self-management of Chronic Obstructive Pulmonary Disease

Little attention has been paid to the many behavioral issues involved in the management of chronic obstructive pulmonary disease (COPD). Using a patient- centered approach and drawing upon similar work in the area of diabetes self-management, this study evaluates factors related to the self-management behaviors of 65 patients with COPD. The primary focus was on patients' perceptions of the importance of COPD self-care activities, their recall of provider advice regarding COPD self-care, and the relationship of these factors to patient participation in self- care activities during the past month. The self-management behaviors assessed included smoking cessation, medication- taking, physical activity, diet, relaxation, breathing techniques, controlled coughing and bronchial drainage. Both patient- importance ratings and recall of provider advice showed moderate to strong correlations ( r = 0.43-0.79) with the frequency of self-care in the past month, indicating that both the patient's perception (i.e. perceived-importance ratings) and the receipt of health-care provider advice may be important influences on the extent to which patients engage in the various COPD self-management behaviors. Implications for behaviorally-focused interventions are discussed.

Using Innovative Video Doctor Technology in Primary Care to Deliver Brief Smoking and Alcohol Intervention

Given physicians' increased responsibilities and time constraints, it is increasingly difficult for primary care physicians to assume a major role in delivering smoking and alcohol assessment and intervention. The authors developed an innovative use of computer technology in the form of a “video doctor” to support physicians with this. In this article, two brief interventions, delivered by an interactive, multimedia video doctor, that reduce primary care patients' smoking and alcohol use are detailed: (a) a patient-centered advice message and (b) a brief motivational intervention. The authors are testing the use of the video doctor to deliver these interventions in a randomized, controlled study, Project Choice. A pilot study testing the feasibility and acceptability of the video doctor suggests it was well received and accepted by patients (n = 52) and potentially provides an innovative, cost-effective, and practical way to support providers' efforts to reduce smoking and alcohol use in primary care populations.

Contingent vouchers and motivational interviewing for cigarette smokers in residential substance abuse treatment

Residential drug treatment provides an opportunity to intervene with smokers with substance use disorders (SUD). A randomized controlled clinical trial compared: (1) contingent vouchers (CV) for smoking abstinence to noncontingent vouchers (NCV), crossed with (2) motivational interviewing (MI) or brief advice (BA), for 184 smokers in SUD treatment. During the voucher period, 36% of carbon monoxide readings indicated smoking abstinence for those receiving CV versus 13% with NCV (p < .001). Post-treatment (3-9 months) point-prevalence abstinence rates were low (3-4% at each follow up), with more abstinence when CV was combined with MI (6.6% on average) than with BA (0% on average). No differential effects on drug use or motivation to quit smoking occurred. Thus, CV had limited effects on long-term smoking abstinence in this population but effects were improved when CV was combined with MI. More effective methods are needed to increase motivation to quit smoking and quit rates in this high-risk population.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine: the effectiveness of different forms of print-based self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to print-based self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search April 2014.

SELECTION CRITERIA

We included randomized trials of smoking cessation with follow-up of at least six months, where at least one arm tested a print-based self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We identified 74 trials which met the inclusion criteria. Many study reports did not include sufficient detail to judge risk of bias for some domains. Twenty-eight studies (38%) were judged at high risk of bias for one or more domains but the overall risk of bias across all included studies was judged to be moderate, and unlikely to alter the conclusions.Thirty-four trials evaluated the effect of standard, non-tailored self-help materials. Pooling 11 of these trials in which there was no face-to-face contact and provision of structured self-help materials was compared to no intervention gave an estimate of benefit that just reached statistical significance (n = 13,241, risk ratio [RR] 1.19, 95% confidence interval [CI] 1.04 to 1.37). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Six further trials without face-to-face contact in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials (n = 7023, RR 0.88, 95% CI 0.74 to 1.04). When these two subgroups were pooled, there was no longer evidence for a benefit of standard structured materials (n = 20,264, RR 1.06, 95% CI 0.95 to 1.18). We failed to find evidence of benefit from providing standard self-help materials when there was brief contact with all participants (5 trials, n = 3866, RR 1.17, 95% CI 0.96 to 1.42), or face-to-face advice for all participants (11 trials, n = 5365, RR 0.97, 95% CI 0.80 to 1.18).Thirty-one trials offered materials tailored for the characteristics of individual smokers, with controls receiving either no materials, or stage matched or non-tailored materials. Most of the trials used more than one mailing. Pooling these showed a benefit of tailored materials (n = 40,890, RR 1.28, 95% CI 1.18 to 1.37) with moderate heterogeneity (I² = 32%). The evidence is strongest for the subgroup of nine trials in which tailored materials were compared to no intervention (n = 13,437, RR 1.35, 95% CI 1.19 to 1.53), but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data, since the subgroup of 10 trials where the number of contacts was matched did not detect an effect (n = 11,024, RR 1.06, 95% CI 0.94 to 1.20). In two trials including a direct comparison between tailored materials and brief advice from a health care provider, there was no evidence of a difference, but confidence intervals were wide (n = 2992, RR 1.13, 95% CI 0.86 to 1.49).Only four studies evaluated self-help materials as an adjunct to nicotine replacement therapy, with no evidence of additional benefit (n = 2291, RR 1.05, 95% CI 0.88 to 1.25). A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Standard, print-based self-help materials increase quit rates compared to no intervention, but the effect is likely to be small. We did not find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective than non-tailored materials, although the absolute size of effect is still small. Available evidence tested self-help interventions in high income countries; further research is needed to investigate their effect in contexts where more intensive support is not available.

Motivational interviewing versus brief advice for cigarette smokers in residential alcohol treatment

Residential treatment for substance use disorders (SUD) provides opportunity for smoking intervention. A randomized controlled trial compared: (1) motivational interviewing (MI) to brief advice (BA), (2) in one session or with two booster sessions, for 165 alcoholics in SUD treatment. All received nicotine replacement (NRT). MI and BA produced equivalent confirmed abstinence, averaging 10% at 1 month, and 2% at 3, 6 and 12 months. However, patients with more drug use pretreatment (>22 days in 6 months) given BA had more abstinence at 12 months (7%) than patients in MI or with less drug use (all 0%). Boosters produced 16-31% fewer cigarettes per day after BA than MI. Substance use was unaffected by treatment condition or smoking cessation. Motivation to quit was higher after BA than MI. Thus, BA plus NRT may be a cost-effective way to reduce smoking for alcoholics with comorbid substance use who are not seeking smoking cessation.

Results of a specific smoking cessation program for patients with arthritis in a rheumatology clinic

The purpose of this study is to evaluate an intervention program in smoker patients. We selected consecutive active smoker patients with rheumatoid arthritis, spondyloarthritis, or connective tissue diseases. The intervention consisted of the following: (1) a baseline visit, which included verbal and written advice by the rheumatologist, emphasizing the practical benefits of smoking cessation. Patients completed a questionnaire that included smoking dependence tests and previous attempts to quit. (2) A follow-up visit to the nurse in the 3rd month for reinforcement and the receiving of pharmacological treatment to help patients quit smoking. The primary outcome was total abstinence in the last 7 days of a phone interview at 3, 6, and 12 months. The secondary outcome was a reduction in cigarette consumption by at least 50%. A total of 945 patients were screened. About 185 (19.5%) were current smokers, and 152 were included for intervention. In the previous 5 years, the mean annual withdrawal rate was 4.6%. The smoking cessation rate was 11.8, 14.4, and 15.7% at 3, 6, and 12 months (OR compared with previous cessation rate 3.8 (CI 95% 1.8-8.1)). Twenty-nine patients (19%) reduced ≥50% of the cigarette consumption at 12 months. The linear regression analysis showed that a score of less dependence (p = 0.03) and previous attempts to quit smoking (p = 0.04) were significantly associated with definitive smoking cessation at 12 months. One out of six patients quit smoking with the aid of an educational program which included verbal and written advice by the rheumatologist and the nurse. As far as we know, this is the first interventional study in smoker patients with arthritis.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialized Register and CINAHL in June 2013.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Forty-nine studies met the inclusion criteria. Pooling 35 studies (over 17,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention to increase the likelihood of quitting (RR 1.29; 95% CI 1.20 to 1.39). In a subgroup analysis the estimated effect size was similar for the group of seven studies using a particularly low intensity intervention but the confidence interval was wider. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized adults also showed evidence of benefit. Eleven studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Six studies of nurse counselling on smoking cessation during a screening health check or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses, with reasonable evidence that intervention is effective. The evidence for an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

Effectiveness of telephone-based follow-up support delivered in combination with a multi-component smoking cessation intervention in family practice: a cluster-randomized trial

OBJECTIVE

To determine whether telephone-based smoking cessation follow-up counseling (FC), when delivered as part of a multi-component intervention program is associated with increased rates of follow-up support and smoking abstinence.

METHODS

A cluster randomized controlled-trial was conducted within family medicine practices in Ontario, Canada. Consecutive adult patients who smoked were enrolled at two time points, the baseline period (2009) and the post-intervention period (2009-2011). Smoking abstinence was determined by telephone interview 4 months following enrollment. Both groups implemented a multi-component intervention program. Practices randomized to the FC group could also refer patients to a follow-up support program which involved 5 telephone contacts over a 2-month period.

RESULTS

Eight practices, 130 providers, and 928 eligible patients participated in the study. No statistically significant difference in 7-day point-prevalence abstinence was observed between intervention groups. There was a significant increase in referral to follow-up in both intervention groups. Significantly higher rates of smoking abstinence [25.7% vs. 11.3%; adjusted OR 3.1 (95% CI: 1.1, 8.6), p<0.05] were documented among the twenty-nine percent of FC participants who were referred to the follow-up support program compared to the MC group.

CONCLUSION

Access to external follow-up support did not increase rates at which follow-up support was delivered.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register in January 2013 for trials of interventions involving physicians. We also searched Latin American databases through BVS (Virtual Library in Health) in February 2013.

SELECTION CRITERIA

Randomised trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomisation and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. People lost to follow-up were counted as smokers. Effects were expressed as relative risks. Where possible, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 42 trials, conducted between 1972 and 2012, including over 31,000 smokers. In some trials, participants were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics.Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow-up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register in January 2013 for trials of interventions involving physicians. We also searched Latin American databases through BVS (Virtual Library in Health) in February 2013.

SELECTION CRITERIA

Randomised trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomisation and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. People lost to follow-up were counted as smokers. Effects were expressed as relative risks. Where possible, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 42 trials, conducted between 1972 and 2012, including over 31,000 smokers. In some trials, participants were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics.Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow-up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Communication-related behavior change techniques used in face-to-face lifestyle interventions in primary care: a systematic review of the literature

OBJECTIVES

To systematically review the literature on the relative effectiveness of face-to-face communication-related behavior change techniques (BCTs) provided in primary care by either physicians or nurses to intervene on patients' lifestyle behavior.

METHODS

PubMed, EMBASE, PsychINFO, CINAHL and The Cochrane Library were searched for studies published before October 2010. Fifty studies were included and assessed on methodological quality.

RESULTS

Twenty-eight studies reported significantly favorable health outcomes following communication-related BCTs. In these studies, 'behavioral counseling' was most frequently used (15 times), followed by motivational interviewing (eight times), education and advice (both seven times). Physicians and nurses seem equally capable of providing face-to-face communication-related BCTs in primary care.

CONCLUSION

Behavioral counseling, motivational interviewing, education and advice all seem effective communication-related BCTs. However, BCTs were also found in less successful studies. Furthermore, based on existing literature, one primary care profession does not seem better equipped than the other to provide face-to-face communication-related BCTs.

PRACTICE IMPLICATIONS

There is evidence that behavioral counseling, motivational interviewing, education and advice can be used as effective communication-related BCTs by physicians and nurses. However, further research is needed to examine the underlying working mechanisms of communication-related BCTs, and whether they meet the requirements of patients and primary care providers.

Multifactorial intervention with nurse practitioners does not change cardiovascular outcomes in patients with chronic kidney disease

Strict implementation of guidelines directed at multiple targets reduces vascular risk in diabetic patients. Whether this also applies to patients with chronic kidney disease (CKD) is uncertain. To evaluate this, the MASTERPLAN Study randomized 788 patients with CKD (estimated GFR 20-70 ml/min) to receive additional intensive nurse practitioner support (the intervention group) or nephrologist care (the control group). The primary end point was a composite of myocardial infarction, stroke, or cardiovascular death. During a mean follow-up of 4.62 years, modest but significant decreases were found for blood pressure, LDL cholesterol, anemia, proteinuria along with the increased use of active vitamin D or analogs, aspirin and statins in the intervention group compared to the controls. No differences were found in the rate of smoking cessation, weight reduction, sodium excretion, physical activity, or glycemic control. Intensive control did not reduce the rate of the composite end point (21.3/1000 person-years in the intervention group compared to 23.8/1000 person-years in the controls (hazard ratio 0.90)). No differences were found in the secondary outcomes of vascular interventions, all-cause mortality or end-stage renal disease. Thus, the addition of intensive support by nurse practitioner care in patients with CKD improved some risk factor levels, but did not significantly reduce the rate of the primary or secondary end points.

A meta-analysis of the efficacy of nonphysician brief interventions for unhealthy alcohol use: implications for the patient-centered medical home

Brief physician interventions can reduce alcohol consumption. Physicians may not have the time to provide brief interventions, and it is unclear whether nonphysicians can do so effectively. We conducted a systematic review and meta-analysis to examine the efficacy of brief interventions by nonphysician clinicians for unhealthy alcohol use. We searched the English-language literature in MEDLINE and other databases covering the domains of alcohol problems, primary care, nonphysician, and brief interventions. Studies of brief interventions delivered at least in part by nonphysicians in primary care and examining drinking outcomes were included. Sensitivity analyses examined the effect of excluding studies that contributed disproportionately to the heterogeneity of results. Thirteen studies, conducted 1996-2008, met our criteria. Seven studies with a total of 2,633 patients were included in the meta-analysis. Nonphysician interventions were associated with 1.7 (95% confidence interval [CI]=-.03 to -3.5) fewer standard drinks per week than control conditions (p = .054). Excluding the one study that increased heterogeneity, the effect was smaller but reached statistical significance; nonphysician counseling was associated with 1.4 (95% CI = .3- 2.4) fewer standard drinks per week compared to control (p = .012). Nonphysician brief interventions are modestly effective at reducing drinking in primary care patients with unhealthy alcohol use.

Identifying evidence-based competences required to deliver behavioural support for smoking cessation

BACKGROUND

No systematic basis has yet been published for specifying competences needed to underpin behavioural support for smoking cessation.

PURPOSE

The purpose of this study was to develop and apply a system for identifying competences required for the delivery of individual and group-based behavioural support for smoking cessation.

METHODS

Sets of recommended competences for behavioural support were identified from a range of guidance documents. Where possible, these were compared with ones based on behaviour change techniques identified within behavioural support programmes found to be effective in randomised controlled trials (RCTs) and, for individual behavioural support, ones associated with higher success rates in the English Stop Smoking Services.

RESULTS

Ninety-four competences were identified (71 individual and 23 additional group competences), of which 59 were cited in at least two guidance documents (51 and 8, respectively). Fourteen of the individual competences and three of the group competences were supported by RCT evidence and, for individual competences, nine were supported by evidence from the services.

CONCLUSIONS

It is possible to identify competences recommended for behavioural support for smoking cessation and subsets supported by different types of evidence. This approach can form the basis for the development of assessment and training of stop smoking practitioners and is currently doing so in a national programme in England. With further research, the list of evidence-based competences is likely to be extended.

Medical comorbidities increase motivation to quit smoking among veterans being treated by a psychiatric facility

PURPOSE

This study determined if comorbidities predicted motivation to quit smoking among smokers treated in a primarily psychiatric Veterans Affairs facility.

DESIGN AND METHODS

A cross-sectional study was conducted with a convenience sample of smokers (N = 117).

FINDINGS

Multivariate analyses showed a history of arthritis, diabetes, lung disease, or stroke predicted motivation to quit smoking (p < .05). Having a history of high blood pressure, heart disease, or cancer was not associated with motivation to quit smoking.

PRACTICE IMPLICATIONS

Relating smoking behavior to the patient's medical comorbidities may increase motivation to quit smoking among veterans.

Strategies to increase the delivery of smoking cessation treatments in primary care settings: a systematic review and meta-analysis

OBJECTIVES

A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics.

METHODS

The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for "5As" (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies.

RESULTS

Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing "5As" delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6-2.1] for "ask", 1.6 [95% CI 1.4-1.8] for "advice", 9.3 [95% CI 6.8-12.8] for "assist" (quit date) and 3.5 [95% CI 2.8-4.2] for "assist" (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5-2.0] and multi-component interventions [OR 2.2; 95% CI 1.7-2.8] were found to significantly increase smoking abstinence.

CONCLUSION

Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.

Epidemiological study of smoking among Japanese physicians

OBJECTIVE

In this study, we attempted to clarify recent changes in the prevalence of smoking among Japanese physicians and factors related to smoking among physicians.

METHOD

We conducted three self-administered questionnaire surveys on members of the Japan Medical Association in 2000, 2004, and 2008. In each survey, 3000 male and 1500 female physicians were randomly selected.

RESULTS

The total number of effective responses was 3771 in 2000, 3633 in 2004, and 3486 in 2008. The prevalence of smoking among male physicians decreased significantly from 27.1% in 2000 to 21.5% in 2004, and then to 15.0% in 2008 (p<0.01). The prevalence of smoking among female physicians was 6.8%, 5.4%, and 4.6%, in 2000, 2004, and 2008, respectively (p=0.07). With regard to factors associated with being a current smoker, the odds ratios were significantly high for "male gender," "greater number of days on call/night shift," and "habit of daily alcohol consumption."

CONCLUSIONS

The prevalence of smoking among Japanese male physicians has shown a declining trend. When planning antismoking measures for physicians, the number of days on call/night shift as well as the habit of daily alcohol consumption must be taken into consideration.

Effectiveness of Nurse Based Motivational Interviewing for smoking cessation in high risk cardiovascular outpatients: a randomized trial

OBJECTIVE

To evaluate the feasibility and effectiveness of Nurse Based Motivational Interviewing (NBMI) on top of a routine patient based Lifestyle Inventory with Feedback (LIFE) in a cardiovascular outpatient secondary prevention setting.

METHODS

All current smokers (n=112), identified in 619 successive patients with cardiovascular disease, were randomized for either care as usual (LIFE), or LIFE plus NBMI (intervention group). Cumulative time investment was recorded.

RESULTS

After 3 months of follow-up, the abstinence rate in the control group was 7%, and another 15% diminished the number of cigarettes, whereas 26% of intervention patients quit smoking (p<0.017) and another 31% diminished smoking. On average, each completed motivational interviewing session took 63.5 min. Per quitter, time investment was 3.8 h and NNT appeared 5.9.

CONCLUSION

NBMI strategy on top of routinely administrated lifestyle self evaluation with professional feedback, significantly increases smoking cessation in an outpatient secondary prevention setting. Although cost effectiveness needs to be addressed, time investment per quitter in this approach appears low.

Tobacco use prevalence, knowledge and attitudes among Italian hospital healthcare professionals

BACKGROUND

Healthcare professionals play a key role in tobacco use prevention because they are considered as model by patients. This multicenter study was aimed to evaluate smoking prevalence, knowledge and attitudes towards tobacco among Italian hospital professionals.

METHODS

A cross-sectional study was carried out using a questionnaire administered to healthcare professionals in seven Italian hospitals, to investigate personal and occupational data, knowledge, attitudes, job setting, clinical activities, smoking habits and pattern for current smokers. Potential predictors of current smoking habits were evaluated using multiple logistic regressions.

RESULTS

Sample population was comprised of 1082 health professionals (51.4% females; mean age was 37.3 years: 25.3% were nurses, 24.5% medical doctors, 17.1% students and 33.1% other healthcare workers). Smoking prevalence was 44%. Among responders, 67.7% considered healthcare professional as a model for citizens, 90.5% declared to see colleagues smoking cigarettes inside the hospital (47.4% in the dependents' toilets, 33.4% in the department kitchens and 4.7% in the patient room). Multivariate analysis showed that healthcare professionals working in Naples had a higher risk to be smokers in comparison to Rome [odds ratio (OR) = 2.29; 95% confidence interval (CI) 1.40-3.73]. Compared to medical doctors, post-graduate students (OR = 3.42; 95% CI: 1.81-6.44), nurses (OR = 2.48; 95% CI 1.51-4.08), nursing students (OR = 1.91; 95% CI 1.08-3.38) and auxiliary personnel (OR = 2.72; 95% CI 1.51-4.88), showed a higher likelihood of smoking.

CONCLUSIONS

Among Italian hospital personnel there is a paradoxically large prevalence of smokers, higher than in the general population. Interventions aimed for the development of an adequate culture of health promotion, among these professionals, are urgently needed.

Efficacy of brief interventions in clinical care settings for persons living with HIV

Prevention of HIV transmission from patients living with HIV (PLH) is a high national priority and strategies that are easy to implement and sustain to eliminate sexual transmission acts among PLH are needed. We evaluated a brief intervention that focused primarily on the enhancing motivations and encouraging PLH to act in accordance with their values without providing the intensity of the existing evidence-based programs for PLH. Using a quasiexperimental design, six medical clinics in Los Angeles County, CA, were evaluated across three intervention conditions: 1) computerized delivery; 2) provider delivery; or 3) standard care. We examined longitudinal changes in patients' reports of the number of HIV-negative (HIV-) or serostatus-unknown sexual partners and the number of unprotected vaginal and anal sex acts. Among 566 PLH, PLH in the computerized delivery condition reported a significant decrease in the number of HIV-/unknown sexual partners compared with the provider delivery and standard care conditions and a significant decrease in the number of unprotected sex acts in comparison to the standard care condition. Computerized motivational interventions delivered in waiting rooms at medical clinics may be an efficient strategy to reduce unprotected sex acts among PLH.

Current developments in behavioral interventions for tobacco cessation

PURPOSE OF REVIEW

Tobacco use causes a significant amount of mortality and morbidity globally. The search for optimal cost-effective treatment interventions continues as current treatment modalities at best offer modest success in treatment outcome. This review evaluates current developments in behavioral interventions for tobacco cessation and their effectiveness.

RECENT FINDINGS

Most studies of behavioral interventions reported moderate success in quitting tobacco at 6 months. This finding is seen across different professionals providing interventions in diverse settings using various modalities. Behavioral interventions in adolescents and pregnancy seem presently more effective than pharmacotherapy. Technology-driven interventions have gained recent popularity. Combining interventions shows promising results compared with a single intervention.

SUMMARY

Most tobacco cessation intervention studies are from developed countries and for cigarette smoking. Long-term cessation still poses a challenge. Given the high global morbidity and mortality, there is a need to develop evidence-based, cost-effective intervention in developing countries for both smoking and smokeless tobacco use. Tobacco addiction produces neurobiological and behavioral change and optimal approaches involving behavioral methods and pharmacotherapy need to be developed.

Physician-based physical activity counseling for middle-aged and older adults: a randomized trial

Sedentary behavior among older adults increases risk for chronic diseases. Physicians in a primary care setting can play an important role in promoting physical activity adoption among their older patients. The Physically Active for Life (PAL) project was a randomized, controlled trial comparing the efficacy of brief physician-delivered physical activity counseling to usual care on self-reported physical activity levels. The physical activity counseling was based on the Transtheoretical Model of Change and social learning theory. Twenty-four community-based primary care medical practices were recruited into the study; 12 were randomized to the Intervention condition and 12 to the Control condition. Physicians in the Intervention practices received training in the delivery of brief physical activity counseling. Subjects in the Intervention practices (n=181) received brief activity counseling matched to their stage of motivational readiness for physical activity, a patient manual, a follow-up appointment with their physician to discuss activity counseling, and newsletter mailings. Subjects in the Control practices (n=174) received standard care. Measures of motivational readiness for physical activity and the Physical Activity Scale for the Elderly (PASE) were administered to subjects in both conditions at baseline, 6 weeks following their initial appointment, and at 8 months. Results showed that at the 6-week follow-up, subjects in the Intervention condition were more likely to be in more advanced stages of motivational readiness for physical activity than subjects in the Control condition. This effect was not maintained at the 8 month follow-up and the intervention did not produce significant changes in PASE scores. Results suggest that more intensive, sustained interventions may be necessary to promote the adoption of physical activity among sedentary, middle-aged, and older adults in primary care medical practices.

Changes in smoking prevalence and attitudes to smoking among Japanese physicians between 2000 and 2004

OBJECTIVES

To estimate smoking prevalence among Japanese physicians in 2004, clarify their attitudes towards smoking, and compare and examine the results of the 2004 survey with those of the 2000 survey.

STUDY DESIGN

Cross-sectional study.

METHODS

Among members of the Japan Medical Association, 3000 male and 1500 female physicians were selected at random, and mailed self-administered, anonymous questionnaires. The survey was conducted between February and July 2004. Data from 3633 respondents were analysed.

RESULTS

Smoking prevalence among males in 2004 was 21.5% [95% confidence interval (CI) 19.9-23.1%], which was significantly lower than that found in 2000 (27.1%; 95%CI 25.4-28.8%). Smoking prevalence among females in 2004 was 5.4% (95%CI 4.1-6.7%), which was not significantly different from that in 2000 (6.8%; 95%CI 5.4-8.2%). For nicotine dependency, no significant differences were observed for male or female physicians between 2004 and 2000. The percentages of respondents who agreed that 'physicians should not smoke' and 'patients should not smoke' increased in both males and females. The proportion of physicians that actively encouraged smoking cessation also increased in 2004.

CONCLUSIONS

There were some favourable changes in anti-smoking behaviour among Japanese physicians between 2000 and 2004. However, several problems still need to be resolved, and further anti-smoking measures are required.

Physician advice for smoking cessation

BACKGROUND

Healthcare professionals frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

The aims of this review were to assess the effectiveness of advice from physicians in promoting smoking cessation; to compare minimal interventions by physicians with more intensive interventions; to assess the effectiveness of various aids to advice in promoting smoking cessation, and to determine the effect of anti-smoking advice on disease-specific and all-cause mortality.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search: September 2007.

SELECTION CRITERIA

Randomized trials of smoking cessation advice from a medical practitioner in which abstinence was assessed at least six months after advice was first provided.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the setting in which advice was given, type of advice given (minimal or intensive), and whether aids to advice were used, the outcome measures, method of randomization and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up. We also considered the effect of advice on mortality where long-term follow-up data were available. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Subjects lost to follow up were counted as smokers. Effects were expressed as relative risks. Where possible, meta-analysis was performed using a Mantel-Haenszel fixed effect model.

MAIN RESULTS

We identified 41 trials, conducted between 1972 and 2007, including over 31,000 smokers. In some trials, subjects were at risk of specified diseases (chest disease, diabetes, ischaemic heart disease), but most were from unselected populations. The most common setting for delivery of advice was primary care. Other settings included hospital wards and outpatient clinics, and industrial clinics. Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk (RR) 1.66, 95% confidence interval (CI) 1.42 to 1.94). Amongst 11 trials where the intervention was judged to be more intensive the estimated effect was higher (RR 1.84, 95% CI 1.60 to 2.13) but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37, 95% CI 1.20 to 1.56). Direct comparison also suggested a small benefit of follow-up visits. Only one study determined the effect of smoking advice on mortality. This study found no statistically significant differences in death rates at 20 years follow up.

AUTHORS' CONCLUSIONS

Simple advice has a small effect on cessation rates. Assuming an unassisted quit rate of 2 to 3%, a brief advice intervention can increase quitting by a further 1 to 3%. Additional components appear to have only a small effect, though there is a small additional benefit of more intensive interventions compared to very brief interventions.

Does additional support by nurses enhance the effect of a brief smoking cessation intervention in people with moderate to severe chronic obstructive pulmonary disease? A randomised controlled trial

BACKGROUND

Smoking cessation is the primary disease modifying intervention for chronic obstructive pulmonary disease (COPD).

SETTING

A Regional Respiratory Centre (RRC) out-patient department in Northern Ireland.

METHODS

A randomised controlled trial (RCT) evaluated the effectiveness of brief advice alone or accompanied by individual nurse support or group support facilitated by nurses. Smoking status was biochemically validated and stage of change, nicotine addiction and dyspnoea were recorded at 2, 3, 6, 9 and 12 months.

PARTICIPANTS

Ninety-one cigarette smokers with COPD were enrolled in the study (mean age 61 years, 47 female).

RESULTS

After 12 months cessation rates were not significantly different between groups (p=0.7), but all groups had a significant reduction in their nicotine addiction (p=0.03-0.006). No changes in subjects' motivation or dyspnoea were detected over the 12 months.

CONCLUSION

Patients with COPD were unable to stop smoking regardless of the type of support they received. Harm reduction may be a more appropriate goal than complete cessation for intractable smokers and nurses must evaluate their role in this arena.

Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: a randomised trial in Australian general practice

BACKGROUND

GPs often lack time to provide intensive cessation advice for patients who smoke. This study aimed to determine the effectiveness of opportunistic referral of smokers by their GP for telephone cessation counselling by a trained nurse.

METHODS

Adult smokers (n = 318) attending 30 GPs in South Western Sydney, Australia were randomly allocated to usual care or referral to a telephone-based program comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse. Self-reported point prevalence abstinence at six and 12 months was compared between groups. Characteristics of patients who accepted and completed the intervention were investigated.

RESULTS

Of 169 smokers randomised to the intervention, 76 (45%) consented to referral. Compared with smokers in 'pre-contemplation', those further along the stage-of-change continuum were significantly more likely to consent (p = 0.003). Those further along the continuum also were significantly more likely to complete all four calls of the intervention (OR 2.6, 95% CI: 0.8-8.1 and OR 8.6, 95% CI: 1.7-44.4 for 'contemplation' and 'preparation' respectively). At six months, there was no significant difference between groups in point prevalence abstinence (intention to treat) (9% versus 8%, p = 0.7). There was no evidence of differential intervention effectiveness by baseline stage-of-change (p = 0.6) or patient sex (p = 0.5). At 12 months, point prevalence abstinence in the intervention and control groups was 8% and 6% respectively (p = 0.6).

CONCLUSION

Acceptance of opportunistic referral for nurse delivered telephone cessation advice was low. This trial did not demonstrate improved quit rates following the intervention. Future research efforts might better focus support for those patients who are motivated to quit. AUSTRALIAN CLINICAL TRIALS REGISTRY NUMBER: ACTRN012607000091404.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register and CINAHL in July 2007.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed effect model and reported the outcome as a risk ratio (RR) with 95% confidence interval (CI).

MAIN RESULTS

Forty-two studies met the inclusion criteria. Thirty-one studies comparing a nursing intervention to a control or to usual care found the intervention to significantly increase the likelihood of quitting (RR 1.28, 95% CI 1.18 to 1.38). There was heterogeneity among the study results, but pooling using a random effects model did not alter the estimate of a statistically significant effect. In a subgroup analysis there was weaker evidence that lower intensity interventions were effective (RR 1.27, 95% CI 0.99 to 1.62). There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized patients also showed evidence of benefit. Nine studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Five studies of nurse counselling on smoking cessation during a screening health check, or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses to patients, with reasonable evidence that intervention is effective. The evidence of an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice, so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow up.

Effectiveness of an on-call counselor at increasing smoking treatment

BACKGROUND

Smoking cessation programs are very effective, but little is known about how to get smokers to attend these programs.

OBJECTIVE

To evaluate whether an "on-call" counselor increased smoking cessation program referrals and attendance.

DESIGN

We randomly assigned 1 of 2 primary care teams at the Sepulveda VA Ambulatory Care Center to intervention and the other to usual care. The intervention team had access to an on-call counselor who provided counseling and care coordination. Social marketing efforts included educational outreach, provider feedback, and financial incentives.

MEASUREMENTS

Baseline telephone interviews with a sample of 482 smokers were conducted, covering smoking history, health status, and smoking cessation treatments. Follow-up surveys were conducted at mid-intervention (n = 251) and post-intervention (n = 251).

RESULTS

Two hundred ninety-six patients were referred to the on-call counselor, who counseled each patient in person and provided follow-up calls. The counselor referred 45% to the on-site program, and 27% to telephone counseling; of these, half followed through on the referral; 28% declined referral. Patients on the intervention team were more likely to report being counseled about smoking (68% vs 56%; odds ratio [OR] 1.7, CI 1.0-2.9) and referred to a cessation program (38% vs 23%; OR 2.1, CI 1.2-3.6); having attended the program (11% vs 4%; OR 3.6, CI 1.2-10.5); and receiving a prescription for bupropion (17% vs 8%) (OR 2.3, CI 1.1-5.1). The effect was not sustained after the case management period.

CONCLUSIONS

Having access to an on-call counselor with case management increased rates of smoking cessation counseling, referral, and treatment. The intervention could be reproduced by other health care systems.

Disseminating evidence-based practices in substance abuse treatment: a review with suggestions

Although substance abuse professionals are generally open to new and better therapeutic methods, most evidence-based treatments do not easily find their way into practice. Natural diffusion processes for innovations in substance abuse treatments are relatively informal and have yielded a widely acknowledged gap between science and community practice. This review focuses on methods for effectively disseminating new treatment methods into practice. Therapist manuals and one-time workshops are in themselves relatively ineffective in helping practitioners gain proficiency in new clinical approaches. Individual performance feedback and coaching improve the acquisition of clinical skills. Specific incentives for implementation may also be needed to encourage treatment providers, programs, and systems to adopt new approaches.

Nursing intervention and smoking cessation: meta-analysis update

OBJECTIVE

The study objective was to determine through meta-analysis the effects of nursing-delivered smoking-cessation interventions.

RESULTS

Thirty-four studies met inclusion criteria in this updated meta-analysis. Twenty-six studies compared a nursing intervention with a control or usual care group of adults and found interventions of high and low intensity to modestly increase the odds of quitting (1.36, 95% confidence interval 1.22-1.51). The study results demonstrated heterogeneity; using a random effects model did not make a difference. There was evidence that interventions were most effective for hospital inpatients with cardiovascular disease than for patients with other conditions (odds ratio 2.14, confidence interval 1.39-3.31). Interventions in nonhospitalized adults were beneficial as well; no effect was found for additive intervention components. Counseling during health-screening programs or as part of multifactorial secondary preventions programs was found to be the least effective. The challenge will be to incorporate smoking-cessation interventions into evidence-based nursing practice.

Evaluation of a primary care-oriented brief counselling intervention for obesity with and without orlistat

OBJECTIVE

There is a significant need for an obesity treatment model suitable for the primary care environment. We examined the effectiveness of a brief counselling intervention alone, in combination with orlistat, and drug-alone in a 12-month randomized-clinical trial at a medical school obesity centre.

METHODS

Participants (N = 250) with body mass index (BMI) >or=27 were randomized. Changes in body weight, lipids, blood pressure and serum glucose were examined. Drug adherence and attendance were also evaluated.

RESULTS

Completers analysis was conducted on 136 participants with data at baseline, 6 and 12 months and intention-to-treat analyses (ITT) for the total sample. Amongst completers, participants in the drug only (P = 0.012) and drug + brief counselling (P = 0.001) groups lost more weight (mean +/- SD: -3.8 +/- 5.8 kg and -4.8 +/- 4.4 kg, respectively) than participants in the brief counselling only group at 6 months (-1.7 +/- 3.3 kg), but there were no significant group differences at 12 months. ITT model results were similar to completers at 6 months and remained significant at 12 months, but the weight losses were more modest (<3 kg) for both groups receiving orlistat. For brief counselling alone, participants gained weight (1.7 +/- 4.2 kg). Cardiovascular disease (CVD) parameter changes were negligible.

CONCLUSIONS

Pharmacotherapy alone or combined with brief counselling resulted in modest weight losses that had minimal impact on cardiovascular parameters, but were greater than brief counselling alone. Whilst brief interventions and primary pharmacotherapy have been suggested as viable treatments for implementation in primary care settings, our study suggests that such minimal interventions provide minimal benefits.

[Effectiveness of a programme of intensive tobacco counselling by nursing professionals]

OBJECTIVE

To determine the effectiveness of a systematic intensive tobacco counselling programme conducted by nursing professionals.

DESIGN

Randomised clinical trial with control.

SETTING

Primary care nursing and medical consultations.

PARTICIPANTS

Smokers requesting help in our centre's medical clinics during the recruitment period, up to the sample size required (125). Inclusion criteria were: aged between 18 and 70, people who smoked during the preceding month any number of cigarettes a day, and a score over 7 on the Richmond test.

INTERVENTIONS

The patients recruited were randomised, according to the clinic from which they came, to the group that received brief counselling from the doctor (control group) or to the group that received brief counselling plus nursing follow-up (intervention group). Follow-up visits were programmed in this latter group for up to 3 months after giving up smoking.

MAIN MEASUREMENTS

Abstinence at 12 and 24 months.

RESULTS

The effectiveness of the intervention considered as the rate of abstinence at 12 months was 13.8% (95% CI, 6.5-24.7) in the control group and 6.7% (95% CI, 1.8-16.2) in the intervention group, with no significant differences between the two.

CONCLUSIONS

In smokers seen in primary care, the effectiveness of a programme of intensive tobacco counselling by nursing staff is no more effective than the doctor's brief, one-off counselling. Brief counselling has a better cost-effectiveness relationship than intensive counselling.

Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness

BACKGROUND

This report updates 2001 estimates of disease burden prevented and cost effectiveness of tobacco-use screening and brief intervention relative to that of other clinical preventive services. It also addresses repeated counseling because the literature has focused on single episodes of treatment, while in reality that is neither desirable nor likely.

METHODS

Literature searches led to four models for calculating the clinically preventable burden of deaths and morbidity from smoking as well as the cost effectiveness of providing the service annually over time. The same methods were used in similar calculations for other preventive services to facilitate comparison.

RESULTS

Using methods consistent with existing literature for this service, an estimated 190,000 undiscounted quality-adjusted life years (QALYs) are saved at a cost of $1100 per QALY saved (discounted). These estimates exclude financial savings from smoking-attributable disease prevented and use the average 12-month quit rate in clinical practice for tobacco screening and brief cessation counseling with cessation medications (5.0%) and without (2.4%). Including the savings of prevented smoking-attributable disease and using the effectiveness of repeated interventions over the lifetime of smokers (23.1%), 2.47 million QALYs are saved at a cost savings of $500 per smoker who receives the service.

CONCLUSIONS

This analysis makes repeated clinical tobacco-cessation counseling one of the three most important and cost-effective preventive services that can be provided in medical practice. Greater efforts are needed to achieve more of this potential value by increasing current low levels of performance.