Tracking intervention delivery in the ‘Tobacco-Free Teachers/Tobacco-Free Society’ program, Bihar, India

In health education and behavior change interventions, process tracking monitors the delivery of an intervention and its receipt to the intended audience. A randomized controlled trial in the state of Bihar, India was conducted to help school teachers become tobacco free through appropriately designed intervention program and delivery system. We describe the results from process tracking of this intervention delivery. The intervention program was centred on six topics delivered in each school through 12 sessions over 6 successive months. The program deliverers recorded the process measures as total number of sessions and program-components implemented (fidelity); time spent conducting sessions (dose) and proportion of teachers attending at least one session (reach). The outcome measures (teachers’ exposure to intervention messages and tobacco policy adoption) were assessed post-intervention. All 12 sessions were delivered in 33 out of 36 schools. Thirty-one schools implemented all six program components. In 18 schools, ≥95% of the teachers participated in one or more sessions. Thirty-three schools received 12 or more hours of dose. In 29 schools, 100% teachers reported exposure to all program messages. Tobacco policy was adopted by all schools. Thus, the intervention was generally delivered as planned and it had a positive impact on teachers and schools.

Improvement in prevalence of tobacco use among teachers in Bihar after COTPA

CONTEXT

A high prevalence of tobacco use, even among educated professionals like teachers, has been reported from Bihar. After passing of the Cigarette and Other Tobacco Products Act (COTPA) in 2003, there have been major improvements in tobacco control nationwide.

AIMS

To compare tobacco use prevalence among school teachers in Bihar reported in 2000 with a survey in 2008 and investigate correlates of current and past tobacco-use.

METHODS

Data from the baseline survey of a cluster random sample of 72 government schools conducted during the beginning of two consecutive school years was analyzed.

RESULTS

The prevalence of current tobacco use was 35.5% and past use, 11.3%. Likelihood of current use compared with no use increased with age (odds ratio [OR] =3.27 for > 50 years compared to < 30, 95% confidence interval [CI]: [1.50, 7.13]); whereas that of past use compared to current use decreased (OR = 0.25, 95% CI: [0.09-0.68] for age > 50 years compared to < 30 years).

DISCUSSION

Compared to the tobacco use prevalence among Bihar school teachers reported from a survey in the year 2000 (77.4%), the prevalence in this survey in 2008 was much lower and past use, much higher. In the earlier survey, lal dantmajan was counted as a tobacco product. If we do the same in the current survey, and consider ever use, the prevalence even then was 53.9%, lower than the earlier figure. Although the tobacco use among teachers in Bihar is still high, it has decreased after the implementation of COTPA and the cessation has increased.

Utilization of a telephone interactive voice-response tobacco cessation support service in the Islamic Republic of Iran

Telephone smoking cessation counselling is a very cost-effective means of reaching dependent smokers in a population. We investigated the frequency of contacts and the types of topics that people accessed after a national telephone helpline was set up in the Islamic Republic of Iran at the beginning of 2011. From a total of 23 979 calls received over a 24-month period, 26.5% of callers hung up without selecting any menus. The most frequently accessed menu was addresses of smoking cessation support services (23.9%), followed by methods of smoking cessation (14.0%), self-help materials for quitting smoking (11.8%) and nicotine dependence assessment (10.4%). The average number of contacts decreased dramatically after the first month of the service but there was a significant increase in the 2 months preceding the feast of Ramadan. Religious messages provide a good opportunity to engage individuals in smoking cessation and may be useful in the planning of media campaigns.

Patients' attitudes towards the role of dentists in tobacco cessation counselling after a brief and simple intervention

Dental professionals are in a unique position to promote smoking cessation among their patients. We evaluated the effects of a brief counselling intervention by a dentist on patients' attitude towards the role of dentists in tobacco cessation programmes. In a semi-experimental study in Tehran, Islamic Republic of Iran, 70 eligible smokers were selected and randomly assigned to intervention and control groups. The initial attitudes of the patients regarding tobacco cessation counselling services provided by the dentist were determined using a validated questionnaire. The intervention group received a brief chair-side counselling by a dentist based on the 5 A's approach, while no intervention was provided for the control group. At 8-weeks follow-up, smokers receiving the intervention showed significantly more positive attitudes towards the role of the dentist in advising patients to quit smoking compared with those in the control group. More responsibility could be transferred to dentists for tobacco prevention.

Senior dental student's attitudes toward older adults and knowledge of geriatric dental care in the Islamic Republic of Iran

Dental students should have knowledge of geriatric dental care and positive attitudes toward elderly patients. This study assessed senior dental students' knowledge of geriatric dental care and their attitude towards elderly patients. A descriptive cross-sectional questionnaire survey was conducted on volunteer senior students in all dental schools (n = 512) in the Islamic Republic of Iran. The completed questionnaires (n = 464) were analysed. The mean scores of respondents' knowledge and attitudes were 12.7 (SD 2.9) and 48 (SD 6.1) respectively. Female and male students' knowledge did not differ significantly but their attitudes score was different. The majority of dental students had low to moderate levels of knowledge of geriatric dental care and attitudes toward elderly people; therefore, an intervention programme is indicated. We conducted the study to use the findings to incorporate geriatric dental care programmes into dental school curricula in the Islamic Republic of Iran.

WHO MPOWER tobacco control scores in the Eastern Mediterranean countries based on the 2011 report

The aim of this cross-sectional study was to quantify the implementation of MPOWER tobacco control policies among Eastern Mediterranean Region countries. Information was obtained from the 2011 WHO MPOWER report. A checklist was designed and its scoring was agreed by Iranian and international tobacco control specialists. Seven questions were scored from 0-4 and 3 from 0-3. The 22 countries were ranked by their total score on a scale of 0 to 37. The highest scores were achieved by the Islamic Republic of Iran, Egypt and Jordan 29, 28 and 26 respectively. Twelve of the countries (55%) scored more than half of the possible score (19). The lowest and highest scores for all countries summed were on sections related to banning smoking in public places (18) and tobacco advertising bans (66) respectively. Compliance with smoke-free policies was especially low. MPOWER programmes are accepted in the Region but there is considerable room for improvement. Input from countries based on their successes and challenges is needed to strengthen the programmes.

Which form of nicotine replacement therapy is more effective for quitting smoking? A study in Tehran, Islamic Republic of Iran

Nicotine replacement therapy can double the chance of success for smokers attempting to quit. This observational study aimed to compare quit rates of different formulations of nicotine replacement among clients referred to a smoking cessation clinic in Tehran, Islamic Republic of Iran. Clients entering the study (n = 308) participated in 4 sessions of behavioural therapy, chose a type of nicotine replacement to use (patches, chewing gum, tablets or both patches and gum) and were followed up for 12 months. After 4 weeks of quitting, 88.2% (246/279) reported abstaining from smoking. Self-reported maintenance rates for quitting were 54.9% after 6 months and 36.2% after 12 months follow-up. A significant correlation was found between type of nicotine replacement and quit rate. Use of nicotine patches and chewing gum together had the highest quit rate (95.2%) after 4 weeks and at 12 months follow-up (62.5%). Consuming 2 forms of nicotine replacement in therapy could result in enhanced rates of long-term quitting.

Status and costs of smoking cessation in countries of the Eastern Mediterranean Region

The aim of this cross-sectional observational study was to address the health care situation in regard to smoking cessation efforts and expenditure, and to provide a basis for future studies and for implementing tobacco control programmes throughout the Eastern Mediterranean Region of the World Health Organization. Information collected included methods and cost of services for tobacco cessation from all 16 participating countries. In 10 countries, cessation programmes were directed by primary physicians. In 13 countries, nicotine gum and in 14 countries nicotine patches were accessible in pharmacies. Bupropion was available at pharmacies (with a written prescription) in 6 countries and varenicline in 7 countries. However, the mean cost of each service was significantly higher than the price of a pack of cigarettes. In countries with support services for tobacco cessation, directors need to provide care at the society level that is considerably less costly and widely accessible.

Nurses' attitudes concerning the delivery of brief cessation advice to hospitalized smokers

BACKGROUND

Nurses have a unique opportunity to assist hospitalized smokers with cessation. However, relatively little is known about nurses' attitudes and beliefs toward their role in assisting patients with cessation.

METHODS

A cross-sectional survey of staff nurses at four hospitals was conducted. Four scales based on constructs from the Theory of Planned Behavior were developed for this survey: attitudes toward offering cessation advice, beliefs about the outcome of offering advice, perceived normative beliefs, and perceived ability to offer advice. Other survey items included sociodemographics, employment characteristics (shift, unit worked), and personal smoking status.

RESULTS

Of the nurses surveyed, 397 (68%) returned completed questionnaires. Nurses had a relatively positive attitude toward helping patients to quit smoking, 63% believed that hospitalization was an ideal time for patients to try to quit smoking, and 59% believed a nurse had an obligation to advise patients to quit smoking. In the final multiple linear regression model, self-reported delivery of cessation advice was related to attitudes toward offering cessation advice, perceived ability to offer advice, and unit worked.

CONCLUSIONS

Efforts should be made to educate staff nurses about the efficacy of brief cessation advice and current smoking cessation methods and practices.

Barriers among nurses to providing smoking cessation advice to hospitalized smokers

Nine focus groups were conducted with 75 staff nurses in three hospitals to determine the low participation rate of nurses in a smoking cessation programs directed at patients. Nurses felt that hospitalization was an appropriate time to offer quit-smoking advice to patients, particularly those with smoking related diseases. However, many felt advice should be given only to those receptive to it. The most common barriers to providing smoking cessation advice were lack of concrete techniques, or referral to provide and fear of alienating patients who were not receptive to hearing advice.

Promoting smoking abstinence in pregnant and postpartum patients: a comparison of 2 approaches

OBJECTIVE

To compare the implementation, delivery, and implications for dissemination of 2 different maternal smoking-cessation/relapse-prevention interventions in managed care environments.

STUDY DESIGN

Healthy Options for Pregnancy and Parenting (HOPP) was a randomized, controlled efficacy trial of an intervention that bypassed the clinical setting. Stop Tobacco for OuR Kids (STORK) was a quasi-experimental effectiveness study of a point-of-service intervention. Both incorporated prenatal and postnatal components.

PATIENTS AND METHODS

Subjects in both studies were pregnant women who either smoked currently or had quit recently. The major intervention in HOPP was telephone counseling delivered by trained counselors, whereas the STORK intervention was delivered by providers and staff during prepartum, inpatient postpartum, and well-baby visits.

RESULTS

In HOPP, 97% of telephone intervention participants reported receiving 1 or more counselor calls. The intervention delayed but did not prevent postpartum relapse to smoking. Problems with intervention delivery related primarily to identification of the target population and acceptance of repeated calls. STORK delivered 1 or more cessation contacts to 91% of prenatal smokers in year 1, but the rate of intervention delivery declined in years 2 and 3. Modest differences were obtained in sustained abstinence between 6 and 12 months postpartum, but not in point prevalence abstinence at 12 months.

CONCLUSIONS

The projects were compared using 4 of the 5 dimensions of the RE-AIM model including reach, adoption, implementation, and maintenance. It was difficult to apply the fifth dimension, efficacy, because of the differences in study design and purpose of the interventions. The strengths and limitations of each project were identified, and it was concluded that a combined intervention that incorporates elements of both HOPP and STORK would be optimal if it could be implemented at reasonable cost.

The association of smoking and the cost of military training

OBJECTIVE

To determine if premature discharge from the US Air Force was associated with the smoking status of recruits.

DESIGN AND SETTING

A total of 29 044 US Air Force personnel recruited from August 1995 to August 1996 were administered baseline behavioural risk assessment surveys during basic military training. They were tracked over a 12 month period to determine those who were prematurely discharged.

MAIN OUTCOME MEASURES

Excess training costs as a result of premature discharge.

RESULTS

In this 12 month period, 14.0% of those entering the US Air Force were discharged at a one year follow up. In both univariate and multivariate models, the best single predictor of early discharge was smoking status. Overall, 11.8% of non-smokers versus 19.4% of smokers were prematurely discharged (relative risk 1.795).

CONCLUSIONS

Using US Department of Defense data on the cost of military training, recruits who smoke in the US Air Force are associated with $18 million per year in excess training costs. Applied to all service branches, smoking status, which represents a constellation of underlying behaviours and attitudes that can contribute to early discharge, is associated with over $130 million per year in excess training costs.

Patient recall versus physician documentation in report of smoking cessation counselling performed in the inpatient setting

OBJECTIVES

To determine rates of patient reported and physician documented counselling; to identify predictors of each report; and to identify the impact of each report on smoking cessation attempts after discharge from the hospital.

DESIGN

Stickers on subjects' charts prompted physicians to give brief smoking cessation counselling to patients in the hospital. Patients reported counselling received and quit attempts in a phone interview conducted 7-18 days after discharge. Rates of counselling and correlations were calculated, and multivariate analysis identified predictors of patient report, physician documentation, and quit attempts.

SETTING

Four hospitals in the Minneapolis/St Paul metropolitan area.

SUBJECTS

682 hospital patients who had smoked more than 100 cigarettes in their lifetime and had smoked in the last three months.

RESULTS

71.0% of patients reported counselling, and physicians documented counselling in the charts of 46.2% of patients (correlation = 0.15, kappa = 0.13). Patient report was predicted by specific hospital, belief that their hospitalisation was smoking related, diagnosis of a smoking related disease, and physician documentation of counselling. Physician documentation was predicted by female patient, specific hospital, longer hospital stay, and marginally predicted by smoking related disease. Quit attempts were predicted by patient report of counselling, but not physician documentation.

CONCLUSIONS

Physicians document counselling in the hospital at a lower rate than patients report it, and the correlation between reports is very low, making an accurate assessment of true rates of counselling difficult. While it is important to increase physician documentation, it is even more important to increase patient recall, as this is the only report that predicts a quit attempt.

Effectiveness of monetary incentives for recruiting adolescents to an intervention trial to reduce smoking

BACKGROUND

The study objective is to evaluate the effect of monetary incentives on response rates of adolescents to a smoking-related survey as the first step toward participation in an intervention trial.

METHODS

A sample of 4,200 adolescent members of a managed care organization were randomized to one of four incentive groups: a $2 cash group, a $15 cash group, a $200 prize drawing group, or a no-incentive group. We compared group-specific response rates and willingness to be contacted about future study activities, as well as costs.

RESULTS

Incentives increased survey response rates (55% response without incentive vs. a 69% response with incentive), with response of 74% in the $15 cash group, 69% in the token group, and 63% with a prize incentive. Incentives did not adversely affect willingness of adolescents to be contacted about a smoking intervention, (65% willing with incentives vs. 60% without, P = 0.03). In terms of cost per additional survey completed, token and prize groups were marginally more expensive than the no-incentive group ($0.40 and $1.42, respectively) while the large cash incentive was substantially more costly ($11.37).

CONCLUSIONS

Monetary incentives improve response rates to a mailed survey, without adverse impact on willingness to further participate in intervention activities. However, a variety of issues must be considered when using incentives for recruitment to intervention studies.

Ethnic differences in patterns and correlates of age of initiation in a population of Air Force recruits

Early age of initiation is a significant risk factor for long-term dependent smoking and may also relate to other unhealthy behaviors. The current study assessed age of initiation in relationship to smoking dependence and motivation to quit, physical activity, dietary intake, body mass index (BMI), attitude toward illegal drug use, binge drinking, seat belt use, and smoking status at follow-up. Subjects were 7995 Air Force recruits who reported smoking regularly up to Basic Military Training. Euro-Americans initiated smoking more than a year earlier on average (15.5 years) than did African-Americans (16.8 years), with Hispanic-Americans (16.0 years) between these two groups. No gender differences were found for age of initiation for any ethnic group. Early age of initiation in Euro-Americans was associated with greater dependence on tobacco, reduced motivation to quit, less likelihood of quitting in the next 12 months, and a number of other health risk factors including lower self-reported physical activity, greater intake of high-fat foods, more favorable attitudes toward illegal drugs, increased likelihood of binge drinking, and less reported use of seat belts. Relationships between early age of initiation and other unhealthy behaviors were less consistent for African-Americans and for neither African-Americans nor Hispanics did age of initiation predict smoking status at 1-year follow-up.

Reconciling conflicting findings regarding postcessation weight concerns and success in smoking cessation

Correlates of concern about weight gain following smoking cessation and self-efficacy about controlling weight gain were examined in 940 men and 1,166 women who were surveyed on 2 occasions as part of a randomized trial of work-site interventions for smoking cessation. Weight concerns were positively associated with female sex, body weight, dieting for weight control, nicotine addiction, and social encouragement to quit. Bivariate analyses replicated prior findings that elevated weight concerns are associated with a reduced likelihood of quitting smoking, at least in women. Analyses controlling for demographics, nicotine dependence, and social factors replicated prior findings that weight concerns are not negatively related to smoking cessation and that some measures of concern are positively related to cessation. These analyses suggest that conflicting findings found in this literature are due primarily to how weight concerns are defined and whether covariates like nicotine addiction are used in data analyses.

Smokers with multiple behavioral risk factors: how are they different?

OBJECTIVE

The first aim of the present investigation was to examine cross-sectional differences between smokers who engage in additional health risk behaviors (i.e., high-fat diets and low physical activity levels) and those who do not that could affect readiness for smoking cessation treatment and treatment prognosis. The second aim was to examine prospective associations between risk factor status and smoking outcomes (i.e., cessation and quit attempts).

DESIGN

Data were derived from baseline and 1-year follow-up surveys for the SUCCESS project, a randomized trial of worksite smoking interventions conducted in 24 worksites in Minneapolis/St. Paul, Minnesota. Included in the analyses were 2,149 study participants who reported smoking at baseline.

METHODS

Current smokers were categorized into one of three "risk groups": the "1 additional risk factor" group (i.e., either low physical activity level or high dietary fat intake), the "2 additional risk factor" group (i.e., both low physical activity and high dietary fat intake), and the "smoker only" group (i.e., neither low physical activity nor high dietary fat intake). Mixed model regression analyses examined cross-sectional associations between risk group status and baseline demographic variables, smoking dependency, social environments for smoking, and health problems. Prospective associations between baseline risk group status and 1-year follow-up cessation attempts and quits were also examined.

RESULTS

At baseline, risk factor status was associated with smoking dependency for both men and women. Women smokers with at least one additional risk factor reported a greater number of cigarettes smoked per day, higher Fagerstrom Nicotine Dependence scores, and lower self-efficacy for refraining from smoking in a variety of situations compared with smokers with no additional risk factors. Men smokers with at least one additional risk factor reported higher Fagerstrom Nicotine Dependence scores compared with smokers with no additional risk factors. Women smokers with at least one additional risk factor were more likely to report being encouraged to quit by co-workers compared with smokers with no other risk factors. No relationship between risk factor status and social pressure to quit was observed among men. Prospective analyses indicated that baseline risk factor status was marginally related to smoking outcome at 1-year follow-up; however, these relationships were attenuated considerably when controlling for smoking dependence. Relationships between risk factor status and smoking outcomes were stronger for men.

CONCLUSION

Results indicated that the presence of multiple health risk behaviors was related to more serious problems with smoking. However, the presence of additional risk factors did not strongly affect prognosis for smoking cessation.

Reconciling conflicting findings regarding postcessation weight concerns and success in smoking cessation

Correlates of concern about weight gain following smoking cessation and self-efficacy about controlling weight gain were examined in 940 men and 1,166 women who were surveyed on 2 occasions as part of a randomized trial of work-site interventions for smoking cessation. Weight concerns were positively associated with female sex, body weight, dieting for weight control, nicotine addiction, and social encouragement to quit. Bivariate analyses replicated prior findings that elevated weight concerns are associated with a reduced likelihood of quitting smoking, at least in women. Analyses controlling for demographics, nicotine dependence, and social factors replicated prior findings that weight concerns are not negatively related to smoking cessation and that some measures of concern are positively related to cessation. These analyses suggest that conflicting findings found in this literature are due primarily to how weight concerns are defined and whether covariates like nicotine addiction are used in data analyses.

Associations between exercise and health behaviors in a community sample of working adults

BACKGROUND

The present study examined the associations between leisure-time exercise and a range of health behaviors and reports of illness and injury in a sample of community working adults.

METHODS

The study population included 4907 women and 4136 men who completed surveys in 24 worksites in the Minneapolis-St. Paul metropolitan area.

RESULTS

Participants in the study were ranked by gender according to their exercise score and grouped into quartiles. Women and men in the highest activity quartiles were more highly educated and were younger. High-activity men were more likely to be unmarried. Higher levels of leisure-time exercise were positively associated with seat belt use and inversely related to smoking, dietary fat intake, reported stress, and obesity. In men only, leisure-time exercise was related to greater reports of injuries resulting in restriction of usual activities. In women only, leisure-time exercise was positively associated with daily alcohol use. Most of the significant associations were seen in the two highest quartiles of exercise.

CONCLUSIONS

These findings suggest that associations between leisure-time exercise and health behaviors occur at the higher levels of exercise and interventions may need to promote this higher level of leisure-time exercise to impact overall public health.

Stress, depressive symptoms, and smoking cessation among pregnant women

Perceived stress and depressive symptoms were examined as correlates and predictors of smoking cessation during pregnancy in a sample of 819 pregnant smokers (454 baseline smokers and 365 baseline quitters). Women who quit early in pregnancy had lower levels of stress and depressive symptoms than baseline smokers. Adjusting for level of addiction and other demographic factors related to stress and depressive symptoms eliminated the significant association between depressive symptoms and smoking cessation. Lower levels of stress and depressive symptoms were not predictive of cessation in later pregnancy. Prenatal healthcare providers should continue to assess level of addiction and provide targeted intensive cessation interventions. Interventions that reduce stress and depression may also be of benefit to women who are continuing smokers in early pregnancy.

Age of initiation, smoking patterns, and risk in a population of working adults

BACKGROUND

Early age of initiation is a significant risk factor for long-term dependent smoking and may also relate to other unhealthy behaviors and increased likelihood of illness, independent of duration of smoking.

METHODS

The current study assessed age of initiation in relation to cigarette dependence, interest in quitting, social environment pertaining to smoking, behavioral risk factors, and current health problems. Subjects were 2120 current daily smokers in 24 worksites in the Minneapolis/St. Paul, Minnesota, metropolitan area.

RESULTS

Findings were surprisingly consistent with early age of initiation predicting more dependent smoking, less interest and confidence in ability to quit, poorer diet, less use of seat belts, more illness and hospitalization, and greater likelihood of smoking among partner/spouse, friends, and co-workers.

CONCLUSIONS

The overall strength of the findings was unexpected. Early initiation of regular smoking predicted a significant constellation of risk factors throughout adulthood. Interventions that significantly delay smoking onset, even in the absence of permanent prevention, could have important public health implications.

A population comparison of participants and nonparticipants in a health survey

OBJECTIVES

This study examined the characteristics of Air Force recruits willing to take part in a health survey vs those unwilling to participate.

METHODS

US Air Force recruits undergoing basic military training (n = 32,144) were surveyed regarding demographic and health variables.

RESULTS

Respondents indicating an unwillingness to participate in a health survey reported less healthy lifestyles than those willing to participate. Prediction equations modeling the characteristics of those engaging in 4 risky behaviors were nearly identical regardless of whether those refusing to participate were included.

CONCLUSIONS

Results suggest that, despite some low estimates of health behaviors due to response bias, relationships between most risk factors are generally unaffected by those not responding to health surveys.

Predictors of milk consumption in a population of 17- to 35-year-old military personnel

OBJECTIVE

The purpose of this investigation was to survey an entire population of Air Force recruits (N = 32,144) regarding milk consumption and demographic and health-related factors that may predict milk consumption.

DESIGN

All subjects were required to fill out a 53-item health survey at the start of basic military training.

SUBJECTS/SETTING

All recruits who entered the US Air Force from August 1995 to August 1996 participated in this study (N = 32,144).

STATISTICAL ANALYSES PERFORMED

Potential correlates of milk intake were analyzed using Spearman rank order correlations and multiple linear regression. Variables were removed if they did not make a meaningful contribution to variance in milk intake. Because of skewed distributions, several variables were dichotomized (e.g., age: 17 to 24 vs 25 to 35 years).

RESULTS

In terms of milk consumption, 51.7% of the respondents reported intake of fewer than 1 serving per day; only 17.9% reported intake of 3 servings or more per day. Milk intake was positively associated with body weight and fruit/vegetable intake and negatively associated with age, education level, reported milk-related gastric distress, physical activity level, dieting frequency, and concern about weight. Gender (women reported lower intake) and ethnicity (minorities reported lower intake) were independently related to milk consumption. Of all respondents, 16.1% reported themselves to have milk-related gastric distress, but rates varied depending on age, gender, and ethnicity (ranging from 10.2% for younger non-Hispanic white men to 60.4% for older Asian men).

APPLICATIONS/CONCLUSIONS

Despite the efforts of large, costly campaigns designed to increase milk consumption, self-reported milk consumption in young adults is extremely low. Given the importance of dairy products as a major source of calcium in the American diet, dietetics practitioners should assess milk consumption among young adults to ensure sufficient calcium intake to maximize peak bone mass in this group.

Smokeless tobacco use in a population of young adults

The current study examined characteristics of smokeless tobacco users in a large population of Air Force recruits. In addition, smokeless tobacco users were compared to non-tobacco users, to cigarette smokers, and to users of both smokeless tobacco and cigarettes. Participants were 32,144 individuals who entered Basic Military Training from August 1995 to August 1996. A 53-item questionnaire assessed demographics, tobacco use history, risk taking, and other health-risk factors. Those who both chewed and smoked scored considerably higher on a number of risk factors than did those who limited their tobacco consumption to either cigarettes or chew. Cigarette smokers in turn tended to score consistently higher on self-reported risk factors than did nontobacco users.

Prevention of relapse in women who quit smoking during pregnancy

OBJECTIVES

This study is an evaluation of relapse prevention interventions for smokers who quit during pregnancy.

METHODS

Pregnant smokers at 2 managed care organizations were randomized to receive a self-help booklet only, prepartum relapse prevention, or prepartum and postpartum relapse prevention. Follow-up surveys were conducted at 28 weeks of pregnancy and at 8 weeks, 6 months, and 12 months postpartum.

RESULTS

The pre/post intervention delayed but did not prevent postpartum relapse to smoking. Prevalent abstinence was significantly greater for the pre/post intervention group than for the other groups at 8 weeks (booklet group, 30%; prepartum group, 35%; pre/post group, 39%; P = .02 [different superscripts denote differences at P < .05]) and at 6 months (booklet group, 26%, prepartum group, 24%; pre/post group, 33%; P = .04) postpartum. A nonsignificant reduction in relapse among the pre/post group contributed to differences in prevalent abstinence. There was no difference between the groups in prevalent abstinence at 12 months postpartum.

CONCLUSIONS

Relapse prevention interventions may need to be increased in duration and potency to prevent post-partum relapse.

The relationship between smoking and body weight in a population of young military personnel

Evidence indicates that middle-aged smokers weigh less than nonsmokers and that smoking cessation reliably produces weight gain, but recent studies have questioned the weight control "benefits" of smoking in younger populations (the time that people typically initiate smoking). The relationship between smoking and body weight was evaluated in all U.S. Air Force Basic Military Training recruits during a 1-year period (n = 32,144). Those who smoked prior to Basic Military Training (n = 10,440) were compared to never smokers or experimental smokers. Results indicated that regular-current smoking had no relationship to body weight in women (p > .05) and a very small effect in men (p < .05). Ethnicity, education, income, and duration and intensity of smoking did not affect the relationship between smoking and body weight. It was concluded that smoking has no effects on the body weights of young women and minimal effects in young men.

The relationship between smoking and body weight in a population of young military personnel

Evidence indicates that middle-aged smokers weigh less than nonsmokers and that smoking cessation reliably produces weight gain, but recent studies have questioned the weight control "benefits" of smoking in younger populations (the time that people typically initiate smoking). The relationship between smoking and body weight was evaluated in all U.S. Air Force Basic Military Training recruits during a 1-year period (n = 32,144). Those who smoked prior to Basic Military Training (n = 10,440) were compared to never smokers or experimental smokers. Results indicated that regular-current smoking had no relationship to body weight in women (p > .05) and a very small effect in men (p < .05). Ethnicity, education, income, and duration and intensity of smoking did not affect the relationship between smoking and body weight. It was concluded that smoking has no effects on the body weights of young women and minimal effects in young men.

The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. Findings and implications for psychologists

Smoking is the leading cause of preventable morbidity and mortality in the United States, and the health benefits of quitting smoking are substantial. Nevertheless, over 25% of American adults (48 million individuals) continue to smoke, and the vast majority of quit attempts are unsuccessful. The Agency for Health Care Policy and Research recently addressed the smoking problem by conducting a 2-year research project that was published as the Smoking Cessation Clinical Practice Guideline (Fiore et al., 1996). This article reviews methods, analyses, and results from the Guideline project, and highlights major Guideline recommendations. Guideline findings and recommendations are discussed with respect to their implications for psychology.

The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. Findings and implications for psychologists

Smoking is the leading cause of preventable morbidity and mortality in the United States, and the health benefits of quitting smoking are substantial. Nevertheless, over 25% of American adults (48 million individuals) continue to smoke, and the vast majority of quit attempts are unsuccessful. The Agency for Health Care Policy and Research recently addressed the smoking problem by conducting a 2-year research project that was published as the Smoking Cessation Clinical Practice Guideline (Fiore et al., 1996). This article reviews methods, analyses, and results from the Guideline project, and highlights major Guideline recommendations. Guideline findings and recommendations are discussed with respect to their implications for psychology.

Effect of smoking cessation counseling on recovery from alcoholism: findings from a randomized community intervention trial

AIMS

To assess the effects of a smoking cessation program for recovering alcoholics on use of alcohol, tobacco and illicit drugs after discharge from residential treatment.

DESIGN AND SETTING

A randomized community intervention trial design was employed in which 12 residential drug treatment centers in Iowa, Kansas and Nebraska were matched and then randomly assigned to the intervention or control condition.

PARTICIPANTS

Approximately 50 adult residents (inpatients) from each site were followed for 12 months after treatment discharge.

INTERVENTION

Participating residents in the six intervention centers received a 4-part, individually tailored, smoking cessation program while those in the six control sites received usual care.

FINDINGS

Both moderate and heavy drinking rates were reduced in the intervention group. Intervention site participants were significantly more likely than controls to report alcohol abstinence at both the 6-month (OR = 1.59, 95%CI: 1.09-2.35) and 12-month assessment (OR = 1.84, 95%CI: 1.28-2.92). Illicit drug use rates were comparable. Effect of the intervention on tobacco quit rates was not statistically significant.

CONCLUSIONS

Counseling alcoholics in treatment to quit smoking does not jeopardize the alcohol recovery process. However, low-intensity tobacco interventions are unlikely to yield high tobacco quit rates.

The role of tobacco cessation, antiplatelet and lipid-lowering therapies in the treatment of peripheral arterial disease

Despite the widely held belief that there are no effective medical therapies for peripheral arterial disease (PAD), current data suggest that medical therapies can effectively modify the natural history of atherosclerotic lower extremity arterial occlusive disease. The ideal medical therapy would improve claudication, forestall the onset of limb-threatening events, decrease rates of invasive interventional therapies and improve long-term patient survival. These ideal outcomes might be achieved through the use of smoking cessation interventions, including behavioral and pharmacological therapy, and the administration of antiplatelet and lipid-lowering medications in patients with PAD.

Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies

OBJECTIVES

This study examined whether pregnancy intention was associated with cigarette smoking, alcohol drinking, use of vitamins, and consumption of caffeinated drinks prior to pregnancy and in early pregnancy.

METHODS

Data from a telephone survey of 7174 pregnant women were analyzed.

RESULTS

In comparison with women whose pregnancies were intended, women with unintended pregnancies were more likely to report cigarette smoking and less likely to report daily vitamin use. Women with unintended pregnancies were also less likely to decrease consumption of caffeinated beverages or increase daily vitamin use.

CONCLUSIONS

Pregnancy intention was associated with health behaviors, prior to pregnancy and in early pregnancy, that may influence pregnancy course and birth outcomes.

Attitudes and perceptions related to smoking among pregnant and postpartum women in a low-income, multiethnic setting

PURPOSE

The purpose of this study was to gain insight into attitudes and perceptions about smoking during pregnancy, passive smoke exposure, barriers to quitting, and program preferences among women in a low-income, ethnically diverse setting.

DESIGN

Nine focus group discussions were conducted with African-American, Native American, and white women. Discussions were moderated by local residents who shared the same ethnic background as group participants.

SETTING

Discussions were held in neighborhood centers and clinics in an urban area.

SUBJECTS

A total of 57 women participated. Moderators recruited participants from within their social networks and from neighborhood programs. The informal process of recruitment did not allow calculation of response rates.

MEASURES

A series of open-ended questions with selected probes was used to guide the conversation.

RESULTS

Participants were aware that smoking during pregnancy is harmful and were concerned to varying degrees about their smoking behavior. Most women who smoked took active steps to reduce the risks. Actions were frequently accompanied by beliefs that rationalized moderate levels of smoking. While concerned, women were uncertain about what constituted harmful, passive smoke exposure. Personal barriers to quitting included being around others who smoked, feelings of stress and boredom, addiction, and not believing smoking is dangerous enough. Participants tended to value pregnancy-related advice from female friends and relatives over advice from professionals.

CONCLUSIONS

Results suggest that many women respond to warnings about smoking during pregnancy, but actions are not necessarily measured in quit rates. Misconceptions about the risks may help to rationalize continued smoking. Subjects lacked knowledge about how best to reduce the risks of passive smoke. Educational efforts may be effective when directed at networks of women who share information. The nature of qualitative data collection prevents extrapolation of these results to a larger population.

Telephone support as an adjunct to transdermal nicotine in smoking cessation

OBJECTIVES

Transdermal nicotine patches have shown considerable promise in improving smoking cessation outcomes. The present study assessed telephone support as an adjunct to a managed care-based, single-session group orientation smoking cessation program with nicotine patch therapy.

METHODS

The unit of randomization was the orientation session (n = 35). Subjects (n = 509) were randomly assigned to a group session without telephone support, the session plus access to a toll-free help line, or the session with telephone help line plus active telephone outreach.

RESULTS

Contrary to hypothesis, there were no differences between treatment conditions. Overall abstinence rates were 22% at 6 months and 21% at 1 year. Fewer than 1% of eligible subjects called the toll-free help line. An average of 3.8 of a possible 4 calls were completed in the telephone outreach condition.

CONCLUSIONS

Abstinence results obtained in this program were comparable to those obtained with more extensive counseling. However, there was no evidence of benefit from telephone support beyond the initial physician-led group orientation session.

The GAINS project: outcome of smoking cessation strategies in four urban Native American clinics. Giving American Indians No-smoking Strategies

This study was designed to assess the capability of the Doctors Helping Smokers (DHS) model to produce an increase in smoking cessation over controls within four urban Indian Health clinics. A total of 601 Native American smokers were enrolled, surveyed, and measured for cardiovascular risk factors. Of those present in treatment clinics at 1-year follow-up, 7.1% reported being abstinent vs. 4.9% in the control group. Of those who made at least one visit to the clinic during the treatment year, 9.4% self-reported being abstinent in the treatment sites vs. 3.9% in the control group (p = .04). Cotinine validated quits for all enrollees, regardless of whether they attended the clinic during the intervention, are 6.7% (intervention) and 6.8% (control). Number of quit attempts and future quit intentions were greater in the intervention group. Recommendations for future intervention efforts include earlier contact with clinicians, clinic involvement in preplanning, developing the program around the principles and realities of each site, building in more extensive components, and utilizing additional community resources.

Nicotine replacement therapy in a group model HMO

OBJECTIVE

To examine patient response to a smoking cessation program that combined a nicotine replacement system (patch) with telephone support.

DESIGN

Randomized trial.

SETTING

A large Midwestern HMO. PARTICIPANTS. Five hundred and nine smokers who attended orientation sessions where an overview of the study and the use of the nicotine patch was presented.

INTERVENTION

All subjects received a prescription for a nicotine replacement patch (Prostep, Lederle Laboratories, Wayne, NJ). Participants were randomly assigned to one of three intervention groups. Group I participants (n = 166) received no additional support. Group II participants (n = 167) were registered with a 24-hour telephone hotline. Group III participants (n = 167) were registered with the 24-hour telephone hotline and received four follow-up telephone calls from health educators.

OUTCOME MEASURE

The primary outcome measure was smoking cessation. Subject satisfaction with study components was also evaluated.

RESULTS

Overall, there was no significant difference by group in smoking cessation rates: 20% of patients in all three groups were smoke-free after 12 months. Few patients (1%) used the telephone hotline. The telephone follow-up did not have an impact on cessation rates, and most patients (92%) reported that the orientation session was useful.

CONCLUSIONS

The study experience has helped the HMO evaluate various study components and has had an impact on currently used telephone intervention strategies and educational materials.

Incorporating social support into a community-wide smoking-cessation contest

Social support for smoking cessation has been identified as a key factor differentiating which individuals are most likely to quit smoking. Attempts to enhance social support in clinic-based programs have generally been unsuccessful. This study investigated a strategy for increasing the involvement of supportive others among participants in a community-based smoking-cessation contest. These smokers were undertaking quit attempts without the supportive environment offered in clinic-based group programs. Subjects included 734 adult smokers who had participated in a smoking-cessation contest in their local community. Contest participants had the option of designating a "support person" who would assist them in quitting smoking and be eligible for prizes if the participant was a contest winner. Follow-up was by telephone survey 3 months after the end of the contest. No differences were observed in demographic or smoking history variables between those who did and did not elect to name a support person. A relatively high proportion (60%) of contest participants elected to identify a support person and self-reported smoking-cessation rates were significantly better among those who named a support person than among those who did not. Identifying a support person was a particularly effective strategy for those with smoking or nonsupportive spouses.

Promoting abstinence among relapsed chronic smokers: the effect of telephone support

OBJECTIVES

The present study used telephone support both to sustain abstinence and to encourage renewed quit attempts in smokers who had completed an intensive smoking cessation clinic.

METHODS

Subjects were hard-core smokers (n = 1083) who had attended a multisession cessation clinic. They were then assigned randomly to receive telephone support (intervention calls 3, 9, and 21 months after the targeted cessation clinic quit date) or no further intervention.

RESULTS

In the intervention condition, subjects who relapsed were significantly more likely to resume abstinence (that is, to recycle) than those in the comparison condition at follow-up (6 months: 17.8% vs 11.3%; 24 months: 25.7% vs 18.2%). Telephone support was not effective in preventing relapse, and overall differences in abstinence outcome were not significant.

CONCLUSIONS

The major hypothesis of the current study--that telephone support would enhance the resumption of abstinence--received partial support. However, there was no evidence either of an overall treatment effect or of an effect in preventing relapse. Telephone outreach may be more effective in the context of self-help or other less intensive interventions.

Occasional smoking in a Minnesota working population

OBJECTIVES

This study examined the prevalence of occasional smoking in a population of working adults, compared the characteristics of occasional and daily smokers, and prospectively examined the long-term smoking patterns of occasional smokers.

METHODS

At 32 Minnesota work sites, 5681 randomly selected workers were surveyed at baseline; 5248 of these were surveyed again 2 years later. A cross-sectional sample of 5817 workers was also surveyed at follow-up.

RESULTS

Occasional smokers constituted 18.3% of all smokers in the baseline sample and 21.5% of all smokers in the cross-sectional sample surveyed 2 years later. Baseline occasional smokers were significantly more likely than daily smokers to have quit at follow-up. Job monotony or repetitiveness was related to an increase to daily smoking at follow-up among baseline occasional smokers, and a change to a more restrictive workplace smoking policy was associated with quitting.

CONCLUSIONS

The results confirm that a substantial proportion of smokers are low-rate users and suggest that the proportion may be rising. Further research on this group is warranted.

Effects of short-term use of nicotine gum in pregnant smokers

OBJECTIVES

To compare blood concentrations of nicotine and cotinine and maternal and fetal hemodynamic effects resulting from use of nicotine gum versus cigarette smoking in pregnant smokers.

METHODS

Pregnant women (24 to 36 weeks' gestation) who smoked chronically were randomly assigned with a 1:2 randomization scheme to either a group that smoked cigarettes (n = 10) or to a group that stopped smoking and chewed at least six pieces of nicotine gum (2 mg nicotine per piece) per day (n = 19). Blood nicotine and cotinine concentrations, maternal heart rate and blood pressure, uterine resistance index, and fetal heart rate and umbilical artery resistance index were obtained before and after one cigarette was smoked at baseline and after 5 continuous days of either chewing gum or smoking.

RESULTS

A significant reduction from baseline in nicotine (p < 0.0001) and cotinine (p < 0.0025) concentrations was observed in those who chewed nicotine gum compared with those who smoked cigarettes. No significant differences in the changes in maternal or fetal hemodynamic parameters from baseline to estimated time of peak nicotine exposure were observed between those who smoked cigarettes and those who chewed nicotine gum.

CONCLUSION

Short-term use of nicotine gum delivers less nicotine than usual cigarette smoking in pregnant women.

Telephone counseling for smoking cessation: rationales and meta-analytic review of evidence

We review the various ways in which telephone counseling has been used in smoking cessation programs. Reactive approaches--help lines or crisis lines--attract only a small percentage of eligible smokers but are sensitive to promotional campaigns. While difficult to evaluate, they appear to be efficacious and useful as a public intervention for large populations. Proactive phone counseling has been used in a variety of ways. In 13 randomized trials, most showed significant short-term (3-6 month) effects, and four found substantial long-term differences between intervention and control conditions. A meta-analysis of proactive studies using a best-evidence synthesis confirmed a significant increase in cessation rates compared with control conditions [pooled odds ratios of 1.34 (1.19-1.51) and 1.20 (1.06-1.37) at short- and long-term follow-up, respectively]. Proactive phone counseling appeared most effective when used as the sole intervention modality or when augmenting programs initiated in hospital settings. Suggestions for further research and utilization are offered.

Smoking cessation products and programs

Behavioral treatment techniques have facilitated smoking cessation, with intensive multicomponent interventions sometimes producing long-term abstinence rates approaching 50%. There is little evidence that either hypnosis or acupuncture are effective. Both nicotine gum and nicotine patch significantly improve treatment outcomes, although patch is easier for patients to use correctly. Self-help programs may be of benefit, however, smoking cessation products other than nicotine replacement show little evidence of effectiveness. Health professionals should be informed consumers and should be skeptical in evaluating claims for commercial programs or products. Additional information and materials are available from a number of sources including the National Cancer Institute, the U.S. Office on Smoking and Health, and the voluntary health organizations.

Long-term associations of helpful and harmful spousal behaviors with smoking cessation

It has repeatedly been demonstrated that increased levels of social support are positively associated with a smoker's likelihood of achieving abstinence. It remains unclear, however, what specific support behaviors influence smoking cessation. This study explores the effects of supportive and undermining behaviors experienced by subjects (N = 624) in the context of a romantic/marital relationship on a number of smoking cessation outcomes. The associations of social support behaviors with one-, two-, and three-year abstinence and recycling and making quit attempts at 6, 12, 24, and 34 months were examined. Frequencies of both supportive and undermining behaviors predicted the dependent variables under study. Subjects whose spouses demonstrated fewer undermining behaviors were more likely to be successful continuous abstainers, whereas participants' recycling and making quit attempts seemed to be best predicted by a greater frequency of supportive behaviors. Initial success at cessation might be associated with increased supportive behaviors by a spouse, whereas lower rates of undermining behaviors might be associated with long-term maintenance. Long-term tailored feedback to spouses of smokers wanting to quit might be helpful.

Predictors of tobacco quit attempts among recovering alcoholics

Reported here are findings from a randomized community intervention trial that followed 90 recovering alcoholic smokers for 6 months. Because the brief (10-min) study intervention had no effect on tobacco use, intervention and control participants were pooled to identify predictors of attempts to quit smoking that may inform clinical practice. During the first 6 months after discharge from residential alcohol treatment, 31% of all participants reported having quit smoking for 48 hrs or longer. Demographic and drug use history variables did not predict quit attempts, but two baseline tobacco use variables did, specifically the Fagerstrom Test for Nicotine Dependence and stage of readiness to quit smoking, p < .01. Participants with high or very high nicotine dependence scores were significantly less likely than those with moderate or low scores to attempt smoking cessation. Compared to those in precontemplation at baseline, those in the preparation stage of readiness to change were about 12 times more likely to make a serious quit attempt.

Smoking cessation techniques

A key responsibility for all health care professionals is to advise patients to quit smoking, which means being knowledgeable about smoking cessation programs and methods. This article considers both assisted and self-help methods of smoking cessation and their application to female smokers. The most effective assisted programs employ multiple interventions, primarily behavioral, but also pharmacologic, in the form of nicotine replacement. Smoking cessation products have not generally proven effective with the exception of nicotine polacrilex gum and the transdermal nicotine patch. Use of nicotine replacement, especially the patch, in smokers who are pregnant or nursing is controversial. In addition to pregnant women, those with young children and those of color and low socioeconomic status represent important high-risk target populations. Very little work has been done with female adolescents.

Alcohol and tobacco use in the Minnesota Heart Health Program

Correlations between alcohol intake and cigarette smoking have been extensively documented. Prospective data on the relationship between smoking and alcohol remain quite limited. The Minnesota Heart Health Program (MHHP) collected such data as part of a 10-year research and demonstration project intended to reduce the prevalence of heart disease. The study involved six communities, three that received intervention and three, comparison. The current analyses focused upon baseline relationships and longitudinal changes in alcohol and tobacco use. Contrary to prediction, those who quit smoking were no more likely than continuing smokers to reduce alcohol intake. Furthermore, alcohol intake at baseline did not predict smoking status at follow-up. Gender differences were found in a number of comparisons. Further study is needed of changes in smoking and drinking patterns over time in the general population.

The smoking cessation process: longitudinal observations in a working population

BACKGROUND

Few prospective studies have investigated variables related to the smoking cessation process in nonvolunteer samples.

METHODS

Smoking history, behavioral intentions, degree of addiction, and demographic characteristics were examined over a 2-year period as predictors of four behavioral outcomes related to smoking cessation--participation in a smoking cessation program, attempting to quit, relapse, and success in quitting--in 802 working adults who were daily smokers at baseline. Change in behavioral intentions over the 2-year period was also examined.

RESULTS

Sixty-four percent of smokers made a serious quit attempt in the 2-year study period, 16% succeeded in quitting, and an additional 9% shifted from daily to occasional smoking. Stated intention to quit at baseline was a powerful and consistent predictor of three of the behavioral outcomes, but several demographic and smoking-related variables were differentially associated with these three outcomes.

CONCLUSIONS

Study findings indicate that smoking cessation is a dynamic process in which a majority of smokers are actively engaged. Smoking pattern and sociodemographic characteristics are predictors of whether smokers will participate in programs, make quit attempts, and succeed in quitting. Intention to quit is related to smoking outcomes in a manner that would be predicted by the Transtheoretical Model of Behavior Change.