The gold standard program (GSP) for smoking cessation: a cohort study of its effectiveness among smokers with and without cancer

BACKGROUND

Smoking cessation treatment is an important prognostic factor for survival after a cancer diagnosis, especially for tobacco-related cancers. After being diagnosed with lung cancer, approximately 50% of patients continue smoking or frequently relapse after a quit attempt. Given the importance of smoking cessation treatment for cancer survivors, the objective was to compare the effectiveness of a 6-week intensive smoking cessation intervention, the Gold Standard Program (GSP), among cancer survivors compared with smokers without cancer. Second, we compared successful quitting among socioeconomically disadvantaged cancer survivors with that among nondisadvantaged cancer survivors.

MATERIALS AND METHODS

This was a cohort study based on 38,345 smokers from the Danish Smoking Cessation Database (2006-2016). Linkage to the National Patient Register was used to identify cancer survivors undergoing the GSP after being diagnosed with cancer (except nonmelanoma skin cancer). Linkage to the Danish Civil Registration System was used to identify participants who died, went missing, or emigrated before the follow-up. Logistic regression models were applied to evaluate effectiveness.

RESULTS AND CONCLUSION

Six percent (2438) of the included smokers were cancer survivors at the time they undertook the GSP. Their 6-month successful quitting showed no difference compared to that of smokers without cancer, neither before nor after adjustment; 35% versus 37% in crude rates and an aOR of 1.13 (95% CI: 0.97-1.32). Likewise, the results for disadvantaged compared to nondisadvantaged cancer survivors were not significantly different (32% versus 33% and an adjusted aOR of 0.87 (95% CI 0.69-1.11)). Overall, an intensive smoking cessation program seems effective in helping both people without cancer and cancer survivors become successful quitters.

Erythrocyte mean cell volume--correlation to drinking pattern in heavy alcoholics

Erythrocyte mean cell volume (MCV) correlates well to alcohol intake in moderate alcoholism, but only about 50% of heavy drinkers have increased MCV. To evaluate the influence of the duration and extent of a drinking episode on MCV, 64 addictive alcoholics were investigated prospectively within two weeks after a drinking period. Their daily alcohol intake was 120-480 g and the actual drinking period has lasted for 1-104 weeks. For comparison, 21 non-active alcoholics were investigated. There was no correlation between MCV of active alcoholics and daily alcohol consumption or smoking habits, whereas a significant positive correlation was found between MCV and both duration of actual drinking episode and total alcohol intake in this period. We conclude that MCV is probably of greater value in estimating the duration and extent of actual drinking episodes in heavy alcoholics than in screening for alcoholism.

Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation

Background

The aim of this study was to examine the effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation itself.

Methods

Relevant databases were searched for randomized controlled trials (RCTs) of preoperative smoking cessation interventions. Trial inclusion, risk of bias assessment and data extraction were performed by two authors. Risk ratios for the above outcomes were calculated and pooled effects estimated using the fixed-effect method.

Results

Eleven RCTs were included containing 1194 patients. Smoking interventions were intensive, medium intensity and less intensive. Follow-up for postoperative complications was 30 days. For smoking cessation it was from the day of surgery to 12 months thereafter. Overall, the interventions significantly reduced the occurrence of complications (pooled risk ratio 0·56 (95 per cent confidence interval 0·41 to 0·78); P < 0·001). Intensive interventions increased smoking cessation rates both before operation and up to 12 months thereafter. The effects of medium to less intensive interventions were not significant. Meta-analysis of the effect on smoking cessation was not done owing to heterogeneity of data.

Conclusion

Surgical patients may benefit from intensive preoperative smoking cessation interventions. These include individual counselling initiated at least 4 weeks before operation and nicotine replacement therapy.

Smoking and alcohol intervention before surgery: evidence for best practice

Smoking and hazardous drinking are common and important risk factors for an increased rate of complications after surgery. The underlying pathophysiological mechanisms include organic dysfunctions that can recover with abstinence. Abstinence starting 3-8 weeks before surgery will significantly reduce the incidence of several serious postoperative complications, such as wound and cardiopulmonary complications and infections. However, this intervention must be intensive to obtain sufficient effect on surgical complications. All patients presenting for surgery should be questioned regarding smoking and hazardous drinking, and interventions appropriate for the surgical setting applied.

Little effect of transfer technique instruction and physical fitness training in reducing low back pain among nurses: a cluster randomised intervention study

The aim of this study was to evaluate the effect of a transfer technique education programme (TT) alone or in combination with physical fitness training (TTPT) compared with a control group, who followed their usual routine. Eleven clinical hospital wards were cluster randomised to either intervention (six wards) or to control (five wards). The intervention cluster was individually randomised to TT (55 nurses) and TTPT (50 nurses), control (76 nurses). The transfer technique programme was a 4-d course of train-the-trainers to teach transfer technique to their colleagues. The physical training consisted of supervised physical fitness training 1 h twice per week for 8 weeks. Implementing transfer technique alone or in combination with physical fitness training among a hospital nursing staff did not, when compared to a control group, show any statistical differences according to self-reported low back pain (LBP), pain level, disability and sick leave at a 12-month follow-up. However, the individual randomised intervention subgroup (transfer technique/physical training) significantly improved the LBP-disability (p = 0.001). Although weakened by a high withdrawal rate, teaching transfer technique to nurses in a hospital setting needs to be thoroughly considered. Other priorities such as physical training may be taken into consideration. The current study supports the findings of other studies that introducing transfer technique alone has no effect in targeting LBP. However, physical training seems to have an influence in minimising the LBP consequences and may be important in the discussion of how to prevent LBP or the recurrence of LBP among nursing personnel.

Motivation of trauma patients to stop smoking after admission to the emergency department

Every smoker should be offered smoking cessation treatment when they present for clinical care. The Readiness to Change-Smokers (RTC-S) questionnaire and the Heidelberg Smoking History (HSH) are brief questionnaires that divide patients into three stages. The purpose of this study was to prospectively compare the performance of each questionnaire at identifying patients who will successfully quit smoking within one year of Emergency Department (ED) discharge. Out of 1292 injured ED patients nearly half (n = 599, 46.4%) were identified as current smokers. Both questionnaires were given to all 599 subjects, and used to divide patients into three stages. At 12-months postdischarge 306 patients (51.1%) were contacted to determine smoking status. Patients were similarly classified by both tests in only 36% of cases. Concordance between tests was poor (kappa = 0.33). The RTC-S classified fewer patients as ready to quit (A = 13% vs. 22.2%). At 12 month follow-up, 55 patients (17.9%) had stopped smoking. The HSH was more successful to predict quitters. Multivariate logistic regression with respect to smoking cessation resulted in significant impact of HSH (p = 0.024).

Propofol increased the interleukin-6 to interleukin-10 ratio more than isoflurane after surgery in long-term alcoholic patients

This study investigated the effect of an anaesthetic regimen on the immune response in 40 long-term alcoholic patients undergoing surgery. Patients were randomly allocated to receive either propofol or isoflurane during surgery. Plasma cytokines interleukin (IL)-6 and IL-10 were measured at defined times and rates of post-operative infections were documented. The IL-6/IL-10 ratio significantly increased with propofol compared with isoflurane on day 1 after surgery and the IL-10 level significantly increased with isoflurane on day 1 after surgery. The overall post-operative infection rate was significantly higher in isoflurane-treated patients. Our findings indicate that propofol anaesthesia might be the more favourable regimen, with the IL-6/IL-10 ratio indicating an attenuation of the immune imbalance after surgery in long-term alcoholic patients. These results support the undertaking of a properly powered clinical trial to determine if propofol anaesthesia can reduce the postoperative infection rate in this special patient population.

Impaired postoperative outcome in chronic alcohol abusers after curative resection for lung cancer

OBJECTIVE

It has been demonstrated that chronic alcohol misusers, who drink at least 60 g of ethanol per day, are suffering increased postoperative morbidity after various non-pulmonary surgical procedures. The aim of this study was to evaluate the association between alcohol consumption and postoperative morbidity and mortality after potential curative resection for lung cancer.

METHODS

The records of all patients who underwent curative resection for lung cancer in a single University Centre in Cardiothoracic surgery during 1997 and 1998 were retrospectively reviewed. One hundred and seven patients, 42 women and 65 men, median age of 64 (33-79) years, were included and subdivided with regard to alcohol consumption. There were 26 pneumonectomies, 68 lobectomies and 13 lesser resections. Clinical complications occurring within 30 days after surgery and requiring therapy, were registered and subdivided into major, potentially lethal complications, and minor complications. Mortality within 30 days after surgery was also registered.

RESULTS

Patients drinking at least 5 drinks per day had increased postoperative mortality, 3/13 versus 2/94 (odds ratio (95% confidence limits): 13.80 (2.06-92.68); P=0.007). The rate of major, live threatening complications including septicaemia and cardiopulmonary insufficiency was significantly increased among patients drinking at least 5 drinks per day 6/13 versus 19/94 (odds ratio (95% confidence limits): 3.38 (1.02-11.25); P=0.047) in univariate analysis. However, in multivariate analysis this association was not significant.

CONCLUSION

Postoperative mortality after curative resection for lung cancer was significantly increased among patients drinking at least 5 drinks of alcohol per day.

Perioperative morbidity and mortality in chronic alcoholic patients

This article represents the proceedings of a symposium at the 2000 ISBRA Meeting in Yokohama, Japan. The chairs were Claudia Spies and Hanne Tønnesen. The presentations were (1) Relevance of alcohol misuse in surgical patients, by Hanne Tønnesen; (2) Diagnosis of alcohol abuse and alcohol dependence, by Sven Andreasson; (3) Diagnosis of acute alcohol misuse, by Anders Helander; (4) Preoperative intervention for excessive alcohol consumption, by Kate Conigrave; and (5) Prevention and treatment of perioperative complications in chronic alcoholics, by Claudia Spies.

[Emergency room patients and alcohol consumption]

To investigate the consumption of alcohol among emergency room patients, we included 395 patients above 18 years old entering the emergency room during a period of ten days. The patients completed a questionnaire about alcohol consumption, smoking habits and medication. In our investigation 56% of the men and 25% of the women had a daily consumption above the limits recommended by the Ministry of Health (three drinks daily for men and two for women), while 41% men and 14% women consumed at least five drinks daily or 35 per week. Trauma seen in male patients with high alcohol consumption was characterised by excessive damage to the head, trauma of the lower limb and blows from an object, person or an animal. The alcoholic women were characterised by excessive chemical injuries, incisions and stab wounds, and trauma of the upper limb. In conclusion a surprisingly large amount of emergency room patients can be defined as alcohol abusers and drinking is found to be associated with excessive damage.

[Active and passive smoking among personnel at the Bispebjerg Hospital 1992-1999]

The purpose of this study was to describe changes in smoking behaviour and exposure to passive smoking among hospital employees at a large Danish University Hospital (Bispebjerg Hospital) from 1992 until 1999 as part of a program toward a smoke-free hospital. The study was based upon three cross-sectional self-administered questionnaires surveys carried out among all employees at the hospital--approximately 4000 persons--in October 1992, April 1997 and April 1999, participation rates being 84, 80 and 76 percent. During the seven year period the smoking rate has decreased from 46% to 32% among male and 40% to 33% among female employees. A decrease in smoking rate was found among all subgroups of employees. Among male employees the rate of heavy smokers has decreased from 25 to 16%, among female employees this decrease is lacking, the rate of heavy smokers being 15% during the whole period. The numbers of employees exposed to passive smoking all day or most of the day has changed from 39% to 25% from 1992 until 1999. Among the smokers 30%--8% of all employees--responded that they would not be able to manage without smoking tobacco during working hours. This answer is most commonly found among heavy smokers, smokers with short or no education and smokers who smoke at any time of day. It is concluded that even though there has been a reduction in the smoking rate, the exposure to passive smoking among employees at the hospital still is unacceptably high. Based upon these results it has been decided that Bispebjerg Hospital is smoke-free for all employees from the 1st of January 2000. There is a need for initiatives for the smokers, who can't manage work without smoking.

[Smoking cessation and pregnancy]

OBJECTIVES

To assess the effectiveness of smoking cessation programs implemented during pregnancy and to assess the impact of these programs on the health of the fetus and infant, on the mother and on the family.

SEARCH STRATEGY

Randomized and quasi-randomized controlled trials identified by the search strategy of the Cochrane Pregnancy and Childbirth Group, supplemented by the search strategy of the Cochrane Tobacco Group.

SELECTION CRITERIA

Trials in which programs to increase smoking cessation were implemented during pregnancy.

DATA COLLECTION AND ANALYSIS

Data were abstracted according to predetermined criteria by two observers (S Oliver + J Lumley or E Waters + J Lumley). A total of 40 trials, conducted between 1975 and 1997, comprising over 9,000 women were identified and included in the review. An additional study provided data on over 3,000 women in a cluster-randomized trial. Interventions commonly included in these programs were: the provision of information on the risks of smoking to the fetus and infant and the benefits of quitting; recommendations to quit; feedback about the fetus; teaching cognitive-behavioural strategies for quitting smoking. There was substantial variation in the intensity of the intervention and the extent of reminders and reinforcement through pregnancy. Participants were healthy pregnant women and the usual setting was a hospital or community antenatal clinic. The principal outcome measure was continued smoking in late pregnancy. Eight trials provided some information on fetal outcomes: mean birthweight, low birthweight, preterm birth and perinatal mortality.

MAIN RESULTS

Pooled data from 30 trials revealed a significant reduction in the odds of continued smoking in late pregnancy in the intervention groups (odds ratio (OR) = 0.51, 95% confidence interval 0.45 to 0.58). This equates to an absolute difference in the proportion continuing to smoke of 6.6%. The findings were similar when analyses were restricted to the 17 trials with biochemical validated smoking cessation (OR = 0.49, 95% CI 0.42 to 0.58 and an absolute difference in continued smoking of 7.2%); to the 11 trials where the intervention intensity was high (OR = 0.50, 95% CI 0.42 to 0.59 and an absolute difference in continued smoking of 8.6%); and to the 12 trials with a high quality score for the intervention--rated on the theoretical basis, the intensity of the intervention, detailed description of the intervention, process evaluation, validated smoking cessation--(OR = 0.47, 95% CI 0.40 to 0.56 and an absolute difference in continued smoking of 8.9%). The six trials with validated smoking cessation, a high intensity intervention and a high quality score had a pooled OR = 0.47, 95% CI 0.38 to 0.57 and an absolute difference in continued smoking of 9.2%. The subset of trials with information on fetal outcome revealed a reduction in low birthweight (pooled OR = 0.80, 95% CI 0.67 to 0.97), a non-significant reduction in preterm birth (pooled OR = 0.82, 95% CI 0.66 to 1.01), and an increase in mean birthweight of 41 g (95% CI 16.6 to 65.5), but no differences in very low birthweight, stillbirths, neonatal deaths or total perinatal mortality. Three trials of smoking relapse prevention among women who had stopped smoking by the first antenatal visit had a pooled OR = 0.73, 95% CI 0.45 to 1.18, for smoking in late pregnancy, with an absolute difference of 5.5%. The single large cluster-randomized trial showed no evidence of a decrease in continued smoking: the adjusted OR for quitting smoking by late pregnancy was 1.0, 95% CI 0.69 to 1.6. There were no differences in adjusted mean birthweight in this trial by intervention or control clinic. Process evaluation identified some problems with the implementation of this trial.

CONCLUSIONS

Smoking cessation programs implemented in pregnancy increase smoking cessation, lead to a small increase in mean birthweight and a small reduction in low birthweight and preterm birth. (ABSTRACT TRUN

[Group therapy and smoking cessation]

OBJECTIVES

Smoking cessation programmes in which groups of smokers have the opportunity to learn behavioural techniques and benefit from mutual support for quitting are widely available. The aim of this review is to determine the effectiveness of smoking cessation programmes delivered in a group format, for helping smokers achieve long-term smoking cessation.

SEARCH STRATEGY

The Tobacco Addiction Group specialised register was used to identify trials in which one or more treatment arms used behaviour therapy, group therapy or cognitive therapy.

SELECTION CRITERIA

Randomised trials which compared group therapy with self-help, individual counselling, another intervention or usual care or waiting list control were selected. Trials which compared two group programmes with manipulation of the group interaction and social support components were also included. There had to be a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. Trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies were not included unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

The outcome ceasure extracted was the number of successful quitters at the maximum follow-up using the strictest definition of abstinence, with biochemical validation where possible. Participants lost to follow-up were classified as still smoking. Meta-analysis was performed using a fixed effects model.

MAIN RESULTS

Ten studies compared a group programme with a self-help programme presenting the same or similar information and behavioural techniques. There was an increase in cessation with the use of a group programme (OR 2.10 (95% C.I. 1.64-2.70). The direction of effect and significance was robust whether or not trials randomizing workplaces rather than individuals, and trials carried out during campaigns with televised cessation programmes were included. There was no evidence from two trials that group therapy was more effective than a similar intensity of individual counselling, and the trend favoured individual treatment. Comparison of group therapy with advice from a physician or nurse advice found no evidence for an effect, with heterogeneity in the results. Group programmes were more effective than no intervention or minimal contract interventions (OR 1.91 (95% C.I. 1.20-3.04). There was no evidence that manipulating the social interactions between participants in a group programme had an effect on outcome.

CONCLUSIONS

There is reasonable evidence that groups are better than self-help, and other less intensive interventions. There is not enough evidence on their effectiveness compared to intensive individual counselling. From the point of view of the consumer who is motivated to make a quit attempt it is probably worth joining a group if one is available--it will increase the likelihood of quitting. From the public health perspective, groups are unlikely to make a substantial impact because of the low uptake.

[Smoking intervention among hospital staff at the H:S Bispebjerg Hospital. Toward a non-smoking hospital--short-term results]

As part of aiming towards a non-smoking hospital environment, staff at a Copenhagen university hospital were offered participation in a differentiated smoking cessation programme. This consisted of lectures, group therapy, follow-up visits and individually tailored nicotine replacement therapy free-of-charge for six weeks. Three hundred and seventy-four employees started the programme, with 353 continuing for the full six weeks. They were moderately nicotine dependent with a Fagerström score of 5 (0-10). Almost all smoked daily and smoked at work, with 87% having a CO measurement above 5 at the first visit. At six weeks follow-up 209 (59%) were still not smoking and a further seven (2%) had reduced their tobacco consumption substantially. The remainder had started smoking again. Only 10% had a CO measurement > 5 at the end of the study. In conclusion, a combination of theoretical education, individual follow-up visits and nicotine replacement therapy is useful and worthwhile in the effort to support hospital staff in smoking cessation.

Is carbohydrate deficient transferrin a useful marker of harmful alcohol intake among surgical patients?

OBJECTIVE

To find out whether the biological marker, carbohydrate deficient transferrin (CDT), was helpful in the detection of alcoholic patients in a surgical unit.

DESIGN

Prospective open study.

SETTING

Teaching hospital, Denmark.

SUBJECTS

286 men and 248 women admitted to the department of surgical gastroenterology between March and July 1996.

MAIN OUTCOME MEASURES

Specific interview about drinking and correlation with CDT concentration.

RESULTS

31 men (13%) and 10 women (3%) were alcoholic and at special risk of operation. The correlation between intake and CDT:transferrin ratio was 0.63 for men and 0.53 for women. The correlation between consumption and CDT was better, being 0.77 and 0.58, respectively. Younger women had the lowest correlation (0.33). Sensitivity of CDT for men and women was 100% and 80%, respectively; the specificity was 97% and 96%; the positive predictive value 82% and 44%; and the negative predictive value 97% and 99%.

CONCLUSION

CDT is a valid marker of harmful alcohol intake among surgical patients, except among younger women.

Stress response to endoscopy

BACKGROUND

Upper gastrointestinal endoscopy is often accompanied by tachycardia, which may lead to myocardial ischaemia. The pathogenesis for tachycardia is unknown, but the classic endocrine stress response may be of importance.

METHODS

Seventeen patients (median age, 60 years) undergoing diagnostic gastroscopy without sedation or supplemental oxygen therapy were monitored by means of electrocardiogram, blood pressure, and pulse oximetry from 20 min before to 2 h after the procedure. Blood concentrations of glucose, cortisol, epinephrine, and norepinephrine were measured before, during, and after the endoscopy. Anxiety level was rated before the examination.

RESULTS

Endoscopy was followed by a significant increase in norepinephrine and cortisol levels concomitant with a significant peak in heart rate (76 to 90 min(-1)) and mean arterial blood pressure (97 to 111 mmHg). Epinephrine was significantly reduced after the endoscopic procedure. We found no changes in glucose level or in arterial oxygen saturation. None of the patients developed signs of myocardial ischaemia during the procedure. There was no correlation between preendoscopy anxiety and the different stress variables (P > 0.3).

CONCLUSIONS

The endoscopic procedure induces a classic endocrine metabolic stress response, probably causing the observed tachycardia.