Protocol for the Proactive Or Reactive Telephone Smoking CeSsation Support (PORTSSS) trial

BACKGROUND

Telephone quit lines are accessible to many smokers and are used to engage motivated smokers to make quit attempts. Smoking cessation counselling provided via telephone can either be reactive (i.e. primarily involving the provision of evidence-based information), or proactive (i.e. primarily involving repeated, sequenced calls from and interaction with trained cessation counsellors). Some studies have found proactive telephone counselling more effective and this trial will investigate whether or not proactive telephone support for smoking cessation, delivered through the National Health Service (NHS) Smoking Helpline is more effective or cost-effective than reactive support. It will also investigate whether or not providing nicotine replacement therapy (NRT), in addition to telephone counselling, has an adjunctive impact on smoking cessation rates and whether or not this is cost effective.

METHODS

This will be a parallel group, factorial design RCT, conducted through the English national NHS Smoking Helpline which is run from headquarters in Glasgow. Participants will be smokers who call the helpline from any location in England and who wish to stop smoking. If 644 participants are recruited to four equally-sized trial groups (total sample size = 2576), the trial will have 90% power for detecting a treatment effect (Odds Ratio) of 1.5 for each of the two interventions: i) proactive versus reactive support and ii) the offer of NRT versus no offer. The primary outcome measure for the study is self-reported, prolonged abstinence from smoking for at least six months following an agreed quit date. A concurrent health economic evaluation will investigate the cost effectiveness of the two interventions when delivered via a telephone helpline.

DISCUSSION

The PORTSSS trial will provide high quality evidence to determine the most appropriate kind of counselling which should be provided via the NHS Smoking Helpline and also whether or not an additional offer of cost-free NRT is effective and cost effective for smoking cessation.

Do implementation issues influence the effectiveness of medications? The case of nicotine replacement therapy and bupropion in UK Stop Smoking Services

Background

Effective pharmacotherapies are available for smoking cessation but their efficacy is established through randomised controlled trials where the medication is supplied direct to subjects. In health care settings patient access to medicines is often less direct. The process for obtaining supplies of nicotine replacement therapy (NRT) is relatively easy for smokers attending National Health Service (NHS) Stop Smoking Services in the UK, whilst this is not necessarily the case for those wishing to using prescription only medicines (e.g. bupropion and varenicline). This study was a direct comparison of the short-term validated abstinence rates of NRT and bupropion in a clinical setting.

Methods

Data were routinely collected from 2626 clients setting a quit date (82% of those registering) with two London NHS Stop Smoking Services that offered behavioural support combined with pharmacotherapy (NRT and bupropion).

Results

Contrary to what would be expected from multiple randomised controlled trials, the CO-validated 3–4 week abstinence rate in clients using NRT was higher than for bupropion (42% versus 34%, p = .003). This difference persisted even when controlling for smoking characteristics, demographic variables and treatment variables 1.40 (95% CI = 1.08 – 1.83).

Conclusion

Given that the level of behavioural support received by clients on each medication was identical, the most plausible explanation for the difference in effectiveness between NRT and bupropion perhaps lies with how clients of the Stop Smoking Services obtained their medications. Obtaining NRT was relatively easy for clients throughout the study period whilst this was not the case for bupropion. This study suggests that implementation issues and/or self-selection may influence the effectiveness of medications in health care, as opposed to research, settings.

What General Practitioners Can Do to Deliver More Brief Stop-Smoking Interventions: An Exploratory Study

Guidelines recommend that general practitioners (GPs) should advise all smoking patients to quit and provide additional stop-smoking interventions as appropriate. This study aimed to improve our understanding of how this recommendation can be achieved. General practitioners (N = 26) from London completed a questionnaire about their stop-smoking interventions and psychological factors that might affect these. Thirty-one per cent of the patients recognised as smokers by GPs did not receive an intervention and two-thirds of these were judged to be inappropriate for receipt of an intervention. Psychological factors that predicted behaviour were perceptions that doing this was ‘normative’, making an effort to make it happen, and feeling that the behaviour was easy to enact. Strategies to improve guideline implementation may be more effective if they addressed the above psychological factors.

Randomized controlled trial of physical activity counseling as an aid to smoking cessation: 12 month follow-up

There is some evidence to suggest that regular supervised physical activity may be useful as an aid to smoking cessation. It is unclear whether less extensive interventions confer similar benefits. This study examined whether physical activity counseling alone increases long-term smoking abstinence and physical activity levels and reduces weight gain. 299 male and female smokers were randomized to a 7-week smoking cessation program, including nicotine replacement therapy, plus either (i) physical activity counseling ('exercise', N=154), or (ii) health education advice ('control', N=145). There was no significant difference in rates of continuous smoking abstinence between the exercise group and the controls at 12 months following the quit day (9.1% versus 12.4%). Significant increases in physical activity levels observed for the exercise group versus the controls at six weeks were not maintained at 12 months. There was a non-significant tendency for less weight gain in the exercise group versus the controls at 12 months (P=0.06). Further trials are needed to examine the effect of more extensive physical activity interventions on smoking cessation, physical activity levels and post-cessation weight gain.

Hyperion's sponge-like appearance

Hyperion is Saturn's largest known irregularly shaped satellite and the only moon observed to undergo chaotic rotation. Previous work has identified Hyperion's surface as distinct from other small icy objects but left the causes unsettled. Here we report high-resolution images that reveal a unique sponge-like appearance at scales of a few kilometres. Mapping shows a high surface density of relatively well-preserved craters two to ten kilometres across. We have also determined Hyperion's size and mass, and calculated the mean density as 544 +/- 50 kg m(-3), which indicates a porosity of >40 per cent. The high porosity may enhance preservation of craters by minimizing the amount of ejecta produced or retained, and accordingly may be the crucial factor in crafting this unusual surface.

Somali women's experience of childbirth in the UK: Perspectives from Somali health workers

OBJECTIVE

to conduct a qualitative study of perceptions of experiences of childbirth from Somali health workers in the UK.

DESIGN & SETTING

in depth narrative interviews at community centres and places of work in London.

PARTICIPANTS

eight Somali women aged between 23 and 57 years. The interviewees worked within the health sector in the UK and/or as nurses or gynaecologists in Somalia. Six of the women had also given birth in the UK.

KEY FINDINGS

mismanagement of care of female circumcision provided during pregnancy and labour leads to problems at birth for many Somali women. The importance of Somalia's oral culture is not recognised when addressing communication barriers and continuity of care is lacking but important. Somali women also felt that midwives held stereotyped and negative attitudes towards them. Existing pressures as a consequence of migration were compounded by these experiences of childbirth in the UK.

KEY CONCLUSIONS

issues concerning female circumcision, verbal communication, cultural aspects of care and pressures that were a consequence of migration play a part in the experience of childbirth in the UK for Somali women.

IMPLICATIONS FOR PRACTICE

midwives need to possess the necessary clinical knowledge and skills to deal with women who have been circumcised and the issue needs to be raised early in the pregnancy. Attention needs to be paid to ensure continuity of care, maximising verbal communications and challenging stereotypical views of Somali women.

Randomized controlled trial of a social support ('buddy') intervention for smoking cessation

OBJECTIVE

To assess the effectiveness of including a social support intervention ('buddy system') in a group treatment programme to aid smoking cessation.

METHODS

Five hundred and sixty-three smokers attended groups at a smokers' clinic. These groups were randomized either to be (a) groups in which smokers were paired with another person to provide mutual support (buddy condition: n=237 in 14 groups) or (b) to receive the same treatment without the buddy component (control: n=326 in 20 groups). Participants were seen weekly for the first 4 weeks after stopping then followed up again after 26 weeks.

RESULTS

Smokers in the buddy condition were no more likely than smokers in the control condition to stay abstinent at 1, 4 or 26 weeks. The effect was in the right direction at week one post-quit but after controlling for potential confounders the difference was not significant (odds ratio=1.45 (95% CI; 0.92-2.29), p=0.06).

CONCLUSIONS

We were unable to show that a buddy system improved abstinence rates of group treatment programmes. This might be due to the high level of social support already achieved through the groups.

PRACTICE IMPLICATIONS

The buddy system is a simple and very low cost addition to a group treatment programme; but the results from this study suggest that the kind of buddy system tested may not add substantially to the success rates. However there may be merits in a more intensive or protracted form of buddying.

A practical guide to research for nurses and midwives

Research is a key way for nurses and midwives to develop their knowledge and skills. An understanding of the research process and accessing resources is essential if more nurses are to become active in research. This article summarises Conducting Research: A Handbook for Nurses and Midwives (McEwen et al, 2006), which provides information on tools, techniques and contacts.

Effectiveness of specialist group treatment for smoking cessation vs. one-to-one treatment in primary care

OBJECTIVE

Using a quasi-experimental design, this paper contributes to an important debate about the most effective form of psychological treatment to aid smoking cessation: group treatment provided by specialists or one-to-one treatment provided in the community by primary care nurses or pharmacists.

METHODS

Data were routinely collected from 1501 clients of a large London stop smoking service that offered both group and one-to-one treatment.

RESULTS

A quarter (25%) of the clients were continuously abstinent 4 weeks post-quit: 30% for those receiving group treatment and 19% for one-to-one (Fisher's exact [2-sided]<.001). The difference between the specialist and community-based treatment remained after all possible confounding factors were controlled for (OR: 2.27, p<.001).

CONCLUSIONS

In the same service with the same management structure and training programme, group treatment offered by the specialist service yielded higher success rates than counselling by trained primary care nurses and pharmacists.

Triggering anti-smoking advice by GPs: mode of action of an intervention stimulating smoking cessation advice by GPs

OBJECTIVE

To assess the mode of action of an intervention (GP desktop resource, GDR) that increased the frequency of general practitioner (GP) advice to stop smoking.

METHODS

Analyses were undertaken to differentiate between three hypotheses regarding the mode of action of the GDR. That the GDR acts: (1) by altering GPs' attitudes, (2) independently of attitudes in prompting GPs to intervene with smokers or (3) by altering the relationship between attitudes and behaviour.

RESULTS

The GDR was an independent predictor of the number of patients advised to stop smoking (beta = .345, p < .001). Concern about the doctor-patient relationship was the only attitude variable that independently predicted advice giving, in this case negatively (beta = -.465, p < .001). Possession of the GDR did not alter GPs' views on whether intervening with smokers harmed the doctor-patient relationship, but did weaken the relationship between this attitude item and the number of patients advised to stop smoking (beta = .595, p < .001 for the interaction).

CONCLUSION

This study is the first to show that concern over the doctor-patient relationship was an independent predictor of advice giving while in other studies it has merely been noted as something that GPs express concern about. A simple device designed to trigger action on the part of GPs appeared to work by mitigating the negative effect of an attitudinal barrier to action. It would be interesting to explore this phenomenon more generally in relation to health promotion activities on the part of health professionals.

PRACTICE IMPLICATIONS

Recommendations that GPs engage in health promotion activities with their patients need to consider that GPs' concerns over harming the doctor-patient relationship may deter them from making such interventions. The GDR appears to be effective in prompting GPs to advise their smoking patients to stop and its widespread distribution to GPs should be considered.

Cassini Observes the Active South Pole of Enceladus

Cassini has identified a geologically active province at the south pole of Saturn's moon Enceladus. In images acquired by the Imaging Science Subsystem (ISS), this region is circumscribed by a chain of folded ridges and troughs at approximately 55 degrees S latitude. The terrain southward of this boundary is distinguished by its albedo and color contrasts, elevated temperatures, extreme geologic youth, and narrow tectonic rifts that exhibit coarse-grained ice and coincide with the hottest temperatures measured in the region. Jets of fine icy particles that supply Saturn's E ring emanate from this province, carried aloft by water vapor probably venting from subsurface reservoirs of liquid water. The shape of Enceladus suggests a possible intense heating epoch in the past by capture into a 1:4 secondary spin/orbit resonance.

Reduction in cortisol after smoking cessation among users of nicotine patches

OBJECTIVE

Cortisol has been shown to decline after stopping smoking and this decline has been associated with smoking relapse and with reports of increased withdrawal severity and distress. We examined whether a decrease in cortisol is evident in smokers trying to quit using nicotine patches and whether cortisol is related to withdrawal symptoms, smoking urges, subjective stress, nicotine dependence, and smoking relapse.

METHODS

Among 112 smokers trying to quit using 15-mg patches, salivary cortisol and reports of stress, withdrawal, and urges were measured before quitting smoking and up to 6 weeks of abstinence among abstinent smokers using 15-mg nicotine patches. Thirty participants both remained abstinent and provided cortisol samples at all measurement times.

RESULTS

Relative to preabstinence, there was a significant decline in cortisol after abstinence of 1 day, and after 1, 2, and 6 weeks (p < .05). The decline in cortisol on the first day of abstinence was positively associated with reported cigarette consumption (p < .01) and tended (nonsignificant) to be associated with smoking relapse at 6 weeks (p = .07). A lower absolute level of cortisol, but not the change in cortisol, on the first day of abstinence was significantly associated with increased reports of urges, withdrawal symptoms, and stress (p < .05), independently of reported cigarette consumption.

CONCLUSIONS

Smokers using 15-mg nicotine patches are likely to experience a decline in cortisol on stopping smoking. This decline is likely to be greater among heavier smokers and may predict relapse to smoking. Those with lower cortisol after cessation may experience increased withdrawal symptoms, urges to smoke, and subjective stress.

Continuing education of tobacco use cessation (TUC) for dentists and dental hygienists

Tobacco use prevention (TUC) guidelines are mostly designed for undergraduate education. Most practising dental professionals have not been trained in TUC and so current and future guidelines need to be adapted for continuing education. It is important to motivate dental professionals to be involved in TUC. 'The 3 Ts' is one suggested method of stimulating this motivation. Two levels of TUC are recommended, and both brief advice and enhanced interventions can be incorporated into routine practice. It is recommended that TUC continuing education on these interventions should be provided by a team of dental and trans- disciplinary experts. The maintenance of TUC involvement can be divided in individual and collective strategies. The international dental professional organisations can provide important 'benchmarks' for minimum clinical standards and for the involvement of both national dental organisations and individual dental health professionals in TUC continuing education.

The influence of outreach in the development of the nurse consultant role in critical care: cause or effect?

BACKGROUND

Critical care nurse consultant roles have evolved against a background of service innovation that has resulted in the development of critical care outreach services. Despite compelling evidence that there was a serious problem with the management of critically ill patients in the ward environment, there is little evidence to support outreach as a concept or as a role for nurse consultants.

AIMS

The aims for this part of the study were to:

METHODS

A national postal survey of all 72 critical care nurse consultants in post in England by August 2003; response rate 72% (n = 52). All data was entered on to a computer anonymously and analysed using SPSS version 11.5. A factor analysis revealed a sub-set of nurse consultants who had a significantly greater involvement in outreach activity.

RESULTS

Critical care nurse consultants have a high involvement in the development of care for critically ill patients outside the traditional boundaries of critical care. A sub-set emerged that has a significantly greater involvement in outreach activity. This includes roles such as working with an individual or team to develop their practice (whole group mean involvement score M = 4.45, outreach M = 4.88, p < 0.001); developing education outside the ICU/HDU (whole group M = 4.13, outreach M = 4.88, p < 0.001) and receiving nurse led referrals from the wards (whole group M = 3.92, outreach M = 4.81, p < 0.001).

CONCLUSIONS

Given the lack of evidence for outreach, organisations should consider the high level of involvement of the nurse consultant outside the traditional boundaries of the ICU/HDU.

Critical care without walls: The role of the nurse consultant in critical care

BACKGROUND

The nurse consultant role was first described in 1999 and has undergone little evaluation since. Critical care nurse consultant roles have developed against a background of service innovation following a review of adult critical care and have resulted in a variety of job roles and titles. There is some evidence to suggest that these posts are developing differentially and with varied role content.

AIMS

To provide a profile of the nurse consultant in critical care. To identify critical care roles in practice.

METHOD

A national postal survey of all 72 critical care nurse consultants in post in England by August 2003; response rate 72% (n = 52).

RESULTS

The majority (54%) of critical care nurse consultants were aged between 40 and 50 years with a mean of 18.4 years post registration experience. The majority held a higher degree (71%) and at least one additional professional qualification (96%); many (44%) continue to study. Most critical care nurse consultants (69%) reported that a nurse does not manage them operationally. Nurse consultants were taking the lead in developing care outside the traditional boundaries of the Intensive Care Unit (ICU) (mean involvement score, M = 4.25) and with outreach rounds on the wards (M = 3.78). Despite having an overall high involvement (M = 3.37) with the practice and service development function, they had a lower involvement with research activities (M = 2.87). They also had a low involvement with strategic organisations such as the Department of Health (M = 1.63), Strategic Health Authorities (M = 1.54) and Primary Care Trust's (M = 1.49).

CONCLUSIONS

The critical care nurse consultants who responded to this survey were clinically experienced and educated to an advanced level. They were leading the care of critically ill patients outside the traditional boundaries of the ICU, but have significantly less involvement within the ICU. Nurse consultants' restricted involvement with strategic organisations may limit the development of the role.

The attitude of maternity staff to, and smoking cessation interventions with, childbearing women in London

OBJECTIVES

To explore the self-reported smoking-cessation interventions of maternity staff with pregnant smokers, and their attitudes towards smoking in pregnancy.

DESIGN AND SETTING

Postal survey of all 137 maternity staff (clinical grades A-H) at a large acute hospital in London; 78 questionnaires were completed (response rate: 57%).

FINDINGS

Over two-thirds of respondents (71%) reported not advising any pregnant women to give up smoking within the previous 7 days. However, nearly two-thirds (64%) felt that women should not be left to make up their own minds about whether or not to smoke during pregnancy, and even more (81%) agreed or strongly agreed that many pregnant women would like to give up smoking but need help and advice on how to succeed. Helping a pregnant woman to give up smoking was seen as being one of the most important things a midwife can do by 73% of the respondents.

CONCLUSIONS

Although the reported attitudes were supportive of the midwife's role in smoking cessation, they did not translate into practice. The level of smoking cessation interventions was low.

IMPLICATIONS FOR PRACTICE

The findings from this study indicate some deficits in knowledge among maternity staff that training may address. Raising awareness of the local smoking-cessation service, and how to refer women to it, may increase the number of referrals maternity staff make.

Are ward sisters and charge nurses able to fulfil their role?

AIM

To investigate the self-reported duties carried out by sisters and charge nurses working on the wards and to assess the attitudes of these health care professionals towards their management role.

METHOD

Questionnaire.

RESULTS

Sisters/charge nurses were allocated patients in addition to being in charge of their ward for, on average, half of their shifts each week. Most of them did not have time to complete their managerial duties, which included supporting and supervising other staff on patient care issues. More than 50 per cent of the sisters/charge nurses did not have the time to attend clinical supervision.

CONCLUSION

Sisters/charge nurses treat clinical care--both delivering it directly themselves and advising other staff on its delivery--as a higher priority than their managerial and administrative duties; lack of time is a barrier to the successful fulfilment of their role.

General practitioners' views on and referral to NHS smoking cessation services

OBJECTIVES

Increasing the rate of smoking cessation remains a major public health goal. To help achieve this in the UK, National Health Service (NHS) smoking cessation services have been established to provide treatment for smokers wanting help with stopping. Referrals from general practitioners (GPs) are crucial to the success of these clinics. This study aimed to assess English GPs' self-reported interactions with, and attitudes towards, their local smoking cessation services.

STUDY DESIGN

Postal survey assessing the attitudes of GPs in England towards, and formal interactions with, NHS smoking cessation services.

METHODS

A questionnaire was posted to a random sample of 544 GPs in England (response rate 63%). GPs' self-reported interactions with smoking cessation services and their attitudes towards these clinics were assessed. GPs were also asked what factors determined whether they prescribed nicotine-replacement therapy (NRT) and Buproprion (Zyban), and what was the extent and nature of their smoking cessation interventions with their patients.

RESULTS

Most GPs (94%) reported that they were aware of the specialist smoking cessation service in their area. Seventy percent of GPs supported the continuation of current funding for specialist smoking cessation services. Seventy percent reported that they referred patients to these services, and 55% had staff within their practices trained as community smoking cessation advisors. Most GPs (79%) reported 'clinical need' as a determinant of whether they prescribed NRT/Zyban, and a few GPs cited 'budgetary constraints' as a factor (15%). Ninety-eight percent of GPs reported that they record smoking status when new patients join their practice, and they advise smokers to stop 'at least every now and then'.

CONCLUSIONS

GPs support the existence and continuation of specialist smoking cessation services, and most reported that they refer patients to them. Virtually every GP reported that they record smoking status when new patients join their practice, and they advise smokers to stop 'at least every now and then'.