Distribution of smokers by stage in three representative samples

Tobacco smoking within psychiatric inpatient settings: biopsychosocial perspective

Tobacco smoking remains a neglected issue within general psychiatry despite high rates of associated morbidity and mortality. While there has been a coordinated community campaign to reduce tobacco smoking within the general population, mental health facilities have been reluctant to adopt such regulatory controls, and rarely target smoking prevention or treatment. This paper summarizes and discusses evidence relating to the clinical impact of tobacco smoking within inpatient psychiatric settings. A selective review of psychiatric and psychological research on smoking within inpatient settings was conducted, with a particular focus on the influence of smoking on the physical and mental health, pharmacotherapy, and social interactions of patients during their inpatient stay. Patients frequently alter their smoking habits during inpatient treatment, which can affect both their presentation and pharmacotherapeutic management. Smoking also appears to play a central role in social interactions on the ward, with staff frequently using cigarettes to reinforce certain behaviours. Despite current guidelines, mental health professionals rarely address nicotine use among their patients. Nevertheless, programmes that assist patients to quit during an inpatient stay have been shown to be both efficacious and cost-effective. Strategies that address staff concerns and assist in the implementation of effective smoking bans on psychiatric units are also available. Cessation should be a key component of inpatient treatment planning because this setting provides a safe and timely opportunity to help patients quit. A flowchart of interventions that could be incorporated within standard inpatient settings is proposed.

Do paediatricians provide brief intervention for adolescents who smoke?

AIMS

This study aimed to describe the self-reported practice of paediatricians in brief interventions for adolescents who smoke. We also aimed to compare practice with confidence, skills and knowledge of brief intervention and nicotine replacement therapy after a targeted training programme.

METHODS

Medical staff at The Children's Hospital at Westmead completed a questionnaire of clinical practice and confidence in brief intervention for smoking cessation. Data were analysed comparing self-reported practice with confidence, skill and knowledge of brief interventions, based on Fiore's 5A's approach (Ask about smoking at every opportunity, Assess willingness to quit, Advise patients to quit smoking, Assist quit attempts and Arrange follow up).

RESULTS

Fifty-seven clinicians completed questionnaires, 55 (96%) recognised the importance of asking adolescents about smoking. Thirty-one (54%) identified adolescent smokers all or most of the time, increasing to 50 (88%) if their presenting condition was associated with smoking. Twenty-five (44%) clinicians assessed the stage of change, 33 (58%) advised the adolescent to quit smoking, nine (16%) assisted quit attempts and 10 (17.5%) arranged follow up. Clinicians more confident in brief intervention skills, motivational interviewing and relapse prevention were more likely to use the 5A's (P<0.05). Training increased clinician's confidence in brief intervention skills and knowledge of nicotine replacement therapy (P<0.01); however, there was no statistically significant change in clinical practice 1 month post training.

CONCLUSION

Training paediatricians in brief intervention skills, motivational interviewing and relapse prevention can increase the use of 5A's brief intervention in clinical practice, potentially increasing quit attempts in adolescents who smoke.

Prospective determinants of smoking cessation in COPD patients within a high intensity or a brief counseling intervention

OBJECTIVES

The aims of this study were to identify prospective determinants of smoking cessation in COPD patients, and to assess whether prospective determinants vary between two different cessation interventions.

METHODS

Two hundred and twenty-five moderate to severe COPD patients were randomly allocated to two smoking cessation interventions. One-year cotinine-validated continuous abstinence rates were 9% for the minimal intervention strategy for lung patients (LMIS) and 19% for the SmokeStopTherapy (SST). The baseline characteristics that showed a significant univariate relationship with 1-year continuous abstinence (p<.20) were included in the logistic regression model. This procedure was performed for each intervention separately. Variables that did not remain independent predictors were removed.

RESULTS

For the SST separately, no independent significant predictor remained. For the LMIS, attitude towards smoking cessation (OR: 11.8; 95% CI: 1.7-81.5; p=.013) and cotinine level (OR: 2.1; 95% CI: 1.08-3.93; p=.028) remained significant predictors. Within the LMIS, 31% of the variance in continuous abstinence was explained by these variables (p=.003).

CONCLUSION

This study suggests that a moderately intensive intervention (LMIS) is primarily suitable for COPD patients with a positive attitude regarding smoking cessation. The more intensive SST can be an alternative for patients without such baseline characteristic.

PRACTICE IMPLICATIONS

This stepped-care approach in smoking cessation counseling may be useful in clinical practice and will enable health care providers to match interventions to individual needs and increase efficiency.

Are the stages of change socioeconomically distributed? A scoping review

OBJECTIVE

To conduct a rapid scoping review to explore the hypothesis that socioeconomic affluence is associated with a more advanced stage of change for health behaviors.

DATA SOURCE

Key-word searches of MEDline, Embase, PyschlNFO, and www.google.com were conducted.

STUDY INCLUSION AND EXCLUSION CRITERIA

Studies identified by the searches were included if they were published between 1982 and September 2003, written in English, and reported information on the distribution of the stages of change for any health behavior according to a marker of socioeconomic position (SEP).

DATA EXTRACTION

Data on the behavior studied, the sample studied, the measure of SEP used, the definitions of the stages of change used, and the distribution of the stages of change according SEP were extracted by a single reviewer.

DATA SYNTHESIS

As far as possible, data were reanalyzed by the chi-square test to determine if there was evidence that the distribution of the stages of change varied according to SEP. A formal meta-analysis was not appropriate. Results. Twenty-one studies reporting data on 30 samples and 188,850 individuals were included. Significant variations in the distribution of the stages of change were found according to SEP, in the expected direction, in 16 (53%) samples representing 171,183 (91%) individuals.

CONCLUSIONS

There is substantial published evidence that more-affluent people tend to be in more-advanced stages of change than are more-deprived people.

Skalen zur Erfassung der Konstrukte des Transtheoretischen Modells zur Änderung des Rauchverhaltens

Zusammenfassung. Das Transtheoretische Modell der Verhaltensänderung (TTM) stellt eine verbreitete theoretische Basis für die Konzeption von bevölkerungsbezogenen und individualisierten Interventionen dar. Voraussetzung hierfür ist eine valide, reliable und ökonomische Erfassung der Konstrukte des TTM. Für die Implementation derartiger Interventionen stellt die hausärztliche Praxis einen viel versprechenden Zugangsweg dar. Aussagekräftige Daten zu psychometrischen Eigenschaften deutschsprachiger Kurzskalen aus genanntem Setting fehlen jedoch bisher. Im Rahmen der vorliegenden Studie wurden 1653 rauchende Patienten (Teilnahmerate 82%) aus 34 zufällig ausgewählten hausärztlichen Praxen (Teilnahmerate 87%) schriftlich befragt. Es erfolgte eine Prüfung der psychometrischen Eigenschaften der Skalen Entscheidungsbalance, Selbstwirksamkeitserwartung und Prozesse der Verhaltensänderung. Es konnte für alle Skalen die postulierte faktorielle Struktur bestätigt werden. Die Skalen zur Entscheidungsbalance und zur Selbstwirksamkeitserwartung wiesen bei der Reliabilität Mängel auf. Die vorliegenden Kurzskalen und Normdaten bilden eine empirische Basis für die Individualisierung von Interventionen zur Abstinenzförderung in der hausärztlichen Praxis. Einschränkungen und Weiterentwicklungsbedarf der Skalen werden diskutiert.

What are the differences in decisional balance and self-efficacy between Turkish smokers in different stages of change?

This paper reports the results of an examination of decisional balance (pros and cons of smoking), and self-efficacy constructs, sociodemographic and smoking-related variables among smokers from different stages of change as proposed by the transtheoretical model. A convenience sample of 398 smokers completed the research instrument. Almost 60% of the sample were in the precontemplation stage. The results indicated that pros of smoking dropped significantly from precontemplation to contemplation and preparation but then increased again for the action stage smokers. Cons of smoking increased almost linearly from precontemplation to preparation stages and they were the highest for the action stage. Self-efficacy also increased in a linear fashion and preparation and action stages were significantly higher than the precontemplation and contemplation stages. There were also significant differences among stages of change of groups on age, years of education, and smoking duration and number of quit attempts. Results underlined the importance of finding alternatives that may substitute for the pros of smoking and interventions for changing the cognitive evaluations related to cons of smoking. Additionally, smokers may gain from approaches that focus on encouraging and reinforcing self-efficacy during the action and maintenance stages to ensure a long-term positive outcome.

Smoking during pregnancy: where next for stage-based interventions?

Pregnancy is a 'window of opportunity' for encouraging positive behaviour change, such as quitting smoking. Associations have been shown between smoking stage of change and other health behaviour during pregnancy. For example, women in the precontemplative stage have poorer assessment of risks associated with smoking, feel less personally responsible for their unborn child's health and in turn are less likely to adopt health-promoting behaviour. Stage of change models are a popular tool within the health services, but the results of stage-based smoking cessation interventions are mixed. Identifying the crucial components of effective interventions is an important imperative for research in this area. This article reviews the literature to ascertain these components and makes recommendations for designing effective interventions.

Efficacy and effectiveness trials: examples from smoking cessation and bullying prevention

If health psychology is to maximize impacts on health, there will need to be a shift from relying primarily on efficacy trials to increasing reliance on effectiveness trials. Efficacy trials use homogeneous, highly motivated samples with minimal complications from a single setting receiving intensive treatments delivered under highly controlled conditions. Two effectiveness trials on bullying prevention illustrate the use of a heterogeneous population from multiple sites receiving a low intensity tailored treatment delivered under highly variable conditions. In spite of considerable noise the effectiveness trials produced robust results (odds ratios of about four) that bode well for population impacts under real-world dissemination.

Medical students' use of the stages of change model in tobacco cessation counseling

BACKGROUND

Many medical schools have incorporated the Stages of Change Model into their curricula with specific application to tobacco cessation.

OBJECTIVE

This study examined the extent to which medical students were prepared to provide stage-based interventions to treat nicotine dependence.

DESIGN

Using a quasi-experimental design, medical students' counseling interactions were evaluated with a standardized patient portraying a smoker in either the precontemplation or preparation stage of change.

PARTICIPANTS

Participants were 147 third-year medical students at the University of California, San Francisco.

MEASUREMENTS

Checklists completed by standardized patients evaluated students' clinical performance. Surveys administered before and after the encounters assessed students' knowledge, attitudes, confidence and previous experience with treating smoking.

RESULTS

Most students asked about tobacco use (89%), advised patients of the health benefits of quitting (74%), and assessed the patient's readiness to quit (76%). The students were more likely to prescribe medications and offer referrals to patients in the preparation than in the precontemplation stage of change (P < 0.001); however, many students had difficulty identifying patients ready to quit, and few encouraged patients to set a quit date or arranged follow-up to assess progress. Students' tobacco-related knowledge, but not their attitudes, confidence, or previous experience predicted their clinical performance.

CONCLUSIONS

The findings indicated evidence of students tailoring their counseling strategies to the patients' stage of change; however, they still could do more to assist their patients in quitting. Additional training and integration of cessation counseling into clinical rotations are needed.

A randomized controlled trial of smoking cessation for pregnant women to test the effect of a transtheoretical model-based intervention on movement in stage and interaction with baseline stage

OBJECTIVES

To examine whether, as predicted by the transtheoretical model (TTM), stage-matched interventions will be more effective than stage-mismatched interventions.

DESIGN

Randomized controlled trial of smoking cessation advice to pregnant smokers.

METHODS

Pregnant women currently smoking at 12 weeks gestation were enrolled in a pragmatic three-arm trial of TTM-based interventions to help them stop smoking. One arm constituted standard midwifery advice and a self-help leaflet on stopping smoking, which is generally appropriate for women in preparation. Two arms were TTM-based. Differences in positive movement in stage towards quitting from enrolment to 30 weeks gestation and 10 days post-partum were calculated for each arm of the trial. We then examined whether, as predicted from the TTM, the relative benefit of the TTM-based intervention was greater for women in precontemplation and contemplation, for whom the control intervention was stage-mismatched, than for women in preparation, for whom the control intervention was stage-matched.

RESULTS

Women in the TTM-based arms were statistically significantly more likely to move forward in stage than were women in the control arm. Contrary to the TTM-derived hypothesis, the greater relative benefit of the TTM-based intervention was seen for women in preparation stage at baseline, rather than women in precontemplation and contemplation.

CONCLUSIONS

The TTM-based intervention was more effective in stage movement, but this could be due to its greater intensity. The failure to confirm that stage-matching was important casts doubt on the validity of the TTM in explaining smoking cessation behaviour in pregnancy.

Cigarette smoking and interest in quitting in methadone maintenance patients

OBJECTIVES

To examine tobacco use, readiness to quit, and interest in smoking cessation interventions among methadone maintenance patients.

METHODS

Cross-sectional survey of outpatients enrolled in four urban methadone maintenance clinics. Stage of readiness to quit was determined for all smokers, and factors associated with both readiness to quit and interest in attending an on-site smoking cessation program were determined.

RESULTS

Among 389 patients, 83% were current smokers. Nearly half (48%) of smokers were contemplating quitting, and an additional 22% were in the preparation stage of readiness to quit. In multivariate analyses, lower nicotine dependence, prior use of smoking cessation pharmacotherapy, and lower methadone dose were associated with being in the preparation stage. Patients with more education, Hispanics/Latinos, and patients who had used smoking cessation pharmacotherapy or were in the preparation or contemplation stages of behavior change were more interested in attending an on-site smoking cessation program.

CONCLUSIONS

Tobacco use is highly prevalent among methadone maintenance patients, but we also observed a high level of readiness to quit and interest in smoking cessation. Targeted smoking cessation interventions, including on-site programs, should be developed for methadone maintenance patients.

Tailored communications for smoking cessation: past successes and future directions

Tailored communications are one of the most promising approaches to smoking cessation interventions for entire populations. Assessments based on the Transtheoretical Model are processed by computer-based expert systems that generate feedback reports tailored to each individual to accelerate their progress through the stages of change for smoking cessation. Seven studies are reviewed that range from a more traditional clinical trial to trials on entire populations of smokers to population trials designed to change multiple behaviours, including smoking. A series of three tailored communications was found to produce long-term point prevalence abstinence rates within the narrow range of 22-26% abstinence. This same range of abstinence was found even when two or three other behaviours (e.g. diet and sun protection) were treated in the population. These results point to a future in which health behaviour risk interventions will be assessed not solely by their efficacy but by their population impact.

The stages of change in smoking cessation in a representative sample of Korean adult smokers

This study reports the stages of change in smoking cessation in a representative sample of Korean adult smokers. The study subjects, all adult smokers (n=2,422), were recruited from the second Korea National Health and Nutrition Examination Survey conducted in 2001. The stages of change were categorized using demographic (age and sex), socioeconomic (education, residence, and household income), and smoking characteristics (age at smoking onset, duration of smoking, and number of cigarettes smoked per day). Age-stratified analyses of the association of socioeconomic and smoking characteristics with the stages of change in male and female smokers were also conducted. According to the stages of change, the study population consisted of 37.6% (95% CI, 35.7-39.5) pre-contemplation, 56.0% (54.0-58.0) contemplation, and 6.4% (5.4-7.4) preparation. The associations between the characteristics of the smokers and the stages of change were all statistically significant. The age-stratified analyses showed that all the socioeconomic and smoking characteristics were significantly associated with the stages in males, while education and residence had significant associations in females. This study revealed that a relatively small number of Korean smokers were prepared to quit and the stage distribution might be influenced by demographic, socioeconomic, and smoking characteristics.

Attitudes, social influences and self-efficacy expectations across different motivational stages among immigrant smokers: replication of the Ø pattern

BACKGROUND

Information about the factors that determine motivation to quit in immigrant populations is needed to enable the development of tailored smoking cessation programs for them. Dutch studies in the general population suggest that attitudes are important for motivating persons to change and self-efficacy for helping motivated persons to change. We analyzed whether this pattern also exists among Surinamese immigrants.

METHODS

Structured face-to-face interviews were held among 1,100 Surinamese people in Amsterdam (The Netherlands), including measures of attitudes towards smoking (cessation), social influences and self-efficacy expectations (between 2001 and 2003).

RESULTS

The majority of the smokers were not motivated to quit and in the pre-contemplation phase (73%). Pre-contemplators perceived significantly weaker advantages of quitting than contemplators and preparators. Self-efficacy expectations of Surinamese pre-contemplators were lower than those of smokers preparing to quit within a month.

CONCLUSION

Similar attitudinal and self-efficacy patterns as those in the general population were found in an immigrant population. However, the items constituting the factors are culturally sensitive. Furthermore, many Surinamese smokers were unmotivated to quit smoking.

Perceived risk and interest in screening for lung cancer among current and former smokers

Factors associated with perceived risk, interest in screening information, and interest in being screened for lung cancer were examined among current and recent former smokers. Cross-sectional data were analyzed from 585 current and former smokers who participated in 12-month follow-up telephone interviews as part of a population-based cessation intervention trial. Current smokers who were thinking about or preparing to quit were more likely to perceive risk of lung cancer and be interested in lung cancer screening information than those who were not motivated to quit or who were in the process of actively quitting or maintaining abstinence. Smokers who participate in lung cancer screening may be motivated to participate in a broad range of tobacco dependence treatment options.

Changes in the "stages of change" as outcome measures of a smoking cessation intervention: a randomized controlled trial

OBJECTIVE

Employing changes in the "stages of change" as alternative outcome measures of a smoking cessation intervention.

METHOD

RCT carried out between 2002 and 2004 in Germany with 485 daily cigarette smokers recruited from a general population survey. The intervention was conceptually based on the transtheoretical model, involving individualized feedback letters generated by computerized expert-system technology.

RESULTS

Latent transition analysis was applied to test models for patterns of change, to evaluate stage of change distributions and transitions over time, and to compare the intervention and control group. The patterns of change across three time points could best be described by a model including stability, one-stage regressions, and one-to-four-stage progressions. There were no significant differences between the intervention and control group in the stage of change distributions at each time point or in the amount of stage transitions over time.

CONCLUSION

The efficacy of the intervention could not be demonstrated. Reasons may include oversampling of smokers who are interested in health-related topics but do not intend to quit, and power problems due to substantial attrition.

Stage of change transitions and processes of change, decisional balance, and self-efficacy in smokers: a transtheoretical model validation using longitudinal data

Interactions were examined between stage of change transitions and intraindividual increases or decreases in the processes of change, pros and cons of smoking, and situational temptations longitudinally. A total of 786 ever smokers was assessed 2 times, 6 months apart, with respect to the transtheoretical model (TTM) constructs. Two significant discriminant functions within initial precontemplators and 1 significant function within initial contemplators were found. Ten out of 15 TTM variables contributed to at least 1 function. The functions mainly distinguished between preabstinence (precontemplation, contemplation, or preparation) and abstinence (action or maintenance) stages of change, that is, between current and former smokers. This is one of the few studies providing a longitudinal validation of the postulates of the TTM.

Return to smoking following a smoke-free psychiatric hospitalization

This study examined the smoking behaviors and motivations of 100 patients hospitalized in a smoke-free psychiatry unit. The sample averaged nineteen cigarettes per day and had a history of repeated failed quit attempts, yet 65% expressed interest in quitting. During hospitalization, nicotine replacement was provided to 70% of smokers to manage nicotine withdrawal. Provider counseling for smoking cessation, however, was rare, and all patients returned to smoking within five weeks of hospital discharge. The inpatient setting provides a potential site for initiating tobacco dependence treatment; however to maintain abstinence following hospital discharge, greater support is needed.

The relationship between impaired decision-making, sensation seeking and readiness to change in cigarette smokers

OBJECTIVE

The study investigated whether impaired decision-making as measured by the Gambling Task and Sensation Seeking, on one hand, and nicotine-dependence and readiness to change, on the other hand, show mutual influences in cigarette smokers.

METHODS

Cigarette smokers were classified as dependent or non-dependent smokers. Assessment included stages of change (RCQ), decisional balance (DBS), Sensation Seeking Scale Form-V (SSS-V), and performance on the Gambling Task (GT).

RESULTS

With the exception of a significant higher score in the SSS-V subscale Experience Seeking in dependent smokers, correlations between nicotine-dependence and cognitive features were not significant. The directions of the non-significant differences were not consistent. No significant relationship was found between the SSS-V and the GT, on one hand, and the readiness to change smoking behaviour, on the other hand.

CONCLUSIONS

The results of the present study suggest that impaired performance on the GT and high scores in Sensation Seeking do not play an important role in nicotine-dependence and readiness to change smoking behaviour or vice versa.

Construct validity of physical activity and sedentary behaviors staging measures for adolescents

PURPOSE

To evaluate the construct validity of physical activity (PA) and sedentary behaviors (SB) staging measures for adolescents that incorporate the current national recommendations.

METHOD

The Progressive Aerobic Cardiovascular Endurance Run, Actigraph accelerometer, and self-reported hours of TV viewing served as criterion measures. Participants were 878 adolescents (M age = 12.74, 53.6% girls, 39.9% non-White).

RESULTS

The PA staging measure had mixed evidence of convergent validity and strong evidence of divergent validity. The SB staging measure had strong and generalized evidence of convergent validity but weak evidence of divergent validity, which could be related to inaccurate assumptions about the relation of SB to PA and fitness. Results were generally in the expected direction and provide preliminary evidence for the construct validity and generalizability of both staging measures. However, more research is warranted to validate the staging measures with Actigraph-measured PA and sedentary time. Effect sizes (eta(2) values) ranged from small to large (.02-.63).

CONCLUSION

PA and SB stage-of-change measures that are congruent with current national recommendations and appropriate for use among adolescents were partially supported for their construct validity.

Proactive, motivationally enhanced smoking cessation counseling among women with elevated cervical cancer risk

Current treatment guidelines recommend that all smokers be given motivational or action-oriented counseling, as is appropriate to their readiness to quit smoking. The present study assessed the acceptability and impact of a proactively delivered, motivationally tailored phone counseling program targeted to women with elevated risk for cervical cancer. Female smokers with a recent abnormal pap exam or a colposcopy were contacted and invited to participate, regardless of their interest in quitting smoking. Participants were randomly assigned to usual care (UC) or UC plus motivationally enhanced phone counseling (MEC). The intervention was well received: 79% of eligible women enrolled (n = 275), and 90% completed at least three of four calls. Participation did not vary by baseline motivation to quit. Compared with control subjects, counseling participants were more likely to seek additional treatment services and had a higher 7-day point-prevalence abstinence rate at 6 months (20% MEC vs. 12% UC, p<.05). MEC impact was sustained at 12 months, but abstinence increased among the UC group (18% MEC vs. 20% UC, p = ns). There was no difference in repeated point-prevalence abstinence at 6 and 12 months (11% MEC vs. 10% UC, p = ns). Outcomes were similar in a subgroup of 229 women who, at baseline, were interested in quitting in the next 6 months.

Tobacco use and readiness to quit smoking in low-income HIV-infected persons

The study aim was to identify covariates of smoking status and readiness to quit that encompassed key sociodemographic and health status variables, health-related quality of life, drug use and unprotected sex, and tobacco use variables in a cohort of low-income persons living with HIV. We also examined the impact of HIV diagnosis on smoking cessation. The sample (N = 428) was mostly male (59%) and Black (53%) or Hispanic (30%), and had a high school education or less (87%). Mean age was 40 years. Two-thirds of participants were current smokers, 19% former smokers, and 16% never smokers. Current smokers smoked a mean of 16 cigarettes/day for 22 years; 42% were in the precontemplation stage of readiness to quit smoking, 40% were contemplators, and 18% were in preparation. Most current smokers (81%) reported receiving medical advice to quit smoking. Multivariate logistic regression analyses indicated that current smokers, compared with former smokers, were more likely to use illicit drugs, perceive a lower health risk for continued smoking, and report less pain. Current smokers, compared with nonsmokers (former and never smokers), were more likely to report greater illicit drug use in their lifetime, current illicit drug use, and less pain. A multiple linear regression indicated that greater current illicit drug use, greater emotional distress, and a lower number of quit attempts were associated with lower stage of readiness to quit smoking. These findings confirm a high prevalence of smoking among HIV-infected persons and suggest a complex interplay among drug use, pain, and emotional distress that impact smoking status and, among smokers, readiness to quit. Tobacco control programs for HIV-infected persons should build motivation to quit smoking and address salient barriers to cessation--such as comorbid drug use, emotional distress, pain, and access to and coverage for treatment--and should educate smokers regarding the HIV-specific health benefits of cessation.

Racial and ethnic differences in predictors of smoking cessation

Racial/ethnic differences in the determinants of smoking cessation could have important treatment implications. The current study examined racial/ethnic differences in smoking cessation, prospective predictors of cessation, and whether the predictive ability of these factors differed by race/ethnicity. Participants were 709 employed adults recruited through the National Rural Electric Co-op Association or through natural gas pipeline corporations. Data were collected in 1990 and 1994. Although race/ethnicity was not predictive of abstinence, Hispanic, African American, and White smokers displayed differential on tobacco-, alcohol-, and work-related variables. These racial/ethnic differences highlight the specific factors that should be considered when providing smoking cessation treatment to specific populations. Limitations are noted.

Identifying high- and low-success smoking cessation subgroups using signal detection analysis

Signal detection analysis was used to identify mutually exclusive groups of smokers (n = 602) at high and low likelihood for smoking cessation 6- and 18-months post-entry into a smoking cessation intervention. Overall quit rates were 10% at 6-months and 18% at 18-months. Four subgroups were identified at 6-months and five at 18-months. The highest quit-rate subgroup at both time points (42% and 52% cessation, respectively) had low perceived stress. The lowest quit-rate subgroup (7% and 13% cessation, respectively) had higher perceived stress, lower self-efficacy to not smoke, lower use of behavioral processes at 6-months, and higher use of pros of smoking at 18-months. These smoker profiles may be useful in developing targeted smoking cessation interventions. Addressing perceived stress in smoking cessation interventions may help to improve smoking cessation success rates.

Predicting smoking stage of change among emergency department patients and visitors

OBJECTIVES

Little is known about whether emergency department (ED) patients or those who accompany them (visitors) are interested in smoking cessation. The authors hypothesized that several variables would be associated with stage of change, including nicotine dependence, self-efficacy, presence of a smoking-related illness, and anticipated cessation-related health improvement.

METHODS

For two 24-hour periods, consecutive patients and visitors aged 18 years and older presenting to four Boston EDs were interviewed. The authors assessed a range of smoking-related constructs. Exclusion criteria included severe illness, cognitive insufficiency, and acute distress.

RESULTS

One thousand ten subjects were screened (56% patients, 44% visitors). Two hundred thirty-seven (23%) subjects were current smokers, with 57% being in precontemplation, 31% in contemplation, and 12% in preparation stages. When ordinal regression was used, the variables most strongly associated with stage of change were as follows: self-efficacy (odds ratio [OR] = 5.1; p < 0.001), anticipated cessation-related health improvement (OR = 2.7; p = 0.02), and having a smoking-related health problem (OR = 1.9; p = 0.08).

CONCLUSIONS

Because many disenfranchised Americans use the ED as a regular source of health care, increased attention to smoking in the ED setting holds tremendous public health potential. This study's results reinforce the validity of the stage-of-change model within the ED setting. Developers of ED-initiated interventions will have to consider the heterogeneity in stage of change when designing their treatments.

Longitudinal relationships among transtheoretical model constructs for smokers in the precontemplation and contemplation stages of change

BACKGROUND

This study examined the pattern, direction, and magnitude of longitudinal relationships among the constructs involved in the Transtheoretical Model (TTM).

PURPOSE

The goal was to explore within-TTM relationships to create an integrated structural model that adequately represents the change process.

METHOD

Data were collected as part of a representative general adult population study in Germany. A total of 688 smokers in the precontemplation and contemplation stages of change were assessed two times, 6 months apart, with respect to the TTM constructs. Structural equation modeling was used and a step approach was employed to evaluate the relationships between cognitive-affective processes, behavioral processes, the pros and cons of smoking, and self-efficacy, stratified for baseline stage of change.

RESULTS

The model-building process resulted in two final structural equation models detailing longitudinal TTM relationships for precontemplation and contemplation. A structural invariance test showed that the precontemplation model also held for the contemplation sample and visa versa.

CONCLUSIONS

The TTM constructs can be integrated in a longitudinal structural model. The findings provide empirical support for specific relationships that are posited in the TTM framework. However, differing relationships between TTM constructs for precontemplation and contemplation could not be established.

Comparing participants and nonparticipants recruited for an effectiveness study of nicotine replacement therapy

BACKGROUND

Interventions for smoking cessation have been typically evaluated on reactively recruited samples in clinical trials (efficacy trials). However, to have an impact on smoking rates in a general population, the intervention should also be evaluated with proactively recruited representative samples (effectiveness trials).

PURPOSE

The characteristics of participants and two groups of nonparticipants recruited for a population-based nicotine replacement therapy study were compared.

METHODS

All members of a large New England Veterans' Administration Medical Center were contacted, and interviews were completed with 3,239 identified smokers (at least 10 cigarettes per day). At the end of the interview, all smokers were offered participation in a multiple intervention study. Of the interviewed smokers, 2,915 verbally agreed to participate in the study (90%). Of those who gave initial verbal consent, 2,054 returned the written informed consent form and became participants (70%).

RESULTS

The participants (full consent group) differed significantly from both nonparticipant groups-that is, the smokers who were interviewed but declined participation by active refusal (survey only group) and those who gave verbal consent but passively refused participation by failing to return the written consent form (verbal consent only group). Participants were more likely to be married, younger, and female; to live with others; and to have previously used or considered using nicotine replacement therapy. The survey only group was also more likely to be in the precontemplation stage (54%), whereas the participants were more likely to be in the contemplation (46%) or preparation stage (35%). The verbal consent only group was intermediate of the other two groups in stage-of-change characteristics.

CONCLUSIONS

An important finding was that it is possible to recruit a large proportion of a sample of identified smokers to an nicotine replacement therapy study. However, the participants are likely to differ in significant ways from those who either actively or passively decline participation.

Perceptions of Asian American men about tobacco cigarette consumption: a social learning theory framework

Little information exists regarding the perceptions that ethnic-specific groups of Asian American men have about tobacco cigarette smoking. Thirty Asian American men of immigrant status living in Seattle, Washington, were stratified by ethnicity (Chinese and Vietnamese), language (Mandarin, Cantonese, Vietnamese) and age to comprise six focus groups (two Mandarin speaking men aged 20-40 years and 10 aged 41-65+ years; three Cantonese men aged 20-40 years and another six aged 41-65+ years; four Vietnamese men aged 20-40 years and another five aged 41-65+ years). All group interviews were audio-taped and six separate hard-copy transcripts were produced, independently theme-coded by three investigators to ensure inter-rater reliability, and analyzed with QRS NUD*IST ethnographic software. Bandura (1969, 1986) categorized emergent contextual themes within the constructs of "predisposing, enabling, and reinforcing" behavioral determinants from Social Learning Theory. Smoking to be sociable emerged as the most salient theme. Awareness of tobacco-related diseases other than lung cancer was less evident, as was a self-perceived lack of will-power to quit. Concerns about side-stream smoking affecting family members, along with smoking to alleviate stress, were key findings. Further tobacco-related research is needed that incorporates considerations for cultural dynamics.

Evaluation of smoking cessation success in adults

BACKGROUND

Smoking is a preventable cause of increased morbidity and mortality. Therefore, interventions have been used to assist smokers in overcoming their addiction. The aim of the study was to describe factors associated with smoking cessation, in patients applied to our smoking cessation (SC) unit in 1999, in a prospective study.

METHODS

Patients were followed-up during two years. Detailed medical history, Fagerstrom test, Hospital Anxiety and Depression (HAD) scale questionnaire, Motivation scale and replacement therapy were systematically recorded.

RESULTS

Three hundred patients (58% men, 42% women) applied to the SC unit from January to December 1999. The mean age was 42 yrs old. They smoked in average 24 cig/d. Mean duration of smoking was 20 years. Fagerstrom score was 5.86 (min 0; max: 10). Patients seemed to be more anxious (score 9.6) than depressed (5.09), according to the HAD score. 79% of them received both psychosocial intervention, pharmacotherapy and nicotine replacement therapy. 66% of patients were followed-up (n=198). Two years later, the smoking cessation rate was 12% (n=36). Motivation, Fagerstrom and HAD scores were not associated with the quitting rate. Quitting rate was higher (25.9%) in patients who attempted to quit smoking for the first time than in others (19%). By contrast, the quitting rate was significantly associated with age (P=0.03).

CONCLUSION

Success to quit smoking was positively associated with age, and negatively with alcohol dependence.

Stages of change in treatment-seeking pathological gamblers

The transtheoretical model has been applied to many addictive disorders. In this study, psychometrics properties of the University of Rhode Island Change Assessment (URICA) scale were evaluated in 234 pathological gamblers initiating treatment. Four components were identified--reflective of precontemplation, contemplation, action, and maintenance stages--with internal consistency from .74 to .88. Cluster analyses identified 4 patterns of responding, ranging from ambivalent to active change. The 4 clusters differed with respect to baseline gambling variables and treatment engagement and outcomes assessed 2 months later. A continuous measure of readiness to change was also correlated with gambling severity and predictive of reductions in gambling. This study provides initial support for reliability and validity of the URICA in treatment-seeking gamblers, and it suggests that stage of change may have an impact on outcomes.

A randomized trial to promote pharmacotherapy use and smoking cessation in a Medicaid population (United States)

OBJECTIVE

To evaluate the impact of three different intervention conditions designed to increase use of the Medicaid smoking cessation pharmacotherapy benefit and promote smoking cessation among Medicaid clients.

METHODS

In 2002, 608 current smokers receiving Medicaid benefits were recruited from the reception areas at the Department of Social Services in Erie County, New York, USA. Participants were randomized to one of three interventions: Minimal (verbal information on the Medicaid pharmacotherapy benefit), Self Help (verbal information plus self-help information materials), or Case Management (verbal information, self-help information, plus case management assistance to facilitate access to the pharmacotherapy benefit). Outcomes included (a) use of a stop-smoking medication during the three month follow-up period, (b) self-reported 7-day point prevalence abstinence at three months and (c) bioverified non-smoking status at three months (bio-chemically validated by expired Carbon Monoxide (CO) < or =8 ppm).

RESULTS

14.6% reported using a stop-smoking medication and staying off cigarettes for 24 h, 4.6% self-reported being smoke-free at three months, and 1.8% were bioverified as smoke-free. There were no differences by intervention group for these outcomes.

CONCLUSIONS

An intensive intervention designed to promote pharmacotherapy use and smoking cessation among Medicaid smokers was no more effective than less intensive interventions.

What accounts for the association of education and smoking cessation?

BACKGROUND

Education has been identified as a potent sociodemographic predictor of smoking cessation and the Healthy People 2010 goals include the elimination of health disparities attributable to education.

METHOD

The current study prospectively examined the association of education with smoking cessation as well variables that might account for that association among employed adults residing in the southeastern United States.

RESULTS

A strong educational gradient in cessation was evident. Only 6% of smokers with less than a high school (HS) degree quit smoking during the 4-year study period, whereas 17% of smokers with a HS degree but no college degree and 28% of smokers with at least a college degree quit smoking.

CONCLUSIONS

Education appeared to uniquely contribute to the prediction of smoking abstinence over and above the effects of demographic, environmental, tobacco dependence, transtheoretical model, and job-related variables. Obtaining a better understanding of how or why education influences smoking cessation could contribute to reducing the educational gradient in abstinence and warrants further research attention.

Physical activity staging distribution: Establishing a heuristic using multiple studies

The purpose of this study was to identify the population prevalence across the stages of change (SoC) for regular physical activity and to establish the prevalence of people at risk. With support from the National Institutes of Health, the American Heart Association, and the Robert Wood Johnson Foundation, nine Behavior Change Consortium studies with a common physical activity SoC measure agreed to collaborate and share data. The distribution pattern identified in these predominantly reactively recruited studies was Precontemplation (PC) = 5% (+/- 10), Contemplation (C) = 10% (+/- 10), Preparation (P) = 40% (+/- 10), Action = 10% (+/- 10), and Maintenance = 35% (+/- 10). With reactively recruited studies, it can be anticipated that there will be a higher percentage of the sample that is ready to change and a greater percentage of currently active people compared to random representative samples. The at-risk stage distribution (i.e., those not at criteria or PC, C, and P) was approximately 10% PC, 20% C, and 70% P in specific samples and approximately 20% PC, 10% C, and 70% P in the clinical samples. Knowing SoC heuristics can inform public health practitioners and policymakers about the population's motivation for physical activity, help track changes over time, and assist in the allocation of resources.

It is possible to help smokers in early motivational stages to quit. The Inter99 study

BACKGROUND

In a population-based sample of smokers in early motivational stages, we found a high acceptance of smoking cessation groups.

METHODS

Inter99 is a randomized population-based intervention study, in Copenhagen, Denmark. Smokers in all motivational stages were included. All participants underwent a lifestyle consultation and 2,168 smokers in the high intensity intervention group were offered assistance to quit in smoking cessation groups.

RESULTS

Thirty-five percent were validated to be continuously abstinent at the end of the smoking cessation groups. Eighty-four percent of the smokers achieving sustained abstinence in our study had no serious plans to quit soon before the lifestyle consultation. Motivation to quit before the lifestyle consultation could not predict abstinence. Being a man, and having a job and at least 1 year of vocational training were predictors of abstinence in a multivariate model, whereas high nicotine dependence and living with a smoking spouse were predictors of failure.

CONCLUSION

High cessation rates were obtained in a population of heavy smokers with moderate nicotine dependence. It was possible to obtain sustained abstinence in smokers in early motivational stages. These smokers would probably not have been reached by traditional smoking campaigns.

Smoking cessation intervention in a large randomised population-based study. The Inter99 study

BACKGROUND

Several large and well-conducted community interventions have failed to detect an effect on prevalence of smoking.

METHODS

Two thousand four hundred eight daily smokers in all motivational stages were actively recruited and included in a randomised population-based intervention study in Copenhagen, Denmark. All smokers completed a questionnaire and underwent a health examination and a lifestyle consultation. Daily smokers in the high intensity intervention group were offered assistance to quit in smoking cessation groups.

RESULTS

The validated abstinence rate at 1-year follow-up was 16.3% in the high intensity group and 12.7% in the low intensity group compared with a self-reported abstinence rate of 7.3% in the background population. The adjusted odds ratio of abstinence in the high intervention group was significantly higher, OR = 2.2 (1.6-3.0) than in the background population, also in the 'intention-to-treat' analyses, OR = 1.5 (1.1-2.0). Higher socioeconomic status, higher age at onset of daily smoking, and a higher wish to quit were predictors of success.

CONCLUSION

In a population-based setting, using active recruitment and offering assistance to quit, it was possible to include many smokers and to achieve a significantly higher validated abstinence in the high intensity intervention than in the background population, even when using 'intention-to-treat' analyses.

Multiple risk expert systems interventions: impact of simultaneous stage-matched expert system interventions for smoking, high-fat diet, and sun exposure in a population of parents

Three stage-based expert system interventions for smoking, high-fat diet, and unsafe sun exposure were evaluated in a sample of 2,460 parents of teenagers. Eighty-four percent of the eligible parents were enrolled in a 2-arm randomized control trial, with the treatment group receiving individualized feedback reports for each of their relevant behaviors at 0, 6, and 12 months as well as a multiple behavior manual. At 24 months, the expert system outperformed the comparison condition across all 3 risk behaviors, resulting in 22% of the participants in action or maintenance for smoking (vs. 16% for the comparison condition), 34% for diet (vs. 26%), and 30% for sun exposure (vs. 22%). Proactive, home-based, and stage-matched expert systems can produce significant multiple behavior changes in at-risk populations where the majority of participants are not prepared to change.

Comparison of a population-based sample of "risky drinking" smokers and groups consuming just one substance

This population-based study compares a group of "risky drinking" smokers (n = 137) with groups of either smokers (n = 760) or "risky drinkers" (n = 173) regarding sociodemographic, behavioral and motivational variables. The study took place in a rural and urban region of Germany in 1997. No differences were found in sociodemographics, nicotine-related variables, frequency of alcohol consumption, and most alcohol-related diagnoses. People who drink and smoke show a higher proportion of alcohol dependence (ES: h = .20), drink more alcohol per occasion (ES: d = .39), and are more motivated to decrease alcohol consumption (ES: h = .45). The data suggest focusing research in more alcohol-related clinical settings and examining the relationship between smoking cessation and alcohol reduction.

Behavioral interventions and cost-effectiveness analysis

Behavioral health interventions are often gauged with a dichotomous outcome, "success" or "failure." Hidden by this dichotomy is a series of behavior changes that can be followed with the Transtheoretical Model (stages of change). There has been little consideration, however, about whether this information can and should be used in cost-effectiveness analysis. We review the stages of change model and its applications to behavioral health interventions. We then discuss analytical methods for including stages of change, or similar behavior change models, in cost-effectiveness analysis (CEA). This is typically not done but it may be critical for study design and for interpreting CEA results.

Depressed smokers and stage of change: implications for treatment interventions

Tobacco Dependence among smokers with psychiatric disorders has been under-addressed by the mental health, addictions, and tobacco control communities. This study examined depressed smokers' readiness to quit and the applicability of the Stages of Change framework to a psychiatric sample. Currently depressed smokers (N=322) were recruited from four outpatient psychiatric clinics. Participants averaged 16 cigarettes per day (S.D.=10) and 24 years (S.D.=13) of smoking. The majority (79%) reported intention to quit smoking with 24% ready to take action in the next 30 days. Individuals in the preparation stage reported more prior quit attempts, a greater commitment to abstinence, increased recognition of the cons of smoking, and greater use of the processes of change. Precontemplators were least likely to identify a goal related to their smoking behavior. Depressive symptom severity and history of recurrent depressive episodes were unrelated to readiness to quit. This study is one of the first to examine the smoking behaviors of currently depressed psychiatric outpatients. The level and longevity of their tobacco use underscore the need for cessation interventions. The consistency in hypothesized patterns among theoretical constructs of the Stages of Change model supports the transfer of stage-tailored interventions to this clinical population.

Both smoking reduction with nicotine replacement therapy and motivational advice increase future cessation among smokers unmotivated to quit

Smokers not currently interested in quitting (N = 616) were randomized to receive telephone-based (a) reduction counseling plus nicotine replacement therapy (NRT) plus brief advice to quit, (b) motivational advice plus brief advice, or (c) no treatment. More smokers in the reduction (43%) and motivational (51%) conditions made a 24-hr quit attempt over 6 months than smokers in the no-treatment condition (16%; p < or = .01), but the 2 active conditions did not differ (p > or = .05). Similarly, 18%, 23%, and 4% of each condition were abstinent (7-day point prevalence) at 6 months (p < or = .01). Results indicate smoking reduction using NRT does not undermine cessation but rather increases the likelihood of quitting to a degree similar to motivational advice.

Smoking behavior and interest in quitting among homeless smokers

OBJECTIVES

To examine smoking behavior in homeless persons, including the impact of self-reported tobacco-related health problems and drug and alcohol abuse on readiness to quit and interest in smoking cessation counseling.

METHODS

Cross-sectional survey of outpatients and inpatients on the homeless service at Massachusetts General Hospital.

RESULTS

Among 98 homeless smokers with a mean age of 44 years, tobacco-related medical diagnoses and symptoms and psychiatric illnesses were common, as were drug and alcohol abuse. One third of the smokers in this sample intended to quit smoking within the next 6 months, including 19% who planned to quit in the next 1 month. Forty-four percent of the participants were somewhat or very interested in smoking cessation counseling. In multivariate analyses, significant (P < .05) predictors of readiness to quit smoking were greater confidence in one's ability to quit (self-efficacy) and more social support for quitting. Multivariate predictors of interest in smoking cessation counseling were smoking-related symptoms and higher self-efficacy for quitting.

CONCLUSIONS

Homeless smokers recruited from the inpatient and outpatient services of a large, urban teaching hospital reported interest in both stopping tobacco use and receiving assistance to quit smoking. Having an illness that a smoker believes is tobacco-related, having greater confidence in the ability to quit, and having more social support for quitting were associated with greater readiness to quit and more interest in smoking cessation counseling. Alcohol and drug abuse were not associated with reduced interest in quitting smoking. These findings suggest that homeless smokers may benefit from smoking cessation programs that are colocated in medical or drug treatment settings.

The Transtheoretical Model of Behavior Change and Smokers in Southern Appalachia

BACKGROUND

The southern Appalachian states show a high prevalence of smoking, with associated high rates of both heart disease and cancer, yet cultural differences raise questions concerning the applicability of the most frequently used model for smoking cessation, the transtheoretical model, for smokers from this region of the country.

OBJECTIVE

To identify, by examining the applicability of the transtheoretical model for southern Appalachian smokers, the percentage of individuals in each of the five stages of change, the use of the processes of change from the trans-theoretical model, and the scores on recognized predictors of smoking cessation including the temptation to smoke, the perceived barriers to cessation, the pros and cons of smoking, and nicotine dependence.

METHODS

This population-based, descriptive, cross-sectional study used a random sample of 3,800 telephone numbers, which were called up to eight times. The 659 smokers or former smokers who agreed to participate were mailed a written questionnaire consisting of six well-established scales that measure constructs from the transtheoretical model. The final sample consisted of 357 usable questionnaires.

RESULTS

The distribution of smokers in northeastern Tennessee differed from national samples across the first three stages of change, with 56% in precontemplation, as compared with previous findings of 40% in national samples. The subjects' scores for the pros of smoking were similar across the stages of change in this sample, and although the scores for the cons differed significantly across the stages in the sample, post hoc analysis indicated that the only significant change occurred between precontemplation and contemplation. The scores for temptation to smoke did not differ significantly across the stages of change in this sample.

DISCUSSION

Smokers from Appalachian Tennessee differ from smokers in other parts of the United States, and these findings raise questions about the applicability of the transtheoretical model for this population.

Family-Focused Smoking Cessation

While partner support has been found to be an important factor in smoking cessation, programs with partner training have not demonstrated improved efficacy. The goal of this project was to evaluate the effectiveness of a smoking cessation treatment program that included partner support in an innovative education/therapy model similar to alcohol and drug treatment programs. Subjects included 23 smokers, 71% with a support partner. The program consisted of a smoking cessation curriculum, combined with facilitated group therapy for participants and partners, and individualized medication evaluation. Smoking abstinence was 87% at program completion and 80% at one month follow up, 100% abstinence in participants with support and 50% in participants without support (p < 0.05). Smoking Stage of Change at enrollment was: contemplation 22%, preparation 70%, and action 8%, with 87% movement toward action stage. In the present study, partner support enhanced short-term abstinence from smoking.

A low-cost, practical method for increasing smokers' interest in smoking cessation programs

BACKGROUND

Low participation rates reduce the public health impact of smoking cessation programs. Two barriers for improving participation are the cost of media campaigns and the proportion of smokers motivated to quit smoking. The objective of this study was to examine the feasibility of using classified newspaper ads and messages aimed at each stage of change to enhance participation in smoking cessation programs.

METHODS

Three classified ads were run concurrently in a local daily newspaper for five consecutive days. The ads were designed to engage smokers in each of Prochaska's five stages of change. Each ad invited smokers or former smokers to call the local health department to participate in a paid focus group to design a new health department program.

RESULTS

Calls were received from 181 eligible smokers, including 124 who provided data for the study. Thirty-seven, 34, and 29 percent of smoking respondents were in precontemplation, contemplation and preparation respectively. Half of ex-smokers were in the action stage. Ads cost 174 dollars (Cdn), thus the cost per recruit was less than a dollar.

CONCLUSION

Classified ads can recruit smokers from all stages of change. Compared to traditional mass media, classified ads may also be a highly cost-efficient promotional strategy. Results provide justification for further research.