Distribution of smokers by stage in three representative samples

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.

Smoking cessation: two pilot studies exploring the use of continuous response format algorithm to identify subgroups within stage

Stage of change is typically assessed with a series of yes or no questions, a categorical response format staging algorithm. We revised that algorithm by using, instead, the same questions with 7-point agreement scales covering the first three stages with a sample of smokers. Participants were 141 persons enrolled in introductory psychology classes at the University of Louisville during the fall and spring semesters of 1994. Our continuous response format scores showed expected correlations with modified decisional balance scale scores. In addition, the continuous response format algorithm identified substantial differences in intention to quit sometime and in the next 30 days among participants classified as precontemplators by the categorical system. Analyses from an additional small sample (N = 56) demonstrated relationships between the continuous response format scores and Processes of Change as well as Decisional Balance Scale scores within categorical stages. Subgroups of smokers within stages differ on their attitudes toward changing and on the change strategies they are using. These subgroups can be identified with the continuous response format algorithm.

Stage of change for general health promotion action and health-related lifestyle practices in Chinese adults

BACKGROUND

We propose general health promotion action (GHPA) to represent the general intention and actual practices aimed to promote health. The transtheoretical model (TTM) has not been applied to GHPA. The objectives of this study were to determine whether TTM can be applied to Chinese adults by measuring the subjects' stage of change for GHPA, and to study whether stage for GHPA is associated with health-related lifestyle practices.

METHODS

Randomly selected Hong Kong Chinese subjects (3233) aged 18-64 were interviewed in telephone survey.

RESULTS

Thirty-nine percent had not taken any health promotion actions and had no intention to do so (precontemplation). Twelve percent had taken action but had no intention to continue (at-risk for relapse). Three percent had not taken any actions and intended to do so in the next 6 months, but not in the next 1 month (contemplation). Eleven percent had not taken any actions but intended to do so in the next 1 month (preparation). Fifteen percent had been taking action for less than 6 months and intended to continue (action). Twenty-one percent had been taking action for at least 6 months and intended to continue (maintenance). Precontemplators were less likely than maintainers to be never smokers (OR = 0.62; 95% CI = 0.49-0.80), exercisers (0.097; 0.077-0.12), to eat fruit twice a day (0.53; 0.41-0.69) and remove fat when eating (0.72; 0.54-0.95), with increasing trends in the odds of reporting these practices from precontemplation to maintenance.

CONCLUSIONS

Our findings have provided preliminary findings on the applicability of TTM on GHPA in Chinese adults with evidences of concurrent criterion validity.

Efficacy of a smoking-cessation intervention for elective-surgical patients

We tested an intervention to help smokers abstain (fast) from smoking before surgery, maintain abstinence postoperatively, and achieve long-term cessation. A randomized experiment included 237 patients admitted for presurgical assessment who smoked. The intervention included counseling and nicotine replacement therapy. Treatment group participants (73.0%) were more likely to fast than were controls (53.0%): chi(2)(1, N = 228) = 8.89, p =.003, and more likely to be abstinent 6 months after surgery (31.2% vs. 20.2%). There was no significant difference in the abstinence rates at 12 months after surgery, chi(2)(1, N = 169) <.001, p = 1.00. Encouraging patients to fast from smoking before surgery and postoperative support are efficacious ways to reduce preoperative and immediate post-operative tobacco use.

Size, consistency, and stability of stage effects for smoking cessation

In the transtheoretical model (TTM), the stage effect is one of the most important determinants of health behavior change. Randomly assigned to 1 of 11 treatment conditions were 4653 smokers. A total of 66 stage effects were possible with 6 for each of the 11 treatment groups. The results suggest that brief stage-matched interventions that help populations progress one stage could produce 75% more abstinence. Interventions that help populations progress two stages could produce 300% more abstinence. The results also support the importance of replicating the stage effects across treatment conditions and over time.

Telephone counseling increases cessation rates among young adult smokers

During June 2000-May 2001, the American Cancer Society conducted a randomized trial of telephone counseling among more than 3,500 current smokers who called to seek assistance in quitting. All eligible callers were randomized to receive either self-help booklets through the mail or booklets and up to 5 sessions of telephone counseling. Approximately 12% (420/3,522) of study participants were 18-25 years of age. Using intent to treat analyses, 3- and 6-month quit rates among both younger and older smokers were significantly higher among those who received telephone counseling than among those who received self-help booklets only. Three-month rates were 20% versus 9% for 18-25 year olds and 15% versus 10% for older adults. Results indicate that younger smokers can benefit from telephone counseling.

The profile of client's readiness for change and preference to typical processes of change

In the theoretical part of this paper author considers the difficulties to define phenomenon of patient's readiness to change and proposes dimensions of transtheoretical model of change, that is, stages of change and processes as conceptual frames for exceeding those difficulties. Through the research author investigates the possibility to identify typical profiles of patient's readiness from the data about measured levels of particular stages of change. The results infer that several typical profiles of readiness can be identified and that it is possible that these profiles could be connected with tendency of patients to prefer passive or action-restructure processes of change.

Differences in stages of change of smoking behavior among current smokers of four Asian American subgroups

This study assessed the impact of demographics and acculturation on stages of change in smoking behavior among Asian current smokers (Koreans, Chinese, Vietnamese, and Cambodians) who live in the Delaware Valley region. Three stages (precontemplation, contemplation, and preparation) that applied to current smokers in Prochaska's Transtheoretical Model were measured, with a small modification. A cross-sectional self-report survey was conducted by utilizing a stratified cluster proportional sampling technique. Recruited were 1374 Asian Americans from 26 randomly selected community organization clusters and 1174 completed the survey (83%). Data were analyzed using the Pearson chi(2) test of significance. Education was negatively associated with stages of smoking behavior change. Time living in the United States showed a statistically significant positive correlation. Individuals older than 21 years appeared more seriously inclined to quit (be in the preparation stage) than those below age 21. Among the four subgroups, Cambodians (91%) were more likely to fall in either contemplation or preparation, while Chinese had the highest rate in precontemplation stage. Men were more likely than women to be in the preparation stage. Immigration status was not a significant predictor of stages.

Addressing parental smoking in pediatrics and family practice: a national survey of parents

BACKGROUND

Parental smoking has been associated with increased rates of sudden infant death syndrome, low birth weight, otitis media, asthma, and decreased lung growth. No prior parent surveys have assessed national rates of screening and counseling for parental tobacco use in the context of their child's visit to primary care.

OBJECTIVE

To assess and compare rates of pediatrician and family practitioner screening and counseling for parental smoking. Design/Methods. Data were collected by telephone survey of households from July to September 2001. The sample is weighted by race and gender based on 1999 US Census estimates to be representative of the US population.

RESULTS

Of 3566 eligible respondents contacted, 3002 (84%) completed surveys; 902 of those were parents who had a child seen by a pediatrician (62%) or family practitioner (38%) in the past year. About half of all parents who visited a pediatrician or family practitioner reported that they had been asked about household member smoking status (52% vs 48%). More parents who visited pediatricians had been asked if they had rules prohibiting smoking in the home than those who visited family practitioners (38% vs 29%). Of 190 (21%) parents who were smokers, fewer than half reported being counseled by either specialty about dangers of second-hand smoke (41% vs 33%) or risks of modeling smoking behavior (31% vs 28%). Similarly, fewer than half of parental smokers received advice to quit (36% vs 45%).

CONCLUSION

Overall rates of screening and counseling for parental smoking in pediatric and family practice are low. Despite some differences between specialties, significant opportunities exist to improve tobacco control activities in primary care settings that serve children.

Intervention with parental smokers in an outpatient pediatric clinic using counseling and nicotine replacement

OBJECTIVE

To evaluate the feasibility of implementing a smoking cessation intervention for parents at the time of the pediatric visit.

METHODS

A prospective cohort of smoking parents whose child was seen in an outpatient pediatric practice was offered the Stop Tobacco Outreach Program, which includes 3 brief counseling sessions, written materials, free nicotine replacement therapy (NRT), proactive referral to a free state telephone quitline, and fax referral to the parents' primary clinician. The primary outcome was completion of all three counseling sessions. Other outcomes were quit attempts, cessation, NRT use, state quitline use, and household smoking assessed at 2-month follow-up.

RESULTS

One hundred fifty-eight smoking parents met eligibility criteria and 100 (63%) enrolled in the study. Of the 100 enrollees, 81% completed all three counseling sessions and 78% accepted free NRT at the time of enrollment. At 2-month follow-up, of the 100 enrollees, 56% reported making a quit attempt of >or=24 hours, 18% reported 7-day tobacco abstinence, 34% used NRT, and 42% received additional counseling from the state telephone quitline. The mean number of cigarettes smoked inside the home and car declined over 2 months (home, 5.1 vs 1.4; and car, 2.5 vs 1.4).

CONCLUSIONS

This study demonstrates the feasibility of engaging parents in a smoking cessation intervention at the time of a child's clinic visit. This approach may be an effective way to reach smokers who otherwise are unlikely to access smoking cessation interventions. High rates of program enrollment, use of NRT, and completion of telephone counseling in this study support the hypothesis that a child's clinic visit is a teachable moment to address parental smoking cessation.

Relation among stage of change, demographic characteristics, smoking history, and nicotine dependence in an adult German population

BACKGROUND

The aim of this study was to provide evidence about the individual intention to quit smoking and accompanying characteristics in a country with a low amount of tobacco control (TC) provisions.

METHODS

This study used a random sample of the population aged 18-64 in a German area to make a quantitative estimation of the stages of change to quit smoking among current smokers who had at least one quit attempt (n = 1075).

RESULTS

The rate of those who did not intend to stop smoking (precontemplators) was 76.4%, that of those who intended to quit during the next 6 months (contemplators) was 17.0%, and that of those who intended to quit during the next 4 weeks was 6.6%. The three groups did not differ according to gender or age. Of those who had at least 16 years of education, more were contemplators than were those with fewer years of education. Among those who had somatic complaints or nausea from smoking, who had their first cigarette within 1 h or less after awakening, and who had more quit attempts, more were in the contemplation or preparation stage.

CONCLUSIONS

Nicotine dependence may add to contemplating about quitting. The precontemplation rate was substantially higher than in samples from nations or states which show a large amount of TC provisions.

Readiness for Behavioral Changes in Patients With Heart Failure

• Background Successful self-care in heart failure often requires lifestyle changes such as avoiding sodium, excess fluid intake, alcohol, and tobacco; exercising regularly; and losing weight. The Transtheoretical Model, a framework for making behavioral changes, proposes that change requires a series of stages.

• Objectives To identify the stage of readiness for change in 6 lifestyle behaviors important in heart failure and to determine differences in signs and symptoms of heart failure, self-reported knowledge of the disease, and self-reported behavior between patients who have taken action and patients who have not.

• Method A mail survey of 250 patients with heart failure.

• Results Most respondents reported consistent avoidance of tobacco (90.6%), alcohol (87.9%), sodium (81%), and excess fluid (72.6%) and regular participation in exercise (67.1%) and trying to lose weight (64.7%). Yet only 38.7% had a regular exercise program, and 94.2% had eaten high-sodium foods in the preceding 24 hours. Knowledge of heart failure was low (mean score, 67.4%) and did not differ by stage of change. Only 30.4% of the respondents were at their desired weight, and most overweight subjects had been trying to lose weight for more than 6 months.

• Conclusions Although respondents thought they were consistently adhering to recommended guidelines for changes in lifestyle, actual reported behaviors did not always support this evaluation. Use of the stage of change tool to assess stage of readiness to make lifestyle changes may not work well in patients with heart failure, perhaps because of the number and complexity of the changes needed.

Achieving recruitment goals through community partnerships: the SENIOR Project

This article discusses the process of developing collaborative relationships for a community-based health promotion project. A partnership was established among the university, the city where the intervention took place, and the community senior center. A community advisory board was created to identify the strengths, diversity, and needs of each partner. The community advisory board guided the partnership to recruit 1,277 older adults to participate in the intervention study. A sample was deemed representative after comparison with Census 2000 data, with gender and educational attainment being similar.

Predictive value of aspects of the Transtheoretical Model on smoking cessation in a community-based, large-group cognitive behavioral program

OBJECTIVE

To evaluate the predictive value of aspects of the Transtheoretical Model (TTM) of behavior change as applied to smoking cessation in a large-group, community-based cognitive-behavioral intervention.

RESEARCH APPROACH

Cognitive-behavioral intervention followed by 3-month assessment of smoking status.

SETTING

Regional Outpatient Cancer Centre.

STUDY PARTICIPANTS

A total of 2069 participants in smoking cessation clinics held between 1992 and 1999.

INTERVENTION

Eight 90-min sessions over 4 months utilizing education, self-monitoring, a group quit date, and behaviour modification techniques.

MAIN OUTCOME MEASURES

Cessation rates at 3 months postquit date. Differences between successful and unsuccessful participants on the baseline TTM variables of: stages of change, processes of change, decisional balance and situational temptations, as well as of precessation demographic, smoking history, and smoking behavior variables.

RESULTS

Nonsmokers at 3 months endorsed using more of only one of the processes of change (Reinforcement Management) more than smokers prior to starting the program. They also endorsed more Cons of Smoking and had a more negative Decisional Balance score. When the variables of tobacco tolerance on the Fagerstrom Test for Nicotine Dependence (FTND), marital status, association with the Cancer Centre, and amount of vigorous exercise were first entered in a logistic regression model, Reinforcement Management and Cons of Smoking continued to be predictive of smoking cessation success, but again none of the other TTM variables added explanatory power.

CONCLUSIONS

TTM variables measured prior to program attendance added little predictive value for cessation outcome beyond that explained by demographic and smoking history variables. Future studies may benefit from reassessing the TTM variables at the quit date and the 3-month assessment of smoking status to evaluate how the program impacted these variables.

Distribution of daily smokers by stage of change: Current Population Survey results

BACKGROUND

Population-based national estimates of stage of change among daily smokers are unknown. This study described the proportion of U.S. daily smokers, 18 and older, by stage of change. Selected sociodemographic characteristics were delineated.

METHODS

Cross-sectional data were collected via telephone or face-to-face interview in daily smokers who responded to the Current Population Survey in 1992-1993 (n = 39,706), 1995-1996 (n = 34,865), or 1998-1999 (n = 30,153). Main outcomes included stage of change: (1) Precontemplation-not interested in quitting smoking in next 6 months; (2) Contemplation-interested in quitting smoking in next 6 months but not next 30 days; (3) Preparation-interested in quitting smoking in next 30 days and stopped at least 1 day during past year.

RESULTS

During 1992-1993, 59.1% of respondents were precontemplators, 33.2% contemplators, and 7.7% in preparation stage. This distribution was similar in subsequent surveys (1995-1996; 1998-1999). Gender differences were not apparent. Whites were more likely to be precontemplators. As education and income increased, the percentage in precontemplation decreased. Rural residents were more likely in precontemplation and less frequently in preparation.

CONCLUSIONS

Among daily smokers, little movement in stage of change was apparent in the United States during the 1990s. Tobacco control efforts must receive high priority to address these static patterns.

Skalen zu Kernkonstrukten des Transtheoretischen Modells (TTM) im Verhaltensbereich Tabakkonsum

Zusammenfassung. Es werden deutsche Versionen von englischsprachigen Originalinstrumenten zur Erfassung von Kernkonstrukten des Transtheoretischen Modells (TTM) im Kontext des Tabakrauchens vorgestellt. Im Einzelnen werden der “Processes of Change“ - Fragebogen zur Erfassung von Veränderungsprozessen, der “Decisional Balance“ - Fragebogen zur Erfassung der wahrgenommenen Vor- und Nachteile des Rauchens und der “Self-Efficacy“ - Fragebogen zur Erfassung der wahrgenommenen Versuchung zu rauchen bzw. der wahrgenommenen Sicherheit, auf das Rauchen verzichten zu können, präsentiert. Die Erhebungsinstrumente sind Übersetzungen der Originalinstrumente, die auf ihre Adäquatheit für den deutschen Sprach- und Kulturraum geprüft werden. Daten wurden im Rahmen der Studien “Transitions in Alcohol Consumption and Smoking (TACOS)“ erhoben. Es liegt eine bevölkerungsrepräsentative Stichprobe von 898 AktualraucherInnen und ehemaligen RaucherInnen zugrunde. Die statistischen Analysen zu den Testgütekriterien der deutschsprachigen Instrumente umfassten konfirmatorische Faktorenanalysen, Skalen- und Itemkennwerte, sowie Berechnungen zur Reliabilität und Konstruktvalidität. Im Ergebnis können sehr gute Entsprechungen zwischen den Originalinstrumenten und den deutschsprachigen Versionen belegt werden. Die TTM-Erhebungsinstrumente weisen stabile faktorielle Strukturen auf, sind hoch reliabel und valide. Damit wird ein Beitrag zur internationalen Vergleichbarkeit von Studien zum TTM geleistet.

An academic detailing intervention to disseminate physician-delivered smoking cessation counseling: smoking cessation outcomes of the Physicians Counseling Smokers Project

BACKGROUND

Little is known about the effectiveness of interventions to disseminate smoking cessation interventions among a population of primary care physicians. This study's objective was to determine the effect of a community-based academic detailing intervention on the quit rates of a population-based sample of smokers.

METHODS

This community-based, quasi-experimental study involved representative samples of 259 primary care physicians and 4295 adult smokers. An academic detailing intervention was delivered to physicians in intervention areas over a period of 15 months. Analyses were performed on the data from the 2346 subjects who reported at least one physician visit over 24 months. Multivariate regression analyses were conducted to determine the impact of the intervention on self-reported smoking quit rates, reported by adjusted odds ratios.

RESULTS

Among smokers reporting a physician visit during the study period, there was a borderline significant effect for those residing in intervention areas versus control areas (OR = 1.35; 95% CI.99-1.83; P = 0.057). Among a subgroup of 819 smokers who reported a visit with an enrolled physician, we observed a significant effect for those residing in intervention areas (OR = 1.80; 95% CI 1.16-2.75; P = 0.008).

CONCLUSION

An academic detailing intervention to enhance physician delivered smoking cessation counseling is an effective strategy for disseminating smoking cessation interventions among community-based practices.

Smoking cessation for patients with cardiovascular disease: what is the best approach?

Tobacco use remains the major preventable cause of early mortality and morbidity in the US and is a major risk factor for cardiovascular disease (CVD). Quitting smoking rapidly reduces the risk of cardiovascular events. In this review, we identify and discuss best approaches to assist smoking cessation among patients with CVD. Establishing office systems that reliably identify smokers to healthcare providers is an essential first step. Once the patient is identified as a smoker, providers should inquire about their willingness to quit and advise them to quit or provide motivation to get ready to make a quit attempt. Behavioral (counseling) and pharmacologic (nicotine replacement and non-nicotine medications) treatments double or triple long-term cessation rates and should be offered in combination to all patients with CVD who use tobacco. More intensive behavioral therapy is more effective and should be delivered when possible. The choice of pharmacotherapy will depend upon the clinical history of the patient and patient preference. Nicotine replacement and sustained release bupropion (bupropion SR) are first-line treatments for smoking cessation. Nicotine patches have been studied extensively in patients with stable CVD and have been shown to be safe. Bupropion SR has relatively few cardiovascular adverse effects and may be especially useful for patients with CVD; its safety is currently being studied. Special consideration is needed for hospitalized patients with acute coronary syndromes (e.g. myocardial infarction and unstable angina). The safety of pharmacotherapy in the acute setting is not yet established. Behavioral interventions, however, are very effective and should be delivered to all hospitalized smokers. Finally, it is important to create a clinical environment that is supportive of treating patients with tobacco dependence. Simple changes in office and hospital routines and procedures (routine screening to identify smokers, prompts to encourage intervention and links to more intensive tobacco dependence treatment programs) will substantially improve the identification, treatment, and outcomes of patients with CVD who use tobacco.

A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program

OBJECTIVE

Parental smoking is associated with increased rates and severity of childhood respiratory illness. No previous studies have examined child hospitalization as an opportunity for parental smoking cessation. We evaluated the feasibility of implementing a smoking cessation intervention for parents at the time of child hospitalization for respiratory illness.

METHODS

We performed a prospective cohort study of smoking parents who had a child who was admitted to an academic children's hospital for a respiratory illness between January and April 2000. All enrollees were offered the Stop Tobacco Outreach Program, which includes an initial motivational interview, written materials, nicotine replacement therapy (NRT), telephone counseling, and fax referral to parents' primary clinician. The primary outcome was completion of all 3 counseling sessions. Two-month follow-up outcomes were quit attempts, cessation, NRT use, primary care visits, household smoking prohibition, and satisfaction.

RESULTS

A total of 126 smoking parents met eligibility criteria, and 71 (56%) enrolled in the study. Of the 71, 80% completed all counseling sessions and 56% accepted free NRT at the time of enrollment. At the 2-month follow-up, of the 71 initial enrollees, 49% reported having made a quit attempt that lasted at least 24 hours, 21% reported not smoking a cigarette in the last 7 days, 27% reported having used NRT, and 38% had had a visit with their own primary clinician. The proportion of parents who reported rules prohibiting smoking in the house increased (29% vs 71%). Parental rating of the overall usefulness of the program was 4.3 +/- 0.9 (1 standard deviation) on the 5-point scale 1 = not at all and 5 = a great extent.

CONCLUSIONS

This study demonstrates the feasibility of engaging parents in smoking cessation interventions at the time of child hospitalization for respiratory illness. Previous work done in a similar sample of parental smokers has shown extremely low ever-use rates of cessation programs. High rates of acceptance of in-hospital and telephone counseling in this study support the notion of child hospitalization as a teachable moment to address parental smoking.

Is there a role for assessment in smoking cessation treatment?

Recent strides have been made in smoking cessation as a number of behavioral and pharmacological treatments have proven effective. These treatments are briefly reviewed. The role of assessment in the treatment process, however, is less clear. Indeed, to date, there are few data suggesting that specialized assessment can be used to guide prescriptive treatment. As such, the question becomes one of how, or whether, assessment should be used in smoking cessation. We address these questions and argue that despite the dearth of empirical substantiation, certain aspects of smoking behavior should be assessed in that they: (1) help identify behavioral, physiological, and psychological conditions that maintain smoking, (2) help describe the problem (smoking) with enough clarity to foster both clinical understanding and diagnosis, and (3) offer prediction and evaluation of treatment process and outcome. Promising assessment-based treatments are also discussed, as well as recommendations for future directions pertaining to the role of assessment in smoking cessation.

Naturalistic changes in the readiness to quit tobacco smoking in a German general population sample

BACKGROUND

This study examines naturalistic changes, i.e., changes that occur without formal interventions, in the motivational readiness to quit tobacco smoking. The transtheoretical model (TTM) with the proposed five stages of change (precontemplation, contemplation, preparation, action, maintenance) is used as the theoretical framework.

METHODS

Data were collected as part of a representative general population study in Germany. A total of 786 individuals was assessed two times, 6 months apart, with respect to stage of change. Latent Transition Analysis (LTA) was employed as a special statistical method to analyze stage movements over time.

RESULTS

The best-fitting model to describe naturalistic stage movements included both forward and backward movements. A high proportion of the sample was in the precontemplation stage across both measurement occasions. There were high rates of stage regressions over the 6-month period.

CONCLUSIONS

In a German representative population of smokers, smoking behavior change toward abstinence does not occur naturally in a substantial amount over the 6-month period without intervention. Differing findings in studies for populations in the United States could be due to methodological differences or differences in tobacco-control conditions.

Facilitating changes in perinatal smoking. The impact of a stage-based workshop for care-providers in British Columbia

OBJECTIVE

To determine the impact of stage-based smoking cessation workshops for perinatal care-providers.

METHODS

A one-day workshop was designed and piloted with perinatal care-providers in Comox Valley, British Columbia. Dissemination to eight other communities followed. Pre- and post-questionnaires were collected from 270 care-providers. Clients (n = 115) were interviewed after contact with a care-provider.

RESULTS

Workshops increased care-provider knowledge (p < 0.0001), confidence to address smoking with clients (p < 0.0001), and perceived ability to help clients across the stages of change (p < 0.0001). There was an increase in use of the model (p < 0.0001) by care-providers, with 86% reporting changing their work with perinatal clients and 75% applying it beyond that setting. A significant shift in client readiness to change occurred during the pilot (p = 0.001) and dissemination (p = 0.013). Eighty percent of dissemination clients reported altering smoking behaviours as a result of intervention and 36% made at least one attempt to quit. Client satisfaction was high. Spin-off benefits included increased community collaboration, and capacity.

Testing stage effects in an ethnically diverse sample

The Transtheoretical Model (TTM) has been extensively validated in representative samples of adult smokers. Stage effects, i.e., the patterned relationships between Stage of Change (SOC) and other TTM variables, have been reported in a variety of samples. This study describes reliability data for the TTM variables and tests the stage effects with an ethnically diverse sample of 296 parents with young children. On the basis of theory and previous empirical evidence from a general population, it is possible to make quantitative predications about the magnitude of the expected effect sizes for the Decisional Balance, Situational Temptations, and Processes of Change subscales. For each variable, both a test of significance and a comparison with the expected effect sizes is reported. Results indicated significant stage differences for 8 of the 11 TTM subscales, and all quantitative predictions were confirmed. This study supports the use of TTM measures in an ethnically diverse sample.

Understanding people who smoke and how they change: a foundation for smoking cessation in primary care, part 2

The purpose of this 2-part article is to develop an understanding of people who smoke and how they change as a foundation for the delivery of smoking cessation interventions in primary care. Central to our approach is the transtheoretical model of change (TMC). The TMC is an evidence-based model of behavior change that has been developed and tested during the past 2 decades by Prochaska and his colleagues in the context of smoking cessation. We use a review of the literature, in-depth interviews of people who successfully quit smoking, and our experience applying the TMC in the context of primary care and a smoking cessation clinic to explore the clinical work of smoking cessation. This is part 2 of the article "Understanding People Who Smoke and How They Change: A Foundation for Smoking Cessation in Primary Care." Part 1 describes the theoretical information known about smoking cessation: why smoking is a powerful behavior, the scientific background of the TMC, and the building-block constructs of the TMC. The first section of part 2 is a review of the Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence, published in 2000. The second chapter of part 2 is a discussion of clinical assessments and strategies for working with smokers grounded in the Public Health Service practice guideline, our understanding of people who smoke, and the TMC. Woven throughout are transcripts of interviews with 4 people in which they describe their experiences smoking and their pathways to cessation.

Smoking cessation: progress, priorities, and prospectus

The authors review developments in understanding smoking cessation interventions over the past decade. Noteworthy is the unprecedented growth of research and knowledge that has left a deeper understanding of how best to use new and existing behavioral and pharmacologic tools and strategies to help smokers quit. The status of public-health-level interventions is evaluated, questions are raised concerning their efficacy, and suggestions are offered for further refinement of these intervention strategies. Development of cessation guidelines is reviewed, and the state of knowledge concerning behavioral and pharmacologic interventions is summarized. The authors also present agendas for behavioral and pharmacologic research related to smoking cessation and discuss individual difference factors among smokers that may prove to be important in designing new and refining existing treatments.

Gender differences in the psychological determinants of cigarette smoking

AIMS

To compare the distributions of smoking-related variables and the size of associations between these variables in men and women.

DESIGN AND PARTICIPANTS

Mail survey in 2934 daily smokers (1533 women and 1401 men) who volunteered for a smoking cessation trial. Follow-up after 7 months in 2456 people (84%).

SETTING

Community setting (French-speaking part of Switzerland, 1998).

FINDINGS

Women smoked less than men (18 versus 22 cigarettes per day, p < 0.001), had lower confidence in their ability to refrain from smoking, used more frequently the strategy defined as 'coping with the temptation to smoke' and reported more drawbacks of smoking (gender differences ranged between 0.1 and 0.3 standard deviation units on these scales). There was no gender difference in the distribution of smokers by stage of change. At follow-up, smoking cessation rates were similar in men and women (6% versus 5%, p=0.3). Intention to quit, quit attempts in the previous year and a more frequent use of self-change strategies predicted smoking cessation and were associated with tobacco dependence in both sexes. A more frequent use by women of coping strategies suggests that some women are 'self-restrained' smokers who control their smoking permanently. This could explain lower smoking rates in women. The size of associations between smoking-related variables was similar in men and women.

CONCLUSIONS

Even though there were gender differences in the distributions of some smoking-related variables, associations between these variables were similar in men and women. This suggests that smoking behaviour is regulated by similar psychological mechanisms in men and women.

Understanding people who smoke and how they change: a foundation for smoking cessation in primary care, part 1

The purpose of this article is to develop an understanding of people who smoke and how they change as a foundation for the delivery of smoking cessation interventions in primary care. Central to our approach is the transtheoretical model of change (TMC). The TMC is an evidence-based model of behavior change that has been developed and tested during the past 2 decades by Prochaska and his colleagues in the context of smoking cessation. We use a review of the literature, in-depth interviews of people who successfully quit smoking, and our experience applying the TMC in the context of primary care and a smoking cessation clinic to explore the clinical work of smoking cessation. This article on smoking cessation will be presented in 2 issues. Part 1 describes the theoretical information known about smoking cessation: why smoking is a powerful behavior, the scientific background of the TMC, and the building-block constructs of the TMC. The first section of part 2 is a review of the Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence, published in 2000. The second section of part 2 is a discussion of clinical assessments and strategies for working with smokers, which is grounded in the Public Health Service practice guideline, our understanding of people who smoke, and the TMC. Woven throughout are transcripts of interviews with 4 people in which they describe their smoking experiences and their pathways to cessation.

Psychological interventions: state of the art

The usefulness of psychological interventions in smoking cessation is well established. Ongoing efforts are aimed at establishing interventions for specific diagnostic groups, developing interventions that are targeted at smokers who do not seek treatment, and combining psychological and pharmacological treatment. There is emerging evidence that useful treatments have been developed for smokers with a depression history, and that expert system interventions based upon a stage model can be useful in changing the smoking behavior of smokers who are not yet ready to quit. Psychological interventions add to the efficacy of nicotine replacement therapy, but whether they add to the efficacy of other pharmacotherapies is not known. There is a need to determine whether psychological interventions are useful for diagnostic groups other than depressive disorder, and if so, whether they need be specific for that group. Additional research is needed on interventions for smokers who are not ready to quit, both in developing new techniques, and determining the need and usefulness of adaptations of those in existence to specific populations.

Examination of the transtheoretical model in current smokers

Although the transtheoretical model of behavior change has frequently been used as a basisfor smoking-cessation programs, in very few studies have the study variables been linked with the theoretical concepts. This study used a convenience sample of 79 current smokers to determine the relationships among the stages of change and the processes of change. Logistic regressions were used in order to determine whether certain processes were related to specific stages and whether specific processes were related to movement among the stages. Participants in the precontemplation stage and the preparation stage were found to rely on specific processes, whereas those in the contemplation stage did not.

Stages of change for perceived stress in a Swiss population sample: an explorative study

OBJECTIVES

Data from a cross-sectional survey of the Swiss general population were used in an explorative attempt to apply the transtheoretical model of behavioural change to perceived stress.

METHODS

The sample comprised 575 respondents who reported having experienced stressful situations in the previous month. Other variables assessed included gender, age, education, reported symptoms, and three constructs representing stages and processes of change as well as self-efficacy.

RESULTS

Findings indicated that (1) about one third of respondents appeared to cope successfully with the stressful situations they experienced, one third intended to do so, while one quarter appeared to have no intention of managing their stress more effectively. (2) There was no difference in stage of change distribution by gender or age, while those with higher education were more frequently represented in the latter stages than those with lower education. (3) Those in the maintenance stage reported significantly less symptoms than others.

CONCLUSIONS

We conclude that the assessment of readiness to change could be of valuable support in designing stage-specific interventions in the area of stress management.

Are biomarkers a useful aid in smoking cessation? A review and analysis of the literature

Healthcare providers' ability to motivate people to try to quit smoking or to remain abstinent is limited. Even with our best treatments, most smokers relapse within 1 year. Therefore it is important that we constantly strive to develop and test new, effective smoking interventions. Providing feedback on one's biomarkers (e.g., biological indices of smoking-related harm, harm exposure, or genetic susceptibility to disease) have been suggested as potentially useful for increasing smokers' motivation or ability to quit smoking. In fact, variations of this strategy are commonly incorporated into behavioral smoking-cessation interventions, but little empirical evidence has specifically addressed whether this approach is effective. In this article, the author reviews the theoretical rationale and empirical evidence regarding this practice. Although the preliminary evidence is promising, more research is needed to determine the efficacy of using biomarkers and the limits of the strategy's effectiveness. Future investigations should address these issues.

Improved smoking cessation in smokers given ultrasound photographs of their own atherosclerotic plaques

BACKGROUND

We examined whether making smokers aware that they had developed peripheral atherosclerosis would improve smoking cessation.

METHODS

Smokers selected from the general population were randomly allocated to undergo high-resolution B-mode ultrasonography of their carotid and femoral arteries. All smokers received quit-smoking counseling. Smokers with > or =1 atherosclerotic plaque were given two photographs of a plaque with a relevant explanation. Quit rates were assessed by telephone 6 months later.

RESULTS

Seventy-nine smokers did not undergo ultrasonography (A). Among the 74 smokers submitted to ultrasonography, 20 had no plaque (B) and 54 had > or =1 plaque (C). Quit rates were, respectively, 6.3, 5.0, and 22.2% in groups A, B, and C. Quit rates were higher in smokers submitted to ultrasonography (B + C vs A; P = 0.031) and in those receiving photographs (C vs A + B; P = 0.003). Smoking cessation was independently associated with intervention C (OR = 6.2; 95% CI = 1.8-21) and a white-collar job but not with age or gender.

CONCLUSIONS

Providing smokers with photographs demonstrating atherosclerosis on their own person was an effective adjunct to physician's advice to quit smoking. Since ultrasonography is used increasingly often in clinical practice for cardiovascular risk stratification, this can provide an additional opportunity and means to deter smokers from smoking.

Child hospitalization: an opportunity for parental smoking intervention

BACKGROUND

Hospitalization with tobacco-related illness increases smokers' interest in cessation. Because parental smoking increases the child's risk of developing respiratory and other illnesses, a child's hospitalization might motivate a smoking parent to consider changing smoking behavior. It is unclear if parents would be receptive to smoking-cessation interventions at the time when their child is hospitalized.

METHODS

In March 1999, parents of 298 consecutive children admitted to the medical services at Children's Hospital Boston were interviewed to determine the smoking status of household members. Smoking parents were invited to complete a 35-item questionnaire regarding personal smoking history and acceptability of three types of cessation interventions.

RESULTS

Sixty-five smoking parents were identified among the 298 admissions; 62 of 65 (95%) participated in the survey. Among respondents, only 15% had ever participated in any smoking-cessation program, and only 31% had ever used a medication to try to quit. Although 78% of parents were willing to speak with a counselor about their smoking while their child was in the hospital, and 74% would enroll in a telephone-based smoking-cessation program, only 26% were interested in a free program requiring travel back to the hospital. All parents believed that pediatricians should offer parental smokers the chance to participate in a smoking-cessation program.

CONCLUSIONS

At the time of a child's hospitalization, parents are willing to enroll in smoking interventions that include in-hospital and telephone counseling but not to travel back to the hospital. A child's hospitalization may provide a unique opportunity to enroll parents who smoke into cessation programs.

The change-in-stage and updated smoking status results from a cluster-randomized trial of smoking prevention and cessation using the transtheoretical model among British adolescents

BACKGROUND

The transtheoretical model (TTM) and computer technology are promising technologies for changing health behavior, but there is little evidence of their effectiveness among adolescents.

METHOD

Four thousand two hundred twenty-seven Year 9 (ages 13-14) pupils in 26 schools were randomly allocated to control and 4,125 in 26 schools were allocated to TTM intervention. TTM pupils received three whole class lessons and three sessions with an interactive computer program. Control pupils received no special intervention. Positive change in stage and smoking status was assessed from a questionnaire completed at baseline, 1 year, and 2 years. Random effects logistic regression was used to compare the change in stage and smoking status between the arms.

RESULTS

Eighty-nine percent of the TTM group and 89.3% of the control group were present at 1-year and 86.0 and 83.1%, respectively, were present at 2-year follow-up. The adjusted odds ratio (95% confidence interval) for positive stage movement in the TTM relative to control was 1.13 (0.91-1.41) at 1 year and 1.25 (0.95-1.64) at 2 years and for regular smoking was 1.14 (0.93-1.39) at 1 year and 1.06 (0.86-1.31) at 2 years. Subgroup analysis by initial smoking status revealed no benefit for prevention or cessation.

CONCLUSIONS

The intervention was ineffective.

Depression and stages of change for smoking in psychiatric outpatients

This article reports on the relations between depression and stages of change for smoking cessation. A convenience sample of 205 psychiatric outpatients (68% female, mean age 41) completed measures of depression Primary Care Evaluation of Mental Disorders [PRIME-MD] and Beck Depression Inventory-II [BDI-II]), all transtheoretical model constructs related to smoking (stages and processes of change, pros and cons of smoking, and situational temptations), and thoughts about abstinence. As hypothesized, patients who had never smoked showed substantially lower rates of currently diagnosed major depressive disorder (MDD) than those who had ever smoked. Patients in early stages of change did not show more MDD or depressive symptoms but, as hypothesized, showed more negative thoughts about abstinence. Findings are consistent with the documented association between smoking and depression and suggest the appropriateness of building smoking cessation interventions based on the transtheoretical model of change for use with psychiatric populations.

Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation

A stage-matched expert system intervention was evaluated on 4144 smokers in a two-arm randomized control trial with four follow-ups over 24 months. Smokers were recruited by random digit-dial calls, and 80.0% of the eligible smokers were enrolled. Individualized and interactive expert system computer reports were sent at 0, 3, and 6 months. The reports provided feedback on 15 variables relevant for progressing through the stages. The primary outcomes were point prevalence and prolonged abstinence rates. At 24 months, the expert system resulted in 25.6% point prevalence and 12% prolonged abstinence, which were 30% and 56% greater than the control condition. Abstinence rates at each 6-month follow-up were significantly greater in the Expert System (ES) condition than in the comparison condition with the absolute difference increasing at each follow-up. A proactive home-based stage-matched expert system smoking cessation program can produce both high participation rates and relatively high abstinence rates.

[Can we help our patients to stop smoking?: the experience of the Smoking Cessation Program]

OBJECTIVE

To describe the process and results of the Smoking Cessation Program in order to answer this question: Does the lack of time and resources justify poor involvement of physicians in helping patients to stop smoking?

METHODS

Prospective series of cases that included all smokers (n = 1203) who for any reason attended seven general practices over a period of one year. The behaviour of smokers when the program was offered as well as the workload generated by the implementation of the process are described. Subjects who stopped smoking were those who did not smoke two years after enrolment in a sustained and validated form for least 12 months.

RESULTS

A total of 7.3% of all smokers quit (95% confidence interval [CI]: 5.9-8.9). Enrolment of subjects caused an increase in the consultation time of 23 seconds and decreased from a mean of 30 new smokers per month per practice during the first three months to 12 at the end of the first year. All received advise to stop smoking (mean increase of 3 min and 33 s) but only 17.5% accepted the therapeutic plan during the first year (95% CI: 15.4-19.9) that had a duration of 72:11 min and generated a mean of six programmed appointments a month in each practice. Twenty percent of subjects who participated in the therapeutic plan stopped smoking (95% CI: 14.8-26.1).

CONCLUSIONS

Identification and universal advice to smokers, together with treatment of those who are motivated to quit, achieved important success rates without increasing excessively ordinary work loads.

Smoking cessation in China: findings from the 1996 national prevalence survey

OBJECTIVES

To describe patterns of smoking and smoking cessation in China within the context of the stages of change model, using data from the 1996 national prevalence survey.

DESIGN

A cross sectional survey was carried out using the 145 preselected disease surveillance points, which provide a representative sample for the entire country. A standardised questionnaire on smoking was interviewer administered.

SETTING

The country of China.

SUBJECTS

122,220 people aged 15-69 years. MAINTENANCE MEASURES: Smoking cessation patterns, as defined by smoking status (current or former) and stage of change (precontemplation, contemplation, and action).

RESULTS

The sample included 45,995 ever smokers of whom 4336 had quit. About 72% of current smokers reported not intending to give up their smoking behaviour, and about 16% of current smokers said they intended to do so, but have not taken any action. Of all ever smokers, the percentage of former smokers was 9.5%, and 12% of current smokers had quit at least once, but relapsed by the time of the survey. The patterns were similar in men and women with regard to the stated intent to quit. Among males, the percentage of former smokers increased with age but the percentage intending to quit was constant at about 15% across age strata. The most common reason for quitting was illness. Participants with a university education were more likely to have made an attempt to quit.

CONCLUSIONS

The percentage of smokers contemplating quitting was low in China in 1996. The study shows that smokers in China must be mobilised to contemplate quitting and then to take action.

Attitudes toward smoking and smoking behaviors of patients with Crohn's disease

OBJECTIVE

To examine the smoking behaviors of people with Crohn's disease. In active smokers, we measured their willingness to quit, their degree of nicotine dependence, and the proportion that made a quit attempt within 6 months to determine if they were refractory to smoking cessation in comparison to the general population. We also examined factors that were important in their decision to smoke.

METHODS

We conducted a cross-sectional survey of out-patients, supplemented by telephone interviews and a 6-month follow-up questionnaire of active smokers. Measures included disease activity, current smoking behaviors, intentions (stage of change), Fagerstrom Test for Nicotine Dependence, and factors related to their decision to smoke (decisional balance).

RESULTS

The questionnaire was completed by 115 patients (78% response rate). Forty percent were active smokers. Of active smokers, 59% were considering quitting within the next 6 months, and of these, 15% were planning on quitting within the next 30 days. Those with moderate disease activity were more likely to be considering quitting than those with mild or severe activity. Nicotine dependence was rated as high in 33% and as moderate in 43%. Factors unrelated to Crohn's disease were more important in their decision to smoke than were Crohn's disease-related factors. After 6 months, 23% had made an attempt to quit and this attempt was strongly associated with their stated intentions at the baseline questionnaire. Two of three patients who had recently quit at baseline had resumed smoking.

CONCLUSION

When compared to similar data for the general population, patients with Crohn's disease are no more refractory to smoking cessation.

Intervention and policy issues related to children's exposure to environmental tobacco smoke

BACKGROUND

Children's exposure to environmental tobacco smoke (ETS) is unacceptably high; almost 40% of children in the United States are regularly exposed to ETS.

METHODS

This paper presents a review of the literature that evaluates interventions designed to reduce ETS exposure among young children. In addition, it presents the study design for Project KISS (Keeping Infants Safe from Smoke), an intervention designed to utilize exposure-related feedback to increase parents' motivation for ETS reduction and to reduce household ETS levels. Baseline data are presented to illustrate factors that should be addressed in ETS interventions.

RESULTS

The literature review demonstrates the dearth of studies in the literature targeting ETS reduction among children. Participants in Project KISS believed that smoking had affected their children's health and were in later stages of motivational readiness to quit smoking than is typically observed. However, they face a number of challenges to smoking, such as high prevalence of nicotine dependence, high prevalence of living with other smokers, and socioeconomic and stress-related barriers.

CONCLUSIONS

The policy implications of this research are discussed, and recommendations are made for future research.

Smoking cessation in the hospitalized patient using the transtheoretical model of behavior change

Tobacco use continues to be the most prevalent cause of preventable morbidity and mortality in the United States, causing more than 430,000 deaths each year, or 1 in every 5 deaths. In addition, many health care providers employed in critical care settings deal with patients who have experienced a near-death event that has led them to consider smoking cessation. The smoking cessation rate 1 year after a myocardial infarction is approximately 70% in those patients who receive a smoking cessation intervention. Theory-based smoking cessation interventions have been found to be effective. The purpose of this article is to present the transtheoretical model as basis for developing a hospital-based smoking cessation intervention. In addition, symptom management options will be discussed.

Counselor and stimulus control enhancements of a stage-matched expert system intervention for smokers in a managed care setting

BACKGROUND

Previous research has demonstrated the efficacy of an interactive expert system intervention for smoking cessation for a general population. The intervention provides individualized feedback that guides participants through the stages of change for cessation. Enhancing the expert system by adding proactive telephone counseling or a stimulus control computer designed to produce nicotine fading could produce preventive programs with greater population impacts.

METHODS

Four interventions were compared: (a) the interactive expert system intervention; (b) the expert system intervention plus counselor calls; (c) the expert system intervention plus the stimulus control computer; and (d) an assessment only condition. A 4 (intervention) x 4 (occasions) (0,6,12, and 18 months) design was used. Smokers were contacted at home via telephone or mail. The initial subject pool was the 24,178 members of a managed care company. Screening was completed for 19,236 members (79.6%), of whom 4,653 were smokers; 85.3% of the smokers were enrolled.

RESULTS

Thirty-eight percent were in the precontemplation stage, 45% in the contemplation stage, and only 17% in the preparation stage. At 18 months, the expert system resulted in 23.2% point prevalence abstinence, which was 33% greater than that of assessment only. The counselor enhancement produced increased cessation at 12 months but not at 18 months. The stimulus control computer produced no improvement, resulting in 20% worse cessation rates than the assessment only condition.

CONCLUSIONS

The enhanced conditions failed to outperform the expert system alone. The study also demonstrated the ability of the interactive expert system to produce significantly greater cessation in a population of smokers than assessment alone.

Clusters of precontemplating smokers defined by the perception of the pros, cons, and self-efficacy

Western smoker populations contain high percentages of smokers who are not motivated to quit. In order to develop self-help smoking cessation interventions for these smokers, it is of importance to know whether there are subtypes among this group. In the present study, cluster analysis was used to search for clusters of precontemplating smokers. The clusters were described by three cognitive clustering variables: the pros of quitting, the cons of quitting, and self-efficacy expectations. On the basis of earlier studies, three cluster solutions were tested: the 3-, 4-, and 5-cluster solutions. To cross-validate the findings, data from two independently recruited samples of precontemplating smokers were used. Three clusters, which were found in earlier studies in the United States, were replicated. In the present study these were called Unmotivated Pessimists, Motivated Pessimists, and Disengaged. Two additional clusters were identified, which might be typical for the tolerant Dutch smoking culture: Unmotivated Optimists and Motivated Optimists. It is argued that the replicated types are more nicotine-dependent and resistant to change, and represent the hard core smoker population, and that both optimistic types are less dependent, less resistant smokers who will quit with increasing societal anti-smoking pressure. Longitudinal analyses showed that cluster membership was predictive of increases in intention to quit and quitting activity.