Tailoring smoking cessation for older adults

Prevention Strategies of Alcohol and Substance Use Disorders in Older Adults

Older adults are increasingly engaging in unhealthy substance use. Owing to aging and comorbid medical conditions, older adults are at increased risk of adverse effects from alcohol, tobacco, and illicit drug use. Preventative measures, regular screening, and appropriate intervention can protect older adults from the negative outcomes of substance use and potentially improve their quality of life. This article reviews the latest trends of substance use in older adults, impact on health, and the best practice approaches for the clinical assessment of substance use disorders in this age group.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials that provide a structured programme for smokers to follow may increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of print-based self-help materials that provide a structured programme for smokers to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print-based self-help, such as computer-generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The date of the most recent search was March 2018.

SELECTION CRITERIA

We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested print-based materials providing self-help compared with minimal print-based self-help (such as a short leaflet) or a lower-intensity control. We defined 'self-help' as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in accordance with standard methodological procedures set out by Cochrane. The main outcome measure was abstinence from smoking after at least six months' follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each study and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

We identified 75 studies that met our inclusion criteria. Many study reports did not include sufficient detail to allow judgement of risk of bias for some domains. We judged 30 studies (40%) to be at high risk of bias for one or more domains.Thirty-five studies evaluated the effects of standard, non-tailored self-help materials. Eleven studies compared self-help materials alone with no intervention and found a small effect in favour of the intervention (n = 13,241; risk ratio (RR) 1.19, 95% confidence interval (CI) 1.03 to 1.37; I² = 0%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for indirect relevance to populations in low- and middle-income countries because evidence for this comparison came from studies conducted solely in high-income countries and there is reason to believe the intervention might work differently in low- and middle-income countries. This analysis excluded two studies by the same author team with strongly positive outcomes that were clear outliers and introduced significant heterogeneity. Six further studies of structured self-help compared with brief leaflets did not show evidence of an effect of self-help materials on smoking cessation (n = 7023; RR 0.87, 95% CI 0.71 to 1.07; I² = 21%). We found evidence of benefit from standard self-help materials when there was brief contact that did not include smoking cessation advice (4 studies; n = 2822; RR 1.39, 95% CI 1.03 to 1.88; I² = 0%), but not when self-help was provided as an adjunct to face-to-face smoking cessation advice for all participants (11 studies; n = 5365; RR 0.99, 95% CI 0.76 to 1.28; I² = 32%).Thirty-two studies tested materials tailored for the characteristics of individual smokers, with controls receiving no materials, or stage-matched or non-tailored materials. Most of these studies used more than one mailing. Pooling studies that compared tailored self-help with no self-help, either on its own or compared with advice, or as an adjunct to advice, showed a benefit of providing tailored self-help interventions (12 studies; n = 19,190; RR 1.34, 95% CI 1.20 to 1.49; I² = 0%) with little evidence of difference between subgroups (10 studies compared tailored with no materials, n = 14,359; RR 1.34, 95% CI 1.19 to 1.51; I² = 0%; two studies compared tailored materials with brief advice, n = 2992; RR 1.13, 95% CI 0.86 to 1.49; I² = 0%; and two studies evaluated tailored materials as an adjunct to brief advice, n = 1839; RR 1.72, 95% CI 1.17 to 2.53; I² = 10%). When studies compared tailored self-help with non-tailored self-help, results favoured tailored interventions when the tailored interventions involved more mailings than the non-tailored interventions (9 studies; n = 14,166; RR 1.42, 95% CI 1.20 to 1.68; I² = 0%), but not when the two conditions were contact-matched (10 studies; n = 11,024; RR 1.07, 95% CI 0.89 to 1.30; I² = 50%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for risk of bias.Five studies evaluated self-help materials as an adjunct to nicotine replacement therapy; pooling three of these provided no evidence of additional benefit (n = 1769; RR 1.05, 95% CI 0.86 to 1.30; I² = 0%). Four studies evaluating additional written materials favoured the intervention, but the lower confidence interval crossed the line of no effect (RR 1.20, 95% CI 0.91 to 1.58; I² = 73%). A small number of other studies did not detect benefit from using targeted materials, or find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that when no other support is available, written self-help materials help more people to stop smoking than no intervention. When people receive advice from a health professional or are using nicotine replacement therapy, there is no evidence that self-help materials add to their effect. However, small benefits cannot be excluded. Moderate-certainty evidence shows that self-help materials that use data from participants to tailor the nature of the advice or support given are more effective than no intervention. However, when tailored self-help materials, which typically involve repeated assessment and mailing, were compared with untailored materials delivered similarly, there was no evidence of benefit.Available evidence tested self-help interventions in high-income countries, where more intensive support is often available. Further research is needed to investigate effects of these interventions in low- and middle-income countries, where more intensive support may not be available.

Preliminary evaluation of a telephone-based smoking cessation intervention in the lung cancer screening setting: A randomized clinical trial

Incorporating effective smoking cessation interventions into lung cancer screening (LCS) programs will be essential to realizing the full benefit of screening. We conducted a pilot randomized trial to determine the feasibility and efficacy of a telephone-counseling (TC) smoking cessation intervention vs. usual care (UC) in the LCS setting. In collaboration with 3 geographically diverse LCS programs, we enrolled current smokers (61.5% participation rate) who were: registered to undergo LCS, 50-77 years old, and had a 20+ pack-year smoking history. Eligibility was not based on readiness to quit. Participants completed pre-LCS (T0) and post-LCS (T1) telephone assessments, were randomized to TC (N=46) vs. UC (N=46), and completed a final 3-month telephone assessment (T2). Both study arms received a list of evidence-based cessation resources. TC participants also received up to 6 brief counseling calls with a trained cessation counselor. Counseling calls incorporated motivational interviewing and utilized the screening result as a motivator for quitting. The outcome was biochemically verified 7-day point prevalence cessation at 3-months post-randomization. Participants (56.5% female) were 60.2 (SD=5.4) years old and reported 47.1 (SD=22.2) pack years; 30% were ready to stop smoking in the next 30 days. TC participants completed an average of 4.4 (SD=2.3) sessions. Using intent-to-treat analyses, biochemically verified quit rates were 17.4% (TC) vs. 4.3% (UC), p<.05. This study provides preliminary evidence that telephone-based cessation counseling is feasible and efficacious in the LCS setting. As millions of current smokers are now eligible for lung cancer screening, this setting represents an important opportunity to exert a large public health impact on cessation among smokers who are at very high risk for multiple tobacco-related diseases. If this evidence-based, brief, and scalable intervention is replicated, TC could help to improve the overall cost-effectiveness of LCS.

TRIAL REGISTRATION

NCT02267096, https://clinicaltrials.gov.

Promoting Smoking Cessation Among the Elderly

Purpose: To assess the predictors of smoking cessation and intention to quit among the Chinese elderly smokers. Design: A cross-sectional survey of elderly smokers. Setting: Shamsuipo district, Hong Kong. Subject: A total of 1,318 elderly were interviewed (response rate = 83%). Measures: A structured questionnaire was used for data collection. The questionnaire sought information on the subject's sociodemographic background and smoking habits. The predictors for successful quitting and intention to quit were assessed by chi-square tests and multiple logistic regression. Results: Of the respondents, 20.2% were current smokers, 25.4% were ex-smokers, and 54.4% were never smokers. Of the smoker (current and ex-smokers) respondents, 55.7% (335/601) had successfully quit at the time of enumeration. The predictors of quitting were living with others, receiving assistance for mobility, being nondrinkers, smoking for shorter duration, and smoking more cigarettes per day. Having health problems in the past, smoking for shorter duration, and smoking fewer cigarettes per day were predictors of intention to quit smoking. Conclusion:The study identified several predictors of successful quitting that could help improve the provision of current smoking cessation services. Population-based smoking cessation programs, especially those targeted to elderly, should take these predictors into consideration in the design of interventions.

Older Adults’ and Case Managers’ Perceptions of Smoking and Smoking Cessation

Objectives: This study explores older smokers’ and case managers’ perceptions of smoking and smoking cessation. Methods: Data were collected from 48 case managers via focus group sessions and questionnaires and from 20 smoking clients via structured interviews. Results: Case managers identified barriers to addressing clients’ smoking at the client, staff, and organizational levels. Clients and case managers lacked information on the benefits of smoking cessation in older adults. The majority of clients interviewed had no plans to quit smoking. Discussion: Results suggest that smoking cessation programs for this population need to be geared to clients who are not ready to quit. Education about the benefits of quitting smoking in older adults is needed for both case managers and smokers.

How Smart are Smartphone Apps for Smoking Cessation? A Content Analysis

INTRODUCTION

Smartphone technology is ideally suited to provide tailored smoking cessation support, yet it is unclear to what extent currently existing smartphone "apps" use tailoring, and if tailoring is related to app popularity and user-rated quality.

METHODS

We conducted a content analysis of Android smoking cessation apps (n = 225), downloaded between October 1, 2013 to May 31, 2014. We recorded app popularity (>10,000 downloads) and user-rated quality (number of stars) from Google Play, and coded the existence of tailoring features in the apps within the context of using the 5As ("ask," "advise," "assess," "assist," and "arrange follow-up"), as recommended by national clinical practice guidelines.

RESULTS

Apps largely provided simplistic tools (eg, calculators, trackers), and used tailoring sparingly: on average, apps addressed 2.1 ± 0.9 of the 5As and used tailoring for 0.7 ± 0.9 of the 5As. Tailoring was positively related to app popularity and user-rated quality: apps that used two-way interactions (odds ratio [OR] = 5.56 [2.45-12.62]), proactive alerts (OR = 3.80 [1.54-9.38]), responsiveness to quit status (OR = 5.28 [2.18-12.79]), addressed more of the 5As (OR = 1.53 [1.10-2.14]), used tailoring for more As (OR = 1.67 [1.21-2.30]), and/or used more ways of tailoring 5As content (OR = 1.35 [1.13-1.62]) were more likely to be frequently downloaded. Higher star ratings were associated with a higher number of 5As addressed (b = 0.16 [0.03-0.30]), a higher number of 5As with any level of tailoring (b = 0.14 [0.01-0.27]), and a higher number of ways of tailoring 5As content (b = 0.08 [0.002-0.15]).

CONCLUSIONS

Publically available smartphone smoking cessation apps are not particularly "smart": they commonly fall short of providing tailored feedback, despite users' preference for these features.

Clinician advice to quit smoking among seniors

OBJECTIVE

Little smoking research in the past 20years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics.

METHOD

In 2012-4, we analyzed 2010 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from Medicare beneficiaries over age 64 (n=346,674). We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation.

RESULTS

12% of male and 8% of female respondents aged 65 and older smoke. The rate decreases with age (14% of 65-69, 3% of 85+) and education (12-15% with no high school degree, 5-6% with BA+). Rates are highest among American Indian/Alaskan Native (16%), multiracial (14%), and African-American (13%) seniors, and in the Southeast (14%). Only 51% of smokers say they receive cessation advice "always" or "usually" at doctor visits, with advice more often given to the young, those in low-smoking regions, Asians, and women. For all results cited p<0.05.

CONCLUSIONS

Smoking cessation advice to seniors is variable. Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine: the effectiveness of different forms of print-based self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to print-based self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search April 2014.

SELECTION CRITERIA

We included randomized trials of smoking cessation with follow-up of at least six months, where at least one arm tested a print-based self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We identified 74 trials which met the inclusion criteria. Many study reports did not include sufficient detail to judge risk of bias for some domains. Twenty-eight studies (38%) were judged at high risk of bias for one or more domains but the overall risk of bias across all included studies was judged to be moderate, and unlikely to alter the conclusions.Thirty-four trials evaluated the effect of standard, non-tailored self-help materials. Pooling 11 of these trials in which there was no face-to-face contact and provision of structured self-help materials was compared to no intervention gave an estimate of benefit that just reached statistical significance (n = 13,241, risk ratio [RR] 1.19, 95% confidence interval [CI] 1.04 to 1.37). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Six further trials without face-to-face contact in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials (n = 7023, RR 0.88, 95% CI 0.74 to 1.04). When these two subgroups were pooled, there was no longer evidence for a benefit of standard structured materials (n = 20,264, RR 1.06, 95% CI 0.95 to 1.18). We failed to find evidence of benefit from providing standard self-help materials when there was brief contact with all participants (5 trials, n = 3866, RR 1.17, 95% CI 0.96 to 1.42), or face-to-face advice for all participants (11 trials, n = 5365, RR 0.97, 95% CI 0.80 to 1.18).Thirty-one trials offered materials tailored for the characteristics of individual smokers, with controls receiving either no materials, or stage matched or non-tailored materials. Most of the trials used more than one mailing. Pooling these showed a benefit of tailored materials (n = 40,890, RR 1.28, 95% CI 1.18 to 1.37) with moderate heterogeneity (I² = 32%). The evidence is strongest for the subgroup of nine trials in which tailored materials were compared to no intervention (n = 13,437, RR 1.35, 95% CI 1.19 to 1.53), but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data, since the subgroup of 10 trials where the number of contacts was matched did not detect an effect (n = 11,024, RR 1.06, 95% CI 0.94 to 1.20). In two trials including a direct comparison between tailored materials and brief advice from a health care provider, there was no evidence of a difference, but confidence intervals were wide (n = 2992, RR 1.13, 95% CI 0.86 to 1.49).Only four studies evaluated self-help materials as an adjunct to nicotine replacement therapy, with no evidence of additional benefit (n = 2291, RR 1.05, 95% CI 0.88 to 1.25). A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Standard, print-based self-help materials increase quit rates compared to no intervention, but the effect is likely to be small. We did not find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective than non-tailored materials, although the absolute size of effect is still small. Available evidence tested self-help interventions in high income countries; further research is needed to investigate their effect in contexts where more intensive support is not available.

Implications of tobacco smoking on the oral health of older adults

Cigarette smoking is the foremost health risk issue affecting individuals of all age groups globally. It specifically influences the geriatric population as a result of chronic exposure to toxins. Its role in various systemic and oral diseases including cancer, premalignant lesions, periodontitis, tooth loss, dental caries and implant failures is well established. Smoking causes immuno-inflammatory imbalances resulting in increased oxidative stress in the body. The latter hastens the immunosenescence and inflammaging process, which increases the susceptibility to infections. Thus, implementation of smoking cessation programs among older adults is imperative to prevent the development and progression of oral and systemic diseases. The present review focuses on smoking-associated oral health problems in older adults, and the steps required for cessation of the habit.

A comparison of smoking behaviour characteristics between Caucasian smokers in the United Kingdom and Malay smokers in Malaysia

OBJECTIVES

There is evidence that smoking behaviour differs by ethnicity. This study aims to compare smoking behaviour characteristics between Caucasian and Malay smokers.

METHODS

A cross sectional survey, involving 175 smokers attending smoking cessation clinics at the Institute of Psychiatry, London, United Kingdom and University Malaya, Kuala Lumpur, Malaysia between May 2005 and February 2007. Data on demographics, smoking history, nicotine dependence and smoking behaviour were collected.

RESULTS

All participants were males, mean age 30.7 ± 10.3 years. Caucasians initiated smoking significantly earlier (mean age 14.8 ± 2.8 years) (p = 0.001) and smoked regularly significantly earlier (mean age 17.3 ± 3.5) (p = 0.003) than Malays (mean starting age 16.9 ± 4.4 years and mean age regular use 19.5 ± 4.5 years), respectively. Caucasians smoked less for social integration than Malays (p = 0.03) but smoked more for regulation of negative affect than Malays (p = 0.008) and smoked more for hedonism than Malays (p < 0.001).

CONCLUSION

Malays smoke as a means of socially integrating. This has important public health implications. Social reasons and the social environment play a role in smoking uptake, smoking maintenance and smoking cessation and this should be borne in mind for strategies planning to promote smoking cessation.

Tailored Health Communication to Change Lifestyle Behaviors

Tailored health communication research represents a very promising line of inquiry that has the potential to produce major impacts on lifestyle behaviors. This study defines tailoring and discusses how tailored interventions operate, including comparing/ contrasting different tailoring channels. Next, the authors review the literature on tailored interventions to change lifestyle behaviors, with a focus on smoking cessation, dietary change, and physical activity, as well as interventions that address multiple lifestyle behaviors. Finally, future directions for tailoring research are discussed. To date, a large literature has amassed showing the promise of tailored programs delivered via print, Internet, local computer/kiosk, telephone, and interpersonal channels. Numerous studies demonstrate that these programs are capable of significant impacts on smoking cessation, dietary change, physical activity, and multiple behavior change. It is concluded that the potential of tailoring will be more fully realized as (a) the field builds a more cumulative science of tailoring and (b) greater dissemination of efficacious tailored programs takes place.

Extended treatment of older cigarette smokers

AIMS

Tobacco dependence treatments achieve abstinence rates of 25-30% at 1 year. Low rates may reflect failure to conceptualize tobacco dependence as a chronic disorder. The aims of the present study were to determine the efficacy of extended cognitive behavioral and pharmacological interventions in smokers > or = 50 years of age, and to determine if gender differences in efficacy existed.

DESIGN

Open randomized clinical trial.

SETTING

A free-standing, smoking treatment research clinic.

PARTICIPANTS

A total of 402 smokers of > or = 10 cigarettes per day, all 50 years of age or older.

INTERVENTION

Participants completed a 12-week treatment that included group counseling, nicotine replacement therapy (NRT) and bupropion. Participants, independent of smoking status, were then assigned randomly to follow-up conditions: (i) standard treatment (ST; no further treatment); (ii) extended NRT (E-NRT; 40 weeks of nicotine gum availability); (iii) extended cognitive behavioral therapy (E-CBT; 11 cognitive behavioral sessions over a 40-week period); or (iv) E-CBT plus E-NRT (E-combined; 11 cognitive behavioral sessions plus 40 weeks nicotine gum availability).

MEASUREMENTS

Primary outcome variable was 7-day point prevalence cigarette abstinence verified biochemically at weeks 24, 52, 64 and 104.

FINDINGS

The most clinically important findings were significant main effects for treatment condition, time and the treatment x time interaction. The E-CBT condition produced high cigarette abstinence rates that were maintained throughout the 2-year study period [(week 24 (58%), 52 (55%), 64 (55%) and 104 (55%)], and was significantly more effective than E-NRT and ST across that period. No other treatment condition was significantly different to ST. No effects for gender were found.

CONCLUSIONS

Extended cognitive behavioral treatments can produce high and stable cigarette abstinence rates for both men and women. NRT does not add to the efficacy of extended CBT, and may hamper its efficacy. Research is needed to determine if these results can be replicated in a sample with a greater range of ages, and improved upon with the addition of medications other than NRT.

False promises: the tobacco industry, "low tar" cigarettes, and older smokers

To investigate the role of the tobacco industry in marketing to and sustaining tobacco addiction among older smokers and aging baby boomers, We performed archival searches of electronic archives of internal tobacco company documents using a snowball sampling approach. Analysis was done using iterative and comparative review of documents, classification by themes, and a hermeneutic interpretive approach to develop a case study. Based on extensive marketing research, tobacco companies aggressively targeted older smokers and sought to prevent them from quitting. Innovative marketing approaches were used. "Low tar" cigarettes were developed in response to the health concerns of older smokers, despite industry knowledge that such products had no health advantage and did not help smokers quit. Tobacco industry activities influence the context of cessation for older smokers in several ways. Through marketing "low tar" or "light" cigarettes to older smokers "at risk" of quitting, the industry contributes to the illusion that such cigarettes are safer, although "light" cigarettes may make it harder for addicted smokers to quit. Through targeted mailings of coupons and incentives, the industry discourages older smokers from quitting. Through rhetoric aimed at convincing addicted smokers that they alone are responsible for their smoking, the industry contributes to self-blame, a documented barrier to cessation. Educating practitioners, older smokers, and families about the tobacco industry's influence may decrease the tendency to "blame the victim," thereby enhancing the likelihood of older adults receiving tobacco addiction treatment. Comprehensive tobacco control measures must include a focus on older smokers.

Older versus younger treatment-seeking smokers: differences in smoking behavior, drug and alcohol use, and psychosocial and physical functioning

Quitting smoking benefits older individuals, yet few recent studies have described older smokers. The goal of this paper was to test a series of hypotheses about differences between smokers aged 50 years or older (50+) and those younger than age 50 (<50) presenting to the same treatment facility during 2002-2004 for participation in two randomized clinical trials: one exclusively for smokers aged 50+, and a second open to smokers aged 18 or older. As predicted, smokers aged 50+ were more tobacco dependent, had better psychological functioning, and had poorer physical functioning than those aged <50. Contrary to predictions, we found no differences in motivation to quit cigarette smoking or in alcohol use. Women aged 50+ were less likely to report marijuana use than women aged <50, and less likely than men to receive a positive diagnosis for alcohol abuse. Despite higher scores on measures of tobacco dependence, older smokers were less likely to be diagnosed as tobacco dependent or as having tobacco withdrawal using DSM-IV criteria. Rates of DSM-IV alcohol abuse and dependence were high in both age groups but were higher for smokers aged <50. We found no striking differences between studies in reasons for exclusion, but in both the proportion of individuals excluded due to current antidepressant use was high. Implications for the assessment and treatment of older adults are discussed.

Self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register using the terms 'self-help', 'manual*' or 'booklet*'. Date of the most recent search April 2005.

SELECTION CRITERIA

We included randomized trials of smoking cessation with follow up of at least six months, where at least one arm tested a self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow up. The main outcome measure was abstinence from smoking after at least six months follow up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We identified sixty trials. Thirty-three compared self-help materials to no intervention or tested materials used in addition to advice. In 11 trials in which self help was compared to no intervention there was a pooled effect that just reached statistical significance (N = 13,733; odds ratio [OR] 1.24, 95% confidence interval [CI] 1.07 to 1.45). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Four further trials in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials. We failed to find evidence of benefit from adding self-help materials to face-to-face advice, or to nicotine replacement therapy. There were seventeen trials using materials tailored for the characteristics of individual smokers, where meta-analysis supported a small benefit of tailored materials (N = 20,414; OR 1.42, 95% CI 1.26 to 1.61). The evidence is strongest for tailored materials compared to no intervention, but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data. A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Standard self-help materials may increase quit rates compared to no intervention, but the effect is likely to be small. We failed to find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are effective, and are more effective than untailored materials, although the absolute size of effect is still small.

Targeting treatments to special populations

The average rate of long-term tobacco abstinence in a general population of treatment-seeking tobacco users is about 25%. Most of these treatments tend to use generic approaches, although the population of tobacco users is quite heterogeneous. It is entirely possible that special populations of smokers have specific treatment needs. If these needs are addressed, then treatment success may be augmented. This paper will review different issues that may surface when treating special populations. The special populations to be examined will be broken down by gender, age and route of tobacco administration. In addition, gaps in the scientific literature and directions for future research will be discussed. Once population-specific treatment needs are identified, then the effects of tailored treatments in augmenting treatment success can be determined.

Self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to self-help, such as computer generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register using the terms 'self-help', 'manual*' or 'booklet*'. Date of the most recent search March 2002.

SELECTION CRITERIA

We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested a self-help intervention. We defined self-help as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the type of subjects, the nature of the self-help materials, the amount of face to face contact given to subjects and to controls, outcome measures, method of randomisation, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed effects model.

MAIN RESULTS

We identified fifty-one trials. Thirty two compared self-help materials to no intervention or tested materials used in addition to advice. In eleven trials in which self-help was compared to no intervention there was a pooled effect that just reached statistical significance (odds ratio 1.24, 95% confidence interval 1.07 to 1.45) This analysis excluded one trial with a strongly positive outcome that introduced significant heterogeneity. Four further trials in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials. We failed to find evidence of benefit from adding self-help materials to face to face advice, or to nicotine replacement therapy. There was evidence from fourteen trials using materials tailored for the characteristics of individual smokers that such personalised materials were more effective than standard manuals (ten trials, odds ratio 1.36, 95% confidence interval 1.13 to 1.64) or no materials (three trials, odds ratio 1.80, 95% confidence interval 1.46 to 2.23). A small numbers of trials failed to detect benefit from using additional materials or targetted materials.

REVIEWER'S CONCLUSIONS

Standard self-help materials may increase quit rates compared to no intervention, but the effect is likely to be small. We failed to find evidence that they have an additional benefit when used alongside other interventions such as advice from a health care professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective.

Smoking cessation following CT screening for early detection of lung cancer

BACKGROUND

This study was conducted to assess the impact of lung cancer screening participation on smoking cessation.

METHODS

Individuals (n = 134) who reported active smoking at the time of enrollment in our Early Lung Cancer Action Program (ELCAP) completed a brief, follow-up telephone interview assessing any changes in smoking patterns following lung cancer screening. Using logistic regression, we estimated the probability of decreasing or quitting smoking using each enrollee's background information and computed tomography (CT) scan results.

RESULTS

Most survey respondents (74%) agreed that participation in the ELCAP increased their motivation for quitting smoking. In terms of self-reported changes in smoking behavior, 31 (23%) reported that they had quit and 35 (27%) decreased their smoking patterns. Several significant covariates of smoking cessation were identified: perceived benefit of quitting (OR 4.02), cancer anxiety (OR 2.49), younger age (OR 2.47), and abnormal CT finding (1.97).

CONCLUSIONS

Our analyses suggest that low-dose helical CT scanning may serve as a strong catalyst for smoking cessation and that delivery of effective smoking cessation interventions along with CT scanning represents a potential opportunity to increase the overall cancer prevention benefit of lung cancer screening.

Review of computer-generated outpatient health behavior interventions: clinical encounters "in absentia"

OBJECTIVE

To evaluate evidence of the effectiveness of computer-generated health behavior interventions-clinical encounters "in absentia"-as extensions of face-to-face patient care in an ambulatory setting.

DATA SOURCES

Systematic electronic database and manual searches of multiple sources (1996-1999) plus search for gray literature were conducted to identify clinical trials using computer-generated health behavior interventions to motivate individuals to adopt treatment regimens, focusing on patient-interactive interventions and use of health behavior models.

STUDY SELECTION

Eligibility criteria included randomized controlled studies with some evidence of instrument reliability and validity; use of at least one patient-interactive targeted or tailored feedback, reminder, or educational intervention intended to influence or improve a stated health behavior; and an association between one intervention variable and a health behavior.

DATA EXTRACTION

Studies were described by delivery device (print, automated telephone, computer, and mobile communication) and intervention type (personalized, targeted, and tailored). We employed qualitative methods to analyze the retrieval set and explore the issue of patient interactive computer-generated behavioral intervention systems.

DATA SYNTHESIS

Studies varied widely in methodology, quality, subject number, and characteristics, measurement of effects and health behavior focus. Of 37 eligible trials, 34 (91.9 percent) reported either statistically significant or improved outcomes. Fourteen studies used targeted interventions; 23 used tailored. Of the 14 targeted intervention studies, 13 (92.9 percent) reported improved outcomes. Of the 23 tailored intervention studies, 21 (91.3 percent) reported improved outcomes.

CONCLUSIONS

The literature indicates that computer-generated health behavior interventions are effective. While there is evidence that tailored interventions can more positively affect health behavior change than can targeted, personalized or generic interventions, there is little research comparing different tailoring protocols with one another. Only those studies using print and telephone devices reported a theoretic basis for their methodology. Future studies need to identify which models are best suited to which health behavior, whether certain delivery devices are more appropriate for different health behaviors, and how ambulatory care can benefit from patients' use of portable devices.

Can a nutrition intervention improve albumin levels among hemodialysis patients? A pilot study

OBJECTIVE

To determine the effect of a tailored intervention on albumin levels among hemodialysis patients.

DESIGN

Randomized controlled trial.

SETTING

Eight freestanding chronic hemodialysis units in northeast Ohio.

SUBJECTS

Eighty-three randomly selected adult patients who had been on dialysis for at least 6 months and had a mean albumin <3.7 g/dL (bromcresol green method) or <3.4 g/dL (bromcresol purple method) for the last 3 months. To better elucidate the feasibility and outcomes of the intervention, we selected more intervention than control patients.

INTERVENTION

Dietitians of the 52 intervention patients determined whether any of the following potential barriers to adequate protein nutrition were present for each patient: (1) poor knowledge of protein-containing foods, (2) poor appetite, (3) needing help shopping or cooking, (4) low fluid intake, and (5) inadequate dialysis. Depending on the specific barriers present, the dietitians (1) educated patients on protein-containing foods, (2) recommended snacks for which patients had preserved appetite, (3) helped set up social supports, (4) provided recommendations on fluid intake, and/or (5) arranged for improved dialysis. Dietitians of the 31 control patients continued to provide usual care.

MAIN OUTCOME MEASURES

Change in albumin after 6 months, stratified as minimal change (less than.25 g/dL increase or decrease), moderate improvement (.25 to.49 g/dL increase), and large improvement (increase of .50 g/dL or more). To examine the role of inflammatory states, we also determined serum C-reactive protein levels at the beginning and end of the trial.

RESULTS

Among intervention patients, 29% had a minimal change in albumin, 44% had a moderate improvement, and 27% had a large improvement. Among control patients, 74% had a minimal change in albumin, 19% had a moderate improvement, and 6% had a large improvement (P <.001 for comparison of intervention and control subjects). About 60% of subjects had high baseline C-reactive protein levels (> 10 mg/L). However, there was little relationship between change in albumin and either baseline C-reactive protein levels or changes in C-reactive protein levels (P = .83).

CONCLUSION

A nutrition intervention tailored to patient-specific barriers resulted in improved albumin levels even among patients with high C-reactive protein levels. Further work is needed to refine and test this intervention on a larger sample.

Heart Messages: a tailored message intervention for improving heart failure outcomes

Heart failure is a major health problem in the United States leading to high rates of mortality and morbidity and impaired quality of life. Assisting patients to improve compliance with their self-care regimen, including medications, dietary sodium restrictions, and self-monitoring (daily weights, edema assessment), may improve these poor outcomes. This article describes the development and initial evaluation of Heart Messages, a theory-based, tailored message intervention to improve compliance with the self-care regimen recommended for patients with heart failure. The project involved four phases, each of which is described in this article. The Heart Messages tailored message intervention program is available in both printed and Web-based formats. In a pilot study and clinical evaluation project, the program was found to be useful for patient education and feasible for implementation. Larger randomized trials are now warranted to evaluate the effectiveness of the intervention in improving compliance with the self-care regimen and thereby improving outcomes among patients with heart failure.

One size does not fit all: the case for tailoring print materials

Printed health education materials frequently consist of mass-produced brochures, booklets, or pamphlets designed for a general population audience. Although this one-size-fits-all approach might be appropriate under certain circumstances and even produce small changes at relatively modest costs, it cannot address the unique needs, interests, and concerns of different individuals. With the advent and dissemination of new communication technologies, our ability to collect information from individuals and provide feedback tailored to the specific information collected is not only possible, but practical. The purpose of this article is to: (a) distinguish between tailored print communication and other common communication-based approaches to health education and behavior change; (b) present a theoretical and public health rationale for tailoring health information; and (c) describe the steps involved in creating and delivering tailored print communication programs. Studies suggest computer tailoring is a promising strategy for health education and behavior change. Practitioners and researchers should understand the approach and consider the possibilities it presents for enhancing their work in disease prevention.

Challenges and future directions for tailored communication research

As informatics technology advances, a growing number of research trials on tailored communications provide an accumulation of promising evidence to support their efficacy. These trials also reveal gaps and opportunities for future research. The scope and boundaries of tailoring must be redefined in terms of both new technology and the trade-offs between complexity, demand burden on participants, and the minimal information required for effective and efficient tailoring. Basic and methods research is needed to broaden theory, develop a common language, standardize measures, and isolate the key mediating mechanisms that facilitate tailored communications. Applied research must consider more rigorous research designs for efficacy trials and conduct more effectiveness trials to investigate the mechanisms of technology transfer to enhance large-scale diffusion of tailored communications. The role of contextual variables needs to be examined, as well as their interaction with different population groups, and also the channels, modes, and methods of tailored message delivery. Research is also needed on the feasibility of tailoring across clusters of multiple risk factors to identify the commonalities, differences, and interrelations among diverse behaviors. The potential cost-effectiveness of tailored communications must also be examined. No matter how efficacious, tailored communications delivered to large populations (i.e. mass-customization) will not make a public health impact unless proven to be practical and cost-efficient.

Population-based recruitment for quit-smoking programs: an analytic review of communication variables

BACKGROUND

Attempts to reduce the prevalence of smoking through quit-smoking programs have been unsuccessful because they have not attracted large numbers of smokers to participate in them.

METHOD

An analytic review of the literature was conducted to identify potential communication variables that might enhance recruitment for community-based quit-smoking programs. Recruitment was defined as the number of smokers who enroll in a quit-smoking program divided by the estimated number of smokers in the target population.

RESULTS

Thirty-three publications reporting the results of 40 recruitment campaigns were located. The median recruitment rate was 2.0%. Logistic regression was used to examine the effect of six variables on recruitment rate: the type of program sponsor, the type of program, program costs, use of participation incentives, whether messages were segmented by stage of change, and the type of channel used to send messages. The only significant predictor of recruitment rate was channel type (i.e., the method used to deliver a message). Studies that used interactive recruitment channels (telephone, interpersonal communication) were 66.5 times more effective than those using passive recruitment strategies (mass media, direct mail). Results examining the segmentation of messages by stage of change on recruitment were inconclusive.

CONCLUSIONS

Results suggest that researchers and practitioners interested in population-based smoking cessation programs should pay more attention to recruitment methods. The use of interpersonal channels has been underused and appears to be particularly promising for improving the population impact of quit-smoking programs.

Providers' smoking cessation attitudes and practices for older patients

A mail survey of 136 providers in a health maintenance organization in the Chicago metropolitan area examined smoking cessation attitudes and performance of the 4As protocol (asking, advising, assisting, arranging) for patients aged 50 years or older. Asking about smoking was most frequent, followed by arranging, advising, and assisting. Physicians and nurse practitioners performed each of the 4As more often than did registered and licensed practical nurses. In multiple logistic regression analyses, provider type was the only significant predictor of asking about smoking. Advising, assisting, and arranging follow-ups were more likely to be performed by providers who perceived a sense of professional responsibility about older patients' smoking; advising was more likely for providers who perceived that they had enough time to advise older patients about smoking; and assisting and arranging were more likely for providers with a stronger sense of self-efficacy for helping older patients stop smoking.

Patients' perceptions of their physician's role in smoking cessation by age and readiness to stop smoking

BACKGROUND

Patients' perceptions of their physician's role in smoking cessation, using the 4As protocol (asking, advising, assisting, and arranging), were assessed with a focus on associations with age (18-29, 30-49, and > or = 50) and stage of readiness to stop smoking (precontemplation, contemplation, and preparation).

METHODS

Self-administered questionnaires were completed by 524 smokers presenting for regularly scheduled appointments at six clinics of an HMO in the Chicago metropolitan area.

RESULTS

Almost all patients said their physician should ask about their smoking status and advise them to quit. About half said their physician should assist them with quitting, and about two-thirds said their physician should follow up (arrange) on their smoking behavior. Bivariate associations were found for endorsement of the 4As with both age and stage. Multiple logistic regressions found age was the most consistent and strongest correlate of 4As endorsement, with younger smokers more likely than those age 50 or older to endorse the 4As protocol.

CONCLUSIONS

A proactive health promotion orientation should be encouraged among physicians. Patients should be screened for stage of readiness to stop smoking so that health-care providers can emphasize aspects of the 4As protocol that are most appropriate for each patient. Age-tailored smoking cessation strategies should be employed within stages of readiness to stop smoking.

Quitting motives and barriers among older smokers. The 1986 Adult Use of Tobacco Survey revisited

BACKGROUND

Adults aged 50-74 years comprise more than 20% of the population and more than 22% of all smokers. Smoking is a risk factor for 7 of the 14 major causes of death for older adults, including cancer, heart disease, and lung disease. Moreover, older smokers can experience significant dramatic health benefits from quitting, including improvements in circulation and pulmonary function and declines in risks for heart disease, heart attacks, and stroke.

METHODS

Smoking patterns, quitting motives, and barriers among older smokers were examined by comparing responses of older smokers (aged 50-74 years) and younger smokers (aged 21-49 years) who took part in the 1986 Adult Use of Tobacco Survey.

RESULTS

Older and younger smokers differed little in current smoking patterns or in past quit attempts, motives, and methods. Survey results show that older smokers are far less likely to accept smoking health harms and more likely to view smoking as a beneficial coping and weight control tactic.

CONCLUSIONS

Motivational strategies should be tailored to the unique health beliefs and cultural history of older smokers.