Training health professionals in smoking cessation

The STOP Program: a Hybrid Smoking Prevention and Cessation Training for Cancer Care Providers in Colombia and Peru

We designed and tested the feasibility of the Smoking Cessation Training Program for Oncology Practice (STOP), a hybrid (face-to-face plus web-based) educational intervention to enhance Spanish-speaking cancer care professionals' (CCPs') ability to provide brief smoking prevention and cessation counseling to cancer patients and survivors. Changes in the CCPs' competencies (knowledge, attitude, self-efficacy, and practices toward smoking and smoking cessation services) were assessed post-training. Sixty CCPs from one major cancer center in Colombia (n = 30) and Peru (n = 30) were invited to participate in a 4-module hybrid training program on smoking prevention and cessation. Demographic and pre- and post-test evaluation data were collected. The training's acceptability was measured after each module. Bivariate analysis was conducted using Wilcoxon signed-rank test to compare the CCPs' competencies before and after the delivery of the STOP Program. Effect sizes were computed over time to assess the sustainability of the acquired competencies. Twenty-nine CCPs in Colombia and 24 CCPs in Peru completed the STOP Program (96.6% and 80.0% retention rates, respectively). In both countries, 98.2% of the CCPs reported that the overall structure and organization of the program provided an excellent learning experience. The pre-post-test evaluations indicated that the CCPs significantly improved their knowledge, attitude, self-efficacy, and practices toward smoking, smoking prevention, and cessation services. We found that the CCPs' self-efficacy and practices increased over time (1-, 3-, and 6-month assessments after completing the 4 educational modules). The STOP Program was effective and well-received, demonstrating remarkable changes in CCPs' competencies in providing smoking prevention and cessation services to cancer patients.

Attitudes of staff towards smoke-free environments in psychiatric hospitals in Germany

INTRODUCTION

Smoke-free environments have already been successfully introduced in hospitals world-wide. But despite convincing evidence of their success, many countries still struggle to make the necessary changes. Not only is the smoking prevalence higher amongst people with mental health problems and staff working in psychiatric units, but employees in psychiatry often resist the implementation of smoke-free policies. This study explores staff attitudes towards smoke-free environments in psychiatric hospitals in Germany and tries to identify barriers and opportunities for implementation.

METHODS

This cross-sectional online survey was carried out at eight psychiatric units of the state-owned healthcare company Vivantes Netzwerk für Gesundheit GmbH in Berlin, Germany, in 2019. A total of 448 members of staff were surveyed on their views towards creating a smoke-free environment in their workplace.

RESULTS

Psychiatric staff present contradictory attitudes towards implementing smoke-free regulations. On the one hand, a majority recognizes the need for smoke-free environments as they promote physical well-being of staff and patients. On the other hand, a majority opposes comprehensive restrictions like a complete smoking ban. Smokers are more likely than non-smokers to resist restrictive measures and show a tendency to only support those measures which they deem unlikely to affect their own smoking habits.

CONCLUSIONS

The contradictory attitudes towards implementing smoke-free regulations present an entry point to elicit behavior change and a shift in attitudes, for example in staff training on smoke-free environments. Staff who smoke, in particular, should be motivated to reflect on the contradiction that is presented by their private smoking behavior and their role as healthcare professionals.

Impact of tobacco cessation education on behaviors of nursing undergraduates in helping smokers to quit smoking

INTRODUCTION

Smoking continues to be a significant public health issue, but nursing students do not receive sufficient training on tobacco cessation education. Integrating the 5As behaviors for tobacco cessation into a compulsory course could improve nursing students’ skills and increase their clinical behaviors for assisting patients in quitting smoking. The aim of this study was to evaluate the impact of evidence-based tobacco cessation education on the perceptions and behaviors of nursing students who are assisting patients to quit smoking.

METHODS

A prospective single-group design was used to evaluate the perceptions and behaviors of 626 senior nursing students enrolled in an education program, at three time points: baseline, 3 months post education, and 6 months post education. Data were collected, before and after the tobacco cessation education, using assessment tools for knowledge, attitudes, and the 5As behaviors for assisting patients to quit smoking.

RESULTS

A total of 572 senior students completed the baseline survey, 289 students completed the survey 3 months post education, 348 students completed the survey 6 months post education, and 285 students completed all three surveys. Knowledge and self-efficacy of tobacco cessation were improved dramatically (p<0.05) after the education program, compared with the baseline survey. At 6 months post education, compared with at 3 months post education, nursing students reported more interventions of asking, advising, assessing, assisting, and arranging smokers to quit smoking (p<0.05).

CONCLUSIONS

The integration of tobacco cessation education into compulsory courses could improve clinical skills and enhance the behaviors of nursing students for assisting patients to quit smoking.

The impact of smoking on oral health and patient assessment of tobacco cessation support from Turkish dentists

INTRODUCTION

Dentists are in a critical position to help patients quit smoking. This study analyses the effectiveness of Turkish dentists in smoking cessation as part of routine patient care.

METHODS

An in-person cross-sectional survey on previous dental visit experiences was completed by 226 patients recruited from the Department of Periodontology, Eskisehir Osmangazi University, Turkey, from March 2019 to September 2019. The questionnaire included topics on patient's smoking/quit characteristics, experiences on smoking cessation from their dentists, and willingness for the implementation of smoking cessation advice by dentists.

RESULTS

In all, 38% of the patients were current smokers, 8% were former smokers, and 68% tried to quit previously. Smokers demonstrated consistently higher scores for plaque index, gingival index, and probing depth, than former/non-smokers (p<0.05). Patients' knowledge of adverse effects was high, and the patients presented a positive attitude toward receiving cessation activities from dentists (86.7%). A total of 89% responded positively to be asked about their smoking behavior. However, the dentists' approach for cessation discussions did not go any further than listing the harmful effects. Only 32% of the patients were informed about side effects of smoking and one-third were encouraged to quit. In general, offering smoking cessation advice was relatively infrequent, and the majority of patients tried to quit smoking by themselves (76%) without using any nicotine replacement product (84%).

CONCLUSIONS

Smoking leads to oral health problems. Dentists in Turkey may ask their patients' about their smoking habits but less frequently offer practical help to quit.

Pediatric Resident Training in Tobacco Control and the Electronic Health Record

Given the dangers posed by tobacco use and tobacco smoke exposure, pediatricians should address tobacco use and exposure with patients and parents at every opportunity, but this is not consistently done in practice. One reason may be that many medical residents do not receive education on how to address tobacco use and tobacco smoke exposure with patients and their parents. In a 2012 survey of U.S. pediatric program directors, 65% of programs reported covering tobacco control in their curricula, but most training programs focused on tobacco's health effects and not intervention strategies for clinical practice. Since that survey, electronic health records have been implemented broadly nationwide and utilized to address tobacco smoke exposure. Investigators surveyed U.S. program directors in 2018 and residents in 2019 to explore the ways in which the residents learn about tobacco use and tobacco smoke exposure, components and use of the electronic record specific to tobacco use and tobacco smoke exposure, and perceived resident effectiveness in this area. All the program directors and 85% of the residents valued training, but 21% of the residents reported receiving none. Moreover, a minority of the residents assessed themselves as effective at counseling parents (19%) or adolescents (23%), and their perceived effectiveness was related to small group learning and active learning workshops, modalities that were infrequently implemented in training. Respondents also reported infrequent use of electronic health record prompts regarding tobacco and the absence of prompts about critical issues (e.g., addressing tobacco smoke exposure in vehicles or other settings or offering treatment or referrals to parents who smoke). This paper provides recommendations about augmenting pediatric resident training in simple ways.

Brief tobacco cessation interventions: Practices, opinions, and attitudes of healthcare professionals

INTRODUCTION

Although brief smoking cessation interventions that follow the 5As algorithm (Ask, Advise, Assess, Assist, Arrange) can trigger smokers to quit, routine delivery remains low in Europe. This study aimed to identify the extent of smoking cessation practices of healthcare professionals interested in tobacco cessation, and their opinions and attitudes.

METHODS

A quantitative, cross-sectional survey design was adopted. Healthcare professionals (n=133) who attended one of ten training sessions on brief interventions for smoking cessation, held every month between September 2018 and June 2019 in Malta, were recruited. Univariate logistic regression and non-parametric tests were carried out to identify associations by participants’ characteristics. Potential confounders were ruled out following multivariate analyses.

RESULTS

Most participants were female nurses who had never smoked. While most professionals reportedly asked (76.3%), advised (83.5%) and assessed (70.5%) patients for cessation, fewer provided assistance (40.9%) and arranged followup (24.2%). Compared to other participants, doctors were more likely to have counselled patients over the previous week. Most professionals were favourably disposed towards counselling patients to quit, however, they claimed they had insufficient time to do so. Although most found it difficult to get clients to quit, former smokers were more likely to disagree when compared to those who never smoked (OR=6.86; 95% CI: 2.17–21.71; p=0.001).

CONCLUSIONS

While more initiatives to train healthcare professionals in providing smoking cessation interventions are recommended, lack of sufficient time, being an organisational barrier, requires healthcare management exploration and action. Given that former smokers were more confident in helping patients quit, engaging them in training activities would be of added value.

Smoking Cessation Beliefs Among Saudi University Students in Qassim Region, Saudi Arabia

INTRODUCTION

Despite Saudi officials initiating a variety of smoking cessation programs, smoking in the country has not decreased. Thus, the objective of this study was to identify the factors associated with Saudi students' beliefs about available smoking cessation interventions.

METHODS

A cross-sectional, pre-tested, and validated paper-based survey was administered to a cohort from a university in the Qassim region. Bivariate analyses and logistic regression were conducted to explore the factors associated with the students' beliefs regarding behavioral and pharmacotherapy interventions for smoking cessation.

RESULTS

Out of 1158 surveys distributed, 958 responses were received (82.7% response rate). Students aged >23 years were more likely to believe in a behavioral intervention (marginal effect = 10.4%; 95% CI, 2.3%-18.6%). However, the respondents who indicated that they had smoked a hookah over the past 30 days were less likely to believe in either the pharmacotherapeutic (marginal effect = -7.9%; 95% CI, -15.6 to -0.3%) or the behavioral (marginal effect = -8.1%; 95% CI, -16.2% to -0.1%) interventions. Students who believed that the hookah was the same as or less harmful than cigarettes (marginal effect = -25.6%; 95% CI, -34.7% to -16.6%) and (marginal effect = -12.3%; 95% CI, -22.3% to -2.3%), respectively, were less likely to believe in pharmacotherapeutic interventions. Multiple logistic regression analyses found that hookah smokers with a willingness to quit smoking were more likely to believe in the effectiveness of cessation medications (marginal effect = 42.9%; 95% CI, 28.2%-57.6%) and behavioral interventions (marginal effect = 28.6%; 95% CI, 9.3%-48.0%).

CONCLUSION

This study found that smoking a hookah and its harmfulness were negatively associated with smoking cessation medications interventions. Regarding beliefs about behavioral interventions, while age was positively associated, hookah smoking and its harmfulness had a negative association. Willingness to quit smoking was positively associated with both medication and behavioral interventions.

Igniting activation: Using unannounced standardized patients to measure patient activation in smoking cessation

Introduction

Despite a decline, smoking rates have remained high, especially in communities with lower income, education, and limited insurance options. Evidence shows that physician-initiated counseling on smoking cessation is effective and saves lives, and that specific skills are needed to appropriately lead this type of patient-physician communication. Residency is a critical moment for future physicians and may be the optimal time to learn, practice, and refine this skillset. Unannounced Standardized Patients (USPs) have been found to be effective, incognito evaluators of resident practices.

Methods

This study introduced rigorously trained actors (USPs) into two urban, safety-net clinics to assess resident ability to engage, activate, and counsel a pre-contemplative smoker. A complementary chart review assessed appropriate documentation in the patient's electronic health record (EHR) and its relationship to counseling style and prescribing practices.

Results

Resident scores (% well done) on patient education and engagement were low (33% and 23%, respectively). Residents who coupled cessation advice with an open discussion style activated their patients more than those who solely advised cessation across all comparable measures. On EHR documentation, residents who accurately documented smoking history were more likely to directly advise their patient to quit smoking when compared to residents who did not document (t(97) = 2.828, p = .006, Cohen's D = 0.56).

Conclusions

Results highlight the need to reinforce training in patient-centered approaches including motivational interviewing, counseling, and shared decision-making. Future research should focus on the effects of smokers in pre-contemplation on physician counseling style and examine the relationship between medical training and provider communication to guide interventions.

•

Counseling, documentation, and prescribing all vary when residents meet an Unannounced Standardized Patient (USP) smoker.

•

Patients are activated to quit smoking when a provider couples cessation advice with an open discussion of pros and cons.

•

Training in motivational interviewing and shared decision-making can enhance patient-provider cessation communication.

Prevalence of smoking among dental students and gauging their knowledge about tobacco cessation methods: An original study

Aims:

The aims of this study are to determine the prevalence and type of tobacco use among dental students and to identify the factors that influence them to initiate tobacco use.

Subjects and Methods:

Dental students at two dental colleges affiliated to State Health University of Kerala answered a 20-item questionnaire during Jan–Feb 2015 that investigated their smoking habits and knowledge about the risk factors of smoking habits. The questions were based on the modified Global Health Professional Students Survey (GHPSS) by WHO. Some additional questions were also added from Global Youth Tobacco Survey (GYTS) by WHO to meet the objective of this study.

Result:

Current smoking was reported by 17% of the participants. None of the participants smoked more than half a packet of cigarette. More students from families with at least one tobacco user were using tobacco than those from families with no members using tobacco (51.2 versus 37.0%, respectively). The majority of dental students (92%) considered education on tobacco use cessation to be the responsibility of dentists/doctors.

Conclusion:

One of the main aims of this study was to shed light on the knowledge and attitudes of dental students on tobacco use cessation. Fairly high number of participants reported receiving inadequate information on tobacco cessation during their studies. Dental students should be taught and encouraged early on to routinely discuss with smokers the impacts of smoking on health.

Efficiency and adverse events of electronic cigarettes: A systematic review and meta-analysis (PRISMA-compliant article)

BACKGROUND

Electronic cigarettes (e-cigarettes) are a prevalent smoking cessation aid worldwide; however, a consensus regarding their efficacy and safety has yet to be reached.

METHODS

We conducted a systematic review of the literature from related studies written in English or Chinese and published between January 1, 2003, and July 30, 2017. Eligible studies reporting the number of smokers who reduced or quit smoking and suffered from adverse events after e-cigarette use were selected according to predefined criteria; pertinent data were then extracted for a meta-analysis.

RESULTS

Our search produced 198 articles; of these publications, 14 including 35,665 participants were analyzed. The pooled efficacy rate of e-cigarettes ranged from 48.3% to 58.7% for smoking reduction and from 13.2% to 22.9% for smoking cessation. The pooled rate of adverse events associated with e-cigarettes ranged from 49.1% to 51.6% based on 11 studies including 16,406 participants. The most prevalent adverse events were mouth or throat irritation, anxiety, depressed mood, nausea, and insomnia. No significant differences in overall CO2 exhalation (eCO) levels were observed after e-cigarette use according to the data from 5 studies.

CONCLUSION

Our findings suggest that e-cigarettes are moderately effective with regard to smoking reduction and smoking cessation. eCO levels are unreliable for evaluating the efficacy of e-cigarettes. E-cigarette related adverse events frequently occur, especially due to high-dose nicotine-containing cartridges.

Motivational Benefits of Social Support and Behavioural Interventions for Smoking Cessation

This study examined the role of social support and behavioral interventions used during the last unsuccessful quit attempt for smokers' intentions to quit smoking within the next 6 months, and identified smokers' attributes associated with use of social support and behavioral interventions. The analytic sample included 7,195 adult daily smokers who responded to the 2010-2011 Tobacco Use Supplement to the Current Population Survey, conducted in the US, and indicated having a serious quit attempt in the past 12 months. Smokers who relied on social support from friends and family had higher odds of intending to quit than those who did not (OR= 1.39, 95% CI= 1.22:1.58), and smokers who used interventions had higher odds of intending to quit than those who did not (OR= 1.36, 95% CI= 1.07:1.74). These associations were similar for both sexes, all age groups, and nicotine dependence levels. Both, relying on social support and use of behavioral interventions were more common among smokers who were female, higher educated, residing in the Western US region, and those who used pharmacological aids for smoking cessation. Social support and behavioral interventions are associated with higher intentions to quit among attempters who relapsed and thus, may aid future smoking cessation.

Improving implementation of the smoking cessation guidelines with pregnant women: How to support clinicians?

OBJECTIVE

this study aimed to explore the enablers and barriers to implementation of the Australian smoking cessation in pregnancy guidelines. These guidelines direct clinicians to follow the 5As of cessation: Ask, Advise, Assess, Assist and Arrange follow-up.

DESIGN

semi-structured interviews based on the Theoretical Domains Framework (TDF) elicited clinicians' views and experiences of implementing the guidelines.

SETTING

antenatal care in the NSW public health system.

PARTICIPANTS

27 maternity service managers, obstetricians and midwives.

FINDINGS

participants confirmed that implementation of the smoking cessation guidelines was sub-optimal. This was particularly the case with Assist and Arrange follow up at the initial visit, and with following any of the 5As at subsequent visits. Key barriers included systems which did not support implementation or monitoring, lack of knowledge, skills and training, perceived time restrictions, 'difficult conversations' and perceiving smoking as a social activity. Enablers included clinicians' knowledge of the harms of smoking in pregnancy, clinicians' skills in communicating with pregnant women, positive emotions, professional role and identity, the potential of training and of champions to influence practice, and systems that regulated behaviour.

KEY CONCLUSIONS

these findings will contribute to the development of a multifaceted intervention to support clinicians in implementing the guidelines.

IMPLICATIONS FOR PRACTICE

Building on existing strengths, antenatal care providers may be supported in implementing the guidelines by working with systems which remind and support implementation, the clear reframing of smoking as an addiction, knowledge and skills development and by realizing the potential of leadership to maximise the impact of reinforcement and social influence.

Prevalence, habits and personal attitudes towards smoking among health care professionals

BACKGROUND

Tobacco use is the second major cause of morbidity and the 4th most common health risk factor in the world. Medical professionals have a critical role in the process of smoking cessation both as advisers and behavioural models for the citizens. The aim of this study was to investigate the prevalence of smoking among health care professionals, their smoking habits and personal attitudes toward smoking, role and the responsibility of health care professionals in the prevention of smoking.

RESULTS

Out of the total number of examinees, 175 (35,1%) are active smokers, 29 (5,8%) are former smokers, and 295 (59,1%) are non-smokers. Nurses with secondary education disagree the most with the claim that passive smoking is more harmful to health (χ2 test, p = .008), also with the claim that the introduced Smoking Act is fair to smokers (χ2 test, p = .021). More nurses with secondary education disagree completely or partially that one should pay attention to smoking in the presence of non-smokers (χ2 test, p = .012).

CONCLUSION

Training programs for health care workers are needed to improve their ability in smoking cessation techniques to provide active support to their patients.

Adaptation, Implementation Plan, and Evaluation of an Online Tobacco Cessation Training Program for Health Care Professionals in Three Spanish-Speaking Latin American Countries: Protocol of the Fruitful Study

BACKGROUND

Tobacco cessation training programs to treat tobacco dependence have measureable effects on patients' smoking. Tobacco consumption in low- and middle-income countries (LMICs) is high and slowly decreasing, but these countries usually lack measures to face the epidemic, including tobacco cessation training programs for health professionals and organizations. Based on a previous online smoking cessation training program for hospital workers in Spain, the Fruitful Study aims to increase smoking cessation knowledge, attitudes, self-confidence, and performance interventions among health care professionals of three Spanish-speaking low- and middle-income Latin American and Caribbean (LAC) countries.

OBJECTIVE

The purpose of this paper is to describe the methodology and evaluation strategy of the Fruitful Study intended to adapt, implement, and test the effectiveness of an online, evidence-based tobacco cessation training program addressed to health professionals from Bolivia, Guatemala, and Paraguay.

METHODS

This study will use a mixed-methods design with a pre-post evaluation (quantitative approach) and in-depth interviews and focus groups (qualitative approach). The main outcomes will be (1) participants' attitudes, knowledge, and behaviors before and after the training; and (2) the level of implementation of tobacco control policies within the hospitals before and after the training.

RESULTS

To date, adaptation of the materials, study enrollment, and training activities have been completed. During the adaptation, the main mismatches were language background and content adaptation. Several aids were developed to enable students' training enrollment, including access to computers, support from technicians, and reminders to correctly complete the course. Follow-up data collection is in progress. We have enrolled 281 hospital workers. Results are expected at the beginning of 2017 and will be reported in two follow-up papers: one about the formative evaluation and the other about the summative evaluation.

CONCLUSIONS

There is a need to learn more about the cultural and content elements that should be modified when an online tobacco cessation training program is adapted to new contexts. Special attention should be given to the personal and material resources that could make the implementation possible. Results from the Fruitful Study may offer a new approach to adapting programs to LMICs in order to offer education solutions with the use of emerging and growing communication technologies.

CLINICALTRIAL

Clinicaltrials.gov NCT02718872; https://clinicaltrials.gov/ct2/show/NCT02718872 (Archived by WebCite at http://www.webcitation.org/6mjihsgE2).

Proportion of Time Spent Delivering Support Predicts Stop Smoking Advisor Quit Rate Independently of Training, Experience, and Education

Despite a downwards trend in smoking prevalence, smoking remains the UK's biggest preventable cause of premature mortality. Specialist stop smoking support programmes provided by the NHS have helped to reduce smoking prevalence and whilst there has been a vast amount of research investigating the most effective behavioural and pharmacological support models, little is known about the impact of smoking cessation advisor's smoking status and clinical effectiveness on quit rates. This study aimed to identify factors that contribute to NHS stop smoking advisor performance using a quantitative cross-sectional design via an online survey that was completed by 159 participants in 24 London boroughs. Multiple regression analyses revealed that level of training, years practiced, level of advisor education, number of patients supported in a given year, and smoking status had no significant impact on NHS stop smoking advisor quit rate in this sample. However, the model revealed that proportion of time spent delivering smoking cessation support was significantly associated with quit rate. It is imperative that this finding is considered when recruiting, commissioning, and training new smoking cessation advisors or provider organisations.

When There Is Not Enough Evidence and When Evidence Is Not Enough: An Australian Indigenous Smoking Policy Study

BACKGROUND

The Indigenous Tobacco Control Initiative and Tackling Indigenous Smoking Measure were both announced by the Australian Government at a time when its rhetoric around the importance of evidence-based policy making was strong. This article will (1) examine how the Rudd Government used evidence in Indigenous tobacco control policy making and (2) explore the facilitators of and barriers to the use of evidence.

METHODS

Data were collected through (1) a review of primary documents largely obtained under the Freedom of Information Act 1982 (Commonwealth of Australia) and (2) interviews with senior politicians, senior bureaucrats, government advisors, Indigenous health advocates, and academics. Through the Freedom of Information Act process, 24 previously undisclosed government documents relevant to the making of Indigenous tobacco control policies were identified. Interviewees (n = 31, response rate 62%) were identified through both purposive and snowball recruitment strategies. The Framework Analysis method was used to analyze documentary and interview data.

RESULTS

Government policy design was heavily influenced by the recommendations presented in government authored/commissioned literature reviews. Resulting policies were led by equivocal evidence for improved tobacco control outcomes among Indigenous Australians. Many of the cited studies had methodological limitations. In the absence of high-quality evidence, some policy makers supported policy recommendations that were perceived to be popular among the Indigenous community. Other policy makers recognized that there were barriers to accumulating rigorous, generalizable evidence; in the absence of such evidence, the policy makers considered that the "need for action" could be combined with the "need for research" by introducing innovative strategies and evaluating them.

DISCUSSION

Despite the absence of high-quality evidence, the formulation and adoption of Indigenous tobacco policy was neither irrational nor reckless. The decision to adopt an innovate and evaluate strategy was justifiable given (a) the potential for the gap between Indigenous and non-Indigenous health outcomes to worsen in the absence of an imminent policy response; (b) the existence of circumstances, which made it difficult to obtain high-quality evidence to guide policy; and (c) the need for policy solutions to reflect community preferences, given sociohistorical sensitivities.

Content and Methods used to Train Tobacco Cessation Treatment Providers: An International Survey

Introduction

There are limited existing data describing the training methods used to educate tobacco cessation treatment providers around the world.

Aims

To measure the prevalence of tobacco cessation treatment content, skills training and teaching methods reported by tobacco treatment training programs across the world.

Methods

Web-based survey in May-September 2013 among tobacco cessation training experts across six geographic regions and four World Bank income levels. Response rate was 73% (84 of 115 countries contacted).

Results

Of 104 individual programs from 84 countries, most reported teaching brief advice (78%) and one-to-one counseling (74%); telephone counseling was uncommon (33%). Overall, teaching of knowledge topics was more commonly reported than skills training. Programs in lower income countries less often reported teaching about medications, behavioral treatments and biomarkers and less often reported skills-based training about interviewing clients, medication management, biomarker measurement, assessing client outcomes, and assisting clients with co-morbidities. Programs reported a median 15 hours of training. Face-to-face training was common (85%); online programs were rare (19%). Almost half (47%) included no learner assessment. Only 35% offered continuing education.

Conclusion

Nearly all programs reported teaching evidence-based treatment modalities in a face-to-face format. Few programs delivered training online or offered continuing education. Skills-based training was less common among low- and middle-income countries (LMICs). There is a large unmet need for tobacco treatment training protocols which emphasize practical skills, and which are more rapidly scalable than face-to-face training in LMICs.

Online Tobacco Cessation Training and Competency Assessment for Complementary and Alternative Medicine (CAM) Practitioners: Protocol for the CAM Reach Web Study

Background

Complementary and alternative medicine (CAM) practitioners, such as chiropractors, acupuncturists, and massage therapists, are a growing presence in the US health care landscape and already provide health and wellness care to significant numbers of patients who use tobacco. For decades, conventional biomedical practitioners have received training to provide evidence-based tobacco cessation brief interventions (BIs) and referrals to cessation services as part of routine clinical care, whereas CAM practitioners have been largely overlooked for BI training. Web-based training has clear potential to meet large-scale training dissemination needs. However, despite the exploding use of Web-based training for health professionals, Web-based evaluation of clinical skills competency remains underdeveloped.

Objective

In pursuit of a long-term goal of helping CAM practitioners integrate evidence-based practices from US Public Health Service Tobacco Dependence Treatment Guideline into routine clinical care, this pilot protocol aims to develop and test a Web-based tobacco cessation training program tailored for CAM practitioners.

Methods

In preparation for a larger trial to examine the effect of training on CAM practitioner clinical practice behaviors around tobacco cessation, this developmental study will (1) adapt an existing in-person tobacco cessation BI training program that is specifically tailored for CAM therapists for delivery via the Internet; (2) develop a novel, Web-based tool to assess CAM practitioner competence in tobacco cessation BI skills, and conduct a pilot validation study comparing the competency assessment tool to live video role plays with a standardized patient; (3) pilot test the Web-based training with 120 CAM practitioners (40 acupuncturists, 40 chiropractors, 40 massage therapists) for usability, accessibility, acceptability, and effects on practitioner knowledge, self-efficacy, and competency with tobacco cessation; and (4) conduct qualitative and quantitative formative research on factors influencing practitioner tobacco cessation clinical behaviors (eg, practice environment, peer social influence, and insurance reimbursement).

Results

Web-training and competency assessment tool development and study enrollment and training activities are complete (N=203 practitioners enrolled). Training completion rates were lower than expected (36.9%, 75/203), necessitating over enrollment to ensure a sufficient number of training completers. Follow-up data collection is in progress. Data analysis will begin immediately after data collection is complete.

Conclusions

To realize CAM practitioners’ potential to promote tobacco cessation and use of evidence-based treatments, there is a need to know more about the facilitative and inhibitory factors influencing CAM practitioner tobacco intervention behaviors (eg, social influence and insurance reimbursement). Given marked differences between conventional and CAM practitioners, extant knowledge about factors influencing conventional practitioner adoption of tobacco cessation behaviors cannot be confidently extrapolated to CAM practitioners. The potential impact of this study is to expand tobacco cessation and health promotion infrastructure in a new group of health practitioners who can help combat the continuing epidemic of tobacco use.

What are the factors that influence the delivery of smoking cessation advice in critical care?

BACKGROUND

The world's leading cause of preventable deaths, diseases and disabilities is smoking. Hospitalization can provide an opportunity for smokers to quit. Previous research found that smokers make up a high percentage of patients admitted to intensive care. Health care professionals working in critical care environments can make a valuable contribution to this public health issue by providing smoking cessation advice.

AIM

To identify factors that inhibit and facilitate the delivery of smoking cessation advice by nurses and doctors in critical care settings.

DESIGN

Quantitative design using an online survey.

METHODS

This research was a single centre study carried out in a large tertiary hospital. Study sites were two adult critical care departments including a 14-bed general intensive care and a 16-bed cardiovascular intensive care unit. The target population for this research was the nursing and medical staff working in adult critical care environments.

RESULTS

The data suggests that doctors and nurses have a good understanding of the complications related to tobacco use and also have education on smoking cessation. Additionally the data suggest that doctors and nurses at the study sites generally have positive attitudes towards smoking cessation. Patient acuity and competence were concerns raised in relation to the delivery and effectiveness of smoking cessation advice in critical care environments.

CONCLUSIONS

The recovery phase following critical illness might be an opportunity to provide cessation advice. This could include focusing cessation advice efforts on awake, orientated and extubated patients. Further research might be required to confirm this.

RELEVANCE TO CLINICAL PRACTICE

The provision of smoking cessation advice is an on-going World Health Organization and New Zealand Government priority and all parts of the health sector need to provide responses. However, responses need to be adapted to the specific context such as the unique challenges of critical care.

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background

This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities.

Aims

The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice.

Methods

We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff.

Findings

Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely.

Future Research

Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students

OBJECTIVE

Physicians play a critical role in addressing tobacco dependence, yet report limited training. Tobacco dependence treatment curricula for medical students could improve performance in this area. This study identified student and medical school tobacco treatment curricula characteristics associated with intentions and use of the 5As for tobacco treatment among 3rd year U.S. medical students.

METHODS

Third year medical students (N=1065, 49.3% male) from 10 U.S. medical schools completed a survey in 2009-2010 assessing student characteristics, including demographics, tobacco treatment knowledge, and self-efficacy. Tobacco curricula characteristics assessed included amount and type of classroom instruction, frequency of tobacco treatment observation, instruction, and perception of preceptors as role models.

RESULTS

Greater tobacco treatment knowledge, self-efficacy, and curriculum-specific variables were associated with 5A intentions, while younger age, tobacco treatment self-efficacy, intentions, and each curriculum-specific variable were associated with greater 5A behaviors. When controlling for important student variables, greater frequency of receiving 5A instruction (OR=1.07; 95%CI 1.01-1.12) and perception of preceptors as excellent role models in tobacco treatment (OR=1.35; 95%CI 1.04-1.75) were significant curriculum predictors of 5A intentions. Greater 5A instruction (B=.06 (.03); p<.05) and observation of tobacco treatment (B=.35 (.02); p<.001) were significant curriculum predictors of greater 5A behaviors.

CONCLUSIONS

Greater exposure to tobacco treatment teaching during medical school is associated with both greater intentions to use and practice tobacco 5As. Clerkship preceptors, or those physicians who provide training to medical students, may be particularly influential when they personally model and instruct students in tobacco dependence treatment.

Tobacco brief intervention training for chiropractic, acupuncture, and massage practitioners: protocol for the CAM reach study

BACKGROUND

Tobacco use remains the leading cause of morbidity and mortality in the US. Effective tobacco cessation aids are widely available, yet underutilized. Tobacco cessation brief interventions (BIs) increase quit rates. However, BI training has focused on conventional medical providers, overlooking other health practitioners with regular contact with tobacco users. The 2007 National Health Interview Survey found that approximately 20% of those who use provider-based complementary and alternative medicine (CAM) are tobacco users. Thus, CAM practitioners potentially represent a large, untapped community resource for promoting tobacco cessation and use of effective cessation aids. Existing BI training is not well suited for CAM practitioners' background and practice patterns, because it assumes a conventional biomedical foundation of knowledge and philosophical approaches to health, healing and the patient-practitioner relationship. There is a pressing need to develop and test the effectiveness of BI training that is both grounded in Public Health Service (PHS) Guidelines for tobacco dependence treatment and that is relevant and appropriate for CAM practitioners.

METHODS/DESIGN

The CAM Reach (CAMR) intervention is a tobacco cessation BI training and office system intervention tailored specifically for chiropractors, acupuncturists and massage therapists. The CAMR study utilizes a single group one-way crossover design to examine the CAMR intervention's impact on CAM practitioners' tobacco-related practice behaviors. Primary outcomes included CAM practitioners' self-reported conduct of tobacco use screening and BIs. Secondary outcomes include tobacco using patients' readiness to quit, quit attempts, use of guideline-based treatments, and quit rates and also non-tobacco-using patients' actions to help someone else quit.

DISCUSSION

CAM practitioners provide care to significant numbers of tobacco users. Their practice patterns and philosophical approaches to health and healing are well suited for providing BIs. The CAMR study is examining the impact of the CAMR intervention on practitioners' tobacco-related practice behaviors, CAM patient behaviors, and documenting factors important to the conduct of practice-based research in real-world CAM practices.

Opportunities to address lung cancer disparities among African Americans

Race and socioeconomic status are well known to influence lung cancer incidence and mortality patterns in the U.S. Lung cancer incidence and mortality rates are higher among blacks than whites. In this article we review opportunities to address disparities in lung cancer incidence, mortality, and survivorship among African Americans. First, we summarize recent advances in the early detection and treatment of lung cancer. Then we consider black-white disparities in lung cancer treatment including factors that may contribute to such disparities; the literature on smoking cessation interventions for patients with or without a lung cancer diagnosis; and the important roles played by cultural competency, patient trust in their physician, and health literacy in addressing lung cancer disparities, including the need for culturally competent lung cancer patient navigators. Intervention efforts should focus on providing appropriate quality treatment for lung cancer and educating African Americans about the value of having these treatments in order to reduce these disparities. Culturally competent, patient navigation programs are needed that support lung cancer patients, especially socioeconomically disadvantaged patients, from the point of diagnosis to the initiation and completion of treatment, including cancer staging.

Activating lay health influencers to promote tobacco cessation

OBJECTIVE

To evaluate the effect of tobacco cessation brief-intervention (BI) training for lay "health influencers," on knowledge, self-efficacy and the proportion of participants reporting BI delivery post-training.

METHODS

Randomized, community-based study comparing In-person or Web-based training, with mailed materials.

RESULTS

In-person and Web-training groups had significant post-training cessation knowledge and self-efficacy gains. All groups increased the proportion of individuals reporting BIs at follow-up, with no significant between-group differences. Irrespective of participants' prior intervention experience, 80%-86% reported BIs within the past 90 days; 71%-79% reported >1 in the past 30.

CONCLUSIONS

Web and In-person training significantly increase health influencer cessation knowledge and self-efficacy. With minimal prompting and materials, even persons without BI experience can be activated to encourage tobacco cessation.

Use of provider-based complementary and alternative medicine by adult smokers in the United States: Comparison from the 2002 and 2007 NHIS survey

PURPOSE

To provide a snapshot of provider-based complementary and alternative medicine (pbCAM) use among adult smokers and assess the opportunity for these providers to deliver tobacco cessation interventions.

DESIGN

Cross-sectional analysis of data from the 2002 and 2007 National Health Interview Surveys.

SETTING

Nationally representative sample.

SUBJECTS

A total of 54,437 (31,044 from 2002; 23,393 from 2007) adults 18 years and older.

MEASURES

The analysis focuses on 10 types of pbCAM, including acupuncture, Ayurveda, biofeedback, chelation therapy, chiropractic care, energy therapy, folk medicine, hypnosis, massage, and naturopathy.

ANALYSIS

The proportions of current smokers using any pbCAM as well as specific types of pbCAM in 2002 and 2007 are compared using SAS SURVEYLOGISTIC.

RESULTS

Between 2002 and 2007, the percentage of recent users of any pbCAM therapy increased from 12.5% to 15.4% (p = .001). The largest increases occurred in massage, chiropractic, and acupuncture. Despite a decrease in the national average of current smokers (22.0% to 19.4%; p = .001), proportions of smokers within specific pbCAM disciplines remained consistent.

CONCLUSION

Complementary and alternative medicine (CAM) practitioners, particularly those in chiropractic, acupuncture, and massage, represent new cohorts in the health care community to promote tobacco cessation. There is an opportunity to provide brief tobacco intervention training to CAM practitioners and engage them in public health efforts to reduce the burden of tobacco use in the United States.

Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomised trial

OBJECTIVES

To evaluate the effect of training primary care health professionals in behaviour change counselling on the proportion of patients self reporting change in four risk behaviours (smoking, alcohol use, exercise, and healthy eating).

DESIGN

Cluster randomised trial with general practices as the unit of randomisation.

SETTING

General practices in Wales.

PARTICIPANTS

53 general practitioners and practice nurses from 27 general practices (one each at all but one practice) recruited 1827 patients who screened positive for at least one risky behaviour.

INTERVENTION

Behaviour change counselling was developed from motivational interviewing to enable clinicians to enhance patients' motivation to change health related behaviour. Clinicians were trained using a blended learning programme called Talking Lifestyles.

MAIN OUTCOME MEASURES

Proportion of patients who reported making beneficial changes in at least one of the four risky behaviours at three months.

RESULTS

1308 patients from 13 intervention and 1496 from 14 control practices were approached: 76% and 72% respectively agreed to participate, with 831 (84%) and 996 (92%) respectively screening eligible for an intervention. There was no effect on the primary outcome (beneficial change in behaviour) at three months (362 (44%) v 404 (41%), odds ratio 1.12 (95% CI 0.90 to 1.39)) or on biochemical or biometric measures at 12 months. More patients who had consulted with trained clinicians recalled consultation discussion about a health behaviour (724/795 (91%) v 531/966 (55%), odds ratio 12.44 (5.85 to 26.46)) and intended to change (599/831 (72%) v 491/996 (49%), odds ratio 2.88 (2.05 to 4.05)). More intervention practice patients reported making an attempt to change (328 (39%) v 317 (32%), odds ratio 1.40 (1.15 to 1.70)), a sustained behaviour change at three months (288 (35%) v 280 (28%), odds ratio 1.36 (1.11 to 1.65)), and reported slightly greater improvements in healthy eating at three and 12 months, plus improved activity at 12 months. Training cost £1597 per practice.

DISCUSSION

Training primary care clinicians in behaviour change counselling using a brief blended learning programme did not increase patients reported beneficial behaviour change at three months or improve biometric and a biochemical measure at 12 months, but it did increase patients' recollection of discussing behaviour change with their clinicians, intentions to change, attempts to change, and perceptions of having made a lasting change at three months. Enduring behaviour change and improvements in biometric measures are unlikely after a single routine consultation with a clinician trained in behaviour change counselling without additional intervention.

TRIAL REGISTRATION

ISRCTN 22495456.

Why do cancer patients smoke and what can providers do about it?

Despite the widespread dissemination of information about the health risks associated with smoking, many cancer patients continue to smoke, which results in a decreased quality of life, an increased probability of cancer recurrence, and a decreased survival time. Efficacious interventions are available to assist cancer patients to quit smoking, yet smoking cessation interventions are often not implemented. This review describes how clinicians, administrators, insurers, and purchasers can encourage a culture of health care in which tobacco cessation interventions are implemented consistent with evidenced-based standards of care. Implementing efficacious tobacco cessation interventions can reduce morbidity and mortality among cancer patients.

Knowledge, attitudes and beliefs about tobacco use after an educative intervention in health sciences' students

PURPOSE

To examine the effectiveness of a tobacco control course on the improvement of knowledge, attitudes and beliefs about smoking among health sciences' students.

METHODS

This was a quasi-experimental study of community intervention carried out during the years 2005-2008, at 2 university health science centres in northwest Spain. A total of 290 students on the intervention and 256 on the control campus took part in the study. The intervention consisted of a course on the prevention and control of tobacco use offered only on the intervention campus. Data were collected before the intervention and 6 months afterwards.

RESULTS

After the course, significant differences between groups were observed in the improvement of knowledge, attitudes and perceived ability to act in tobacco control.

CONCLUSIONS

The introduction of training concerning smoking through active methodologies had a positive impact on the knowledge, attitudes and beliefs about tobacco of students.

Pharmacological interventions for promoting smoking cessation during pregnancy

BACKGROUND

Smoking in pregnancy is a substantial public health problem. When used by non-pregnant smokers, pharmacotherapies [nicotine replacement therapy (NRT), bupropion and varenicline] are effective treatments for smoking cessation, however, their efficacy and safety in pregnancy remains unknown.

OBJECTIVES

To determine the efficacy and safety of smoking cessation pharmacotherapies, including NRT, varenicline and bupropion (or any other medications) when used to support smoking cessation in pregnancy.

SEARCH METHODS

We searched the Pregnancy and Childbirth Group's Trials Register (5 March 2012), checked references of retrieved studies and contacted authors in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with designs that permit the independent effects of any type of NRT (e.g. patch, gum etc.) or any other pharmacotherapy on smoking cessation to be ascertained were eligible for inclusion. Trials must provide very similar (ideally identical) levels of behavioural support or cognitive behaviour therapy (CBT) to participants in active drug and comparator trial arms.The following RCT designs are considered acceptable.Placebo RCTs: any form of NRT or other pharmacotherapy, with or without behavioural support/CBT, or brief advice compared with placebo NRT and additional support of similar intensity.RCTs providing a comparison between i) behavioural support/CBT or brief advice and ii) any form of NRT or other pharmacotherapy added to behavioural support of similar (ideally identical) intensity.Parallel- or cluster-randomised design trials are eligible for inclusion. However, quasi-randomised, cross-over and within-participant designs are not eligible for inclusion due to the potential biases associated with these designs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias and extracted data. Two assessors independently extracted data and cross checked individual outcomes of this process to ensure accuracy. The primary efficacy outcome was smoking cessation in later pregnancy (in all but one trial, at or around delivery); safety was assessed by seven birth outcomes that indicated neonatal well being and we also collated data on adherence.

MAIN RESULTS

Six trials of NRT enrolling 1745 pregnant smokers were included; we found no trials of varenicline or bupropion. No statistically significant difference was seen for smoking cessation in later pregnancy after using NRT as compared to control (risk ratio (RR) 1.33, 95% confidence interval (CI) 0.93 to 1.91, six studies, 1745 women). Subgroup analysis comparing placebo-RCTs with those which did not use placebos found that efficacy estimates for cessation varied with trial design (placebo RCTs, RR 1.20, 95% CI 0.93 to 1.56, four studies, 1524 women; non-placebo RCTs, RR 7.81, 95% CI 1.51 to 40.35, two studies, 221 women; P value for random-effects subgroup interaction test = 0.03). There were no statistically significant differences in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care or neonatal death between NRT or control groups.

AUTHORS' CONCLUSIONS

Nicotine replacement therapy is the only pharmacotherapy for smoking cessation that has been tested in RCTs conducted in pregnancy. There is insufficient evidence to determine whether or not NRT is effective or safe when used to promote smoking cessation in pregnancy or to determine whether or not using NRT has positive or negative impacts on birth outcomes. Further research evidence of efficacy and safety is needed, ideally from placebo-controlled RCTs that investigate higher doses of NRT than were tested in the included studies.

Smoking cessation counseling in Qatar: community pharmacists' attitudes, role perceptions and practices

BACKGROUND

Smoking is a major public health problem in Qatar. The potential for community pharmacists to offer smoking cessation counseling in this country can be high.

OBJECTIVES

To determine the current smoking cessation practices of community pharmacists in Qatar, to examine their attitudes about tobacco use and smoking cessation, to evaluate their perceptions about performing professional roles with respect to smoking cessation and to assess their perceived barriers for smoking cessation counseling in the pharmacy setting in Qatar.

SETTING

Community pharmacies in Qatar.

METHODS

The objectives were addressed in a cross sectional survey of community pharmacists in Qatar from June 2010 to October 2010. A phone call was made to all community pharmacists in Qatar (318 pharmacists) inviting them to participate. Consenting pharmacists anonymously completed the survey either online or as paper using fax. Data was analyzed using Statistical Package of Social Sciences (SPSS®) Version 18.

MAIN OUTCOME MEASURES

Qatar community pharmacists' smoking cessation practices, their attitudes toward tobacco use, smoking cessation and smoking cessation counseling and their perceived barriers for smoking cessation counseling.

RESULTS

Over 5 months, we collected 127 surveys (40 % response rate). Only 21 % of respondents reported that they always or most of the time asked their patients if they smoke. When the patients' smoking status was identified, advising quitting and assessing readiness to quit were always or most of the time performed by 66 and 52 % of respondents respectively. Only 15 % always or most of the time arranged follow-up with smokers and 22 % always or most of the time made smoking cessation referrals. Most respondents (>80 %) agreed that smoking could cause adverse health effects and that smoking cessation could decrease the risk of these effects. In addition, the majority (>80 %) believed that smoking cessation counseling was an important activity and was an efficient use of their time. The top two perceived barriers for smoking cessation counseling were lack of time (65 % of respondents) and lack of patients' interest in smoking cessation (54 %).

CONCLUSIONS

Qatar community pharmacists have positive attitudes toward smoking cessation counseling. These attitudes need to be translated into action. Interventions should be implemented to overcome perceived barriers and to improve smoking cessation activities among pharmacists.

Training health professionals in smoking cessation

BACKGROUND

Cigarette smoking is one of the leading causes of preventable death world wide. There is good evidence that brief interventions from health professionals can increase smoking cessation attempts. A number of trials have examined whether skills training for health professionals can lead them to have greater success in helping their patients who smoke.

OBJECTIVES

To determine the effectiveness of training health care professionals in the delivery of smoking cessation interventions to their patients, and to assess the additional effects of training characteristics such as intervention content, delivery method and intensity.

SEARCH METHODS

The Cochrane Tobacco Addiction Group's Specialised Register, electronic databases and the bibliographies of identified studies were searched and raw data was requested from study authors where needed. Searches were updated in March 2012.

SELECTION CRITERIA

Randomized trials in which the intervention was training of health care professionals in smoking cessation. Trials were considered if they reported outcomes for patient smoking at least six months after the intervention. Process outcomes needed to be reported, however trials that reported effects only on process outcomes and not smoking behaviour were excluded.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics of each included study for interventions, participants, outcomes and methods were extracted by two independent reviewers. Studies were combined in a meta-analysis where possible and reported in narrative synthesis in text and table.

MAIN RESULTS

Of seventeen included studies, thirteen found no evidence of an effect for continuous smoking abstinence following the intervention. Meta-analysis of 14 studies for point prevalence of smoking produced a statistically and clinically significant effect in favour of the intervention (OR 1.36, 95% CI 1.20 to 1.55, p= 0.004). Meta-analysis of eight studies that reported continuous abstinence was also statistically significant (OR 1.60, 95% CI 1.26 to 2.03, p= 0.03).Healthcare professionals who had received training were more likely to perform tasks of smoking cessation than untrained controls, including: asking patients to set a quit date (p< 0.0001), make follow-up appointments (p< 0.00001), counselling of smokers (p< 0.00001), provision of self-help material (p< 0.0001) and prescription of a quit date (p< 0.00001). No evidence of an effect was observed for the provision of nicotine gum/replacement therapy.

AUTHORS' CONCLUSIONS

Training health professionals to provide smoking cessation interventions had a measurable effect on the point prevalence of smoking, continuous abstinence and professional performance. The one exception was the provision of nicotine gum or replacement therapy, which did not differ between groups.

Tobacco intervention practices of primary care physicians treating lower socioeconomic status patients

Tobacco use greatly contributes to overall socioeconomic health disparities, and physicians are a major source of information about effective methods for tobacco cessation. This study examined the tobacco intervention practices of primary care physicians in Arkansas who treat a high proportion of lower socioeconomic status patients. More than 70% of respondents' patients were covered by Medicaid and/or Medicare or paid for primary care services without health insurance. Although physicians were highly motivated and considered cessation to be very important, 74% had no training of any kind in the treatment of tobacco dependence and familiarity with the free treatment services in Arkansas was low. Younger and nonwhite physicians and physicians with any type of training in treating tobacco dependence reported more positive attitudes, more frequent intervention behaviors and more familiarity with treatment services. More frequently seeing the effects of tobacco use on the health of patients as well as increased knowledge, preparedness, and perceived effectiveness of treatments were related to a higher frequency of providing cessation assistance. More frequently seeing the effects of tobacco use on patients, as well as increased familiarity with treatment services were related to a higher frequency of referring patients to treatment services. These findings suggest that training experiences that increase physician awareness of the multiplicity of consequences of tobacco use as well as increase knowledge, preparedness, perceived effectiveness of treatments and familiarity with treatment services will increase the frequency with which physicians assist and refer this important patient population.

A randomized trial of computer-delivered brief intervention and low-intensity contingency management for smoking during pregnancy

INTRODUCTION

Implementation of evidence-based interventions for smoking during pregnancy is challenging. We developed 2 highly replicable interventions for smoking during pregnancy: (a) a computer-delivered 5As-based brief intervention (CD-5As) and (b) a computer-assisted, simplified, and low-intensity contingency management (CM-Lite).

METHODS

A sample of 110 primarily Black pregnant women reporting smoking in the past week were recruited from prenatal care clinics and randomly assigned to CD-5As (n = 26), CM-Lite (n = 28), CD-5As plus CM-Lite (n = 30), or treatment as usual (n = 26). Self-report of smoking, urine cotinine, and breath CO were measured 10 weeks following randomization.

RESULTS

Participants rated both interventions highly (e.g., 87.5% of CD-5As participants reported increases in likelihood of quitting), but most CM-Lite participants did not initiate reinforcement sessions and did not show increased abstinence. CD-5As led to increased abstinence as measured by cotinine (43.5% cotinine negative vs. 17.4%; odds ratio [OR] = 10.1, p = .02) but not for CO-confirmed 7-day point prevalence (30.4% abstinent vs. 8.7%; OR = 5.7, p = .06). Collapsing across CM-Lite status, participants receiving the CD-5As intervention were more likely to talk to a doctor or nurse about their smoking (60.5% vs. 30.8%; OR = 3.0, p = .02).

CONCLUSIONS

Low-intensity participant-initiated CM did not affect smoking in this sample, but the CD-5As intervention was successful in increasing abstinence during pregnancy. Further research should seek to replicate these results in larger and more diverse samples. Should CD-5As continue to prove efficacious, it could greatly increase the proportion of pregnant smokers who receive an evidence-based brief intervention.

Cardiology Rx for Change: improving clinical attention to tobacco use and secondhand smoke exposure in cardiology

BACKGROUND

Heart disease is the leading cause of tobacco-related death in smokers and of deaths due to secondhand smoke (SHS) exposure in nonsmokers. This study centers on the development and evaluation of an evidence-based model curriculum for improving clinical attention to tobacco use and SHS exposure in cardiology.

HYPOTHESIS

We hypothesized that the curriculum would be associated with improvements in clinician tobacco-related knowledge, attitudes, confidence, and counseling behaviors from pre-to post-training and at the 3-month follow-up.

METHODS

The 1-hour Cardiology Rx for Change curriculum was evaluated with 22 cardiology fellows and 77 medical residents with consistent training effects observed between the 2 groups.

RESULTS

Trainees' tobacco treatment knowledge increased significantly from pre- to post-training (t[81] = 6.51, P<0.001), and perceived barriers to providing cessation treatment decreased significantly (t[81] = -3.97, P<0.001). The changes, however, were not sustained at the 3-month follow-up, suggesting the need for booster training efforts. From pretraining to 3-month follow-up, the training was associated with significant sustained gains in clinician confidence for treating tobacco dependence (t[61] = 3.69, P = 0.001) and with improvements in clinicians assessing patients' readiness to quit smoking (from 61% to 79%, t[59] = 3.69,P<0.001) and providing assistance with quitting (from 47% to 59%, t[59] = 2.12, P = 0.038). Asking patients about tobacco use, advising cessation, and arranging follow-up also increased over time, but not significantly. All participants (100%) recommended the curriculum for dissemination to other training programs.

CONCLUSIONS

Available online via http://rxforchange.ucsf.edu, Cardiology Rx for Change offers a packaged training tool for improving treatment of tobacco use and SHS exposure in cardiology care.

A comprehensive model for mental health tobacco recovery in new jersey

Despite the high prevalence of tobacco use, disproportionate tobacco consumption, and excess morbidity and mortality, smokers with mental illness have reduced access to tobacco dependence treatment across the health care spectrum. We have developed a comprehensive model for Mental Health Tobacco Recovery in New Jersey (MHTR-NJ) that has the overarching goal of improving tobacco cessation for smokers with serious mental illness. Important steps involve engaging patients, professionals and the community to increase understanding that addressing tobacco use is important. In addition to increasing demand for tobacco treatment services, we must educate mental health professionals in evidence-based treatments so that patients can seek help in their usual behavioral health care setting. Peer services that offer hope and support to smokers are essential. Each of the policy or cessation initiatives described address the two core goals of this model: to increase demand for tobacco cessation services for mentally ill smokers and to help more smokers with mental illness to quit. Each has been pilot tested for feasibility and/or effectiveness and revised with feedback from stakeholders. In this way this implementation model has brought together academics, clinicians, administrators and mental health consumers to develop tobacco programming and policy that has been tested in a real world environment and serves as a model for other states.

Twelve evidence-based principles for implementing self-management support in primary care

BACKGROUND

Recommendations to improve self-management support and health outcomes for people with chronic conditions in primary care settings are provided on the basis of expert opinion supported by evidence for practices and processes. Practices and processes that could improve self-management support in primary care were identified through a nominal group process. In a targeted search strategy, reviews and meta-analyses were then identifed using terms from a wide range of chronic conditions and behavioral risk factors in combination with Self-Care, Self-Management, and Primary Care. On the basis of these reviews, evidence-based principles for self-management support were developed.

FINDINGS

The evidence is organized within the framework of the Chronic Care Model. Evidence-based principles in 12 areas were associated with improved patient self-management and/or health outcomes: (1) brief targeted assessment, (2) evidence-based information to guide shared decision-making, (3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, (5) collaborative problem solving, (6) self-management support by diverse providers, (7) self-management interventions delivered by diverse formats, (8) patient self-efficacy, (9) active followup, (10) guideline-based case management for selected patients, (11) linkages to evidence-based community programs, and (12) multifaceted interventions. A framework is provided for implementing these principles in three phases of the primary care visit: enhanced previsit assessment, a focused clinical encounter, and expanded postvisit options.

CONCLUSIONS

There is a growing evidence base for how self-management support for chronic conditions can be integrated into routine health care.

A national survey of training and smoking cessation services provided in community pharmacies in Thailand

Over the past few years, several training programs have been run in support of smoking cessation services within community pharmacy circles in Thailand. These have included a comprehensive training program offered by the Thai Pharmacy Network for Tobacco Control (TPNTC) and brief training programs run by other agencies. This study provides an estimate of the scale of smoking cessation activities among Thai pharmacies, and examines the impact of both the brief and comprehensive training programs on the provision of smoking cessation services. A self-administered questionnaire was mailed to 3,600 Thai community pharmacists. A total of 1,001 questionnaires were returned (response rate: 27.8%). Smoking cessation services were provided by 71.1% of the respondents, and 47.4% of such services gave only brief advice. Comprehensive services (defined by the 5A's: ask, advise, assess, assist, and arrange follow-up) accounted for 15.3% of the respondents. Only 293 pharmacists (29.6%) said they had received cessation training; 62.5% of whom had received such training from TPNTC. The receipt of brief and comprehensive training was associated with a higher rate of the provision of brief advice, when compared with no training, showing adjusted odds ratios (ORs) of 2.93 (95% CI, 1.66-5.18) and 5.93 (95% CI, 3.18-10.17) respectively, while evidence of differences between these training programs was not observed, having an adjusted OR of 1.94 (95% CI, .89-4.21). TPNTC trained pharmacists were 4.98 times (95% CI, 2.24-11.05) more likely than those who received other brief training to provided the 5A's cessation services. All types of training program help to promote the provision of brief counseling by pharmacists. Comprehensive training is associated with the increased provision of both 4A's and 5A's cessation services.

Training nurses in the treatment of tobacco use and dependence: pre- and post-training results

AIM

This paper is a report of a study conducted to examine the effects of a brief training in the treatment of tobacco use and dependence on the tobacco use intervention-related knowledge and attitudes of nurses.

BACKGROUND

  Nurses are the largest group of healthcare providers and they have an extended reach into the population of tobacco users. Thus, increasing the number of nurses who deliver brief evidence-based interventions for tobacco use and dependence, such as that prescribed by the Public Health Service Clinical Practice Guideline in the United States of America, is likely to expose more tobacco users to evidence-based treatments and lead to more successful quit attempts. Effective training is key to improving provider proficiency in delivering evidence-based interventions for tobacco use and dependence.

METHOD

  A 1-hour didactic training was delivered to 359 nurses from 2006 to 2007, including 54 Advanced Practice Nurses, 250 Registered Nurses and 55 Licensed Practical Nurses. Pre- and post-training tests assessed attitudes, knowledge and behaviours. Paired samples t-tests were used to compare pre- and post-test results.

RESULTS

  Statistically significant increases on nearly all measures were achieved, with Registered Nurses and Licensed Practical Nurses realizing the largest gains.

CONCLUSION

  Given the overwhelming impact of tobacco use on patients, all nurses should be provided with training in the delivery of brief, evidence-based interventions for tobacco use. As the most trusted healthcare provider group with an extended reach into the tobacco using population, nurses have a large potential impact on the prevalence of tobacco use.

Strategies to increase the delivery of smoking cessation treatments in primary care settings: a systematic review and meta-analysis

OBJECTIVES

A systematic review and meta-analysis was conducted to evaluate evidence-based strategies for increasing the delivery of smoking cessation treatments in primary care clinics.

METHODS

The review included studies published before January 1, 2009. The pooled odds-ratio (OR) was calculated for intervention group versus control group for practitioner performance for "5As" (Ask, Advise, Assess, Assist and Arrange) delivery and smoking abstinence. Multi-component interventions were defined as interventions which combined two or more intervention strategies.

RESULTS

Thirty-seven trials met eligibility criteria. Evidence from multiple large-scale trials was found to support the efficacy of multi-component interventions in increasing "5As" delivery. The pooled OR for multi-component interventions compared to control was 1.79 [95% CI 1.6-2.1] for "ask", 1.6 [95% CI 1.4-1.8] for "advice", 9.3 [95% CI 6.8-12.8] for "assist" (quit date) and 3.5 [95% CI 2.8-4.2] for "assist" (prescribe medications). Evidence was also found to support the value of practice-level interventions in increasing 5As delivery. Adjunct counseling [OR 1.7; 95% CI 1.5-2.0] and multi-component interventions [OR 2.2; 95% CI 1.7-2.8] were found to significantly increase smoking abstinence.

CONCLUSION

Multi-component interventions improve smoking outcomes in primary care settings. Future trials should attempt to isolate which components of multi-component interventions are required to optimize cost-effectiveness.

Perceived difficulty quitting predicts enrollment in a smoking-cessation program for patients with head and neck cancer

PURPOSE/OBJECTIVES

To determine the predictors of participation in a smoking-cessation program among patients with head and neck cancer.

DESIGN

This cross-sectional study is a substudy of a larger, randomized trial of patients with head and neck cancer that determined the predictors of smokers' participation in a cessation intervention.

SETTING

Otolaryngology clinics at three Veterans Affairs medical centers (Ann Arbor, MI, Gainesville, FL, and Dallas, TX), and the University of Michigan Hospital in Ann Arbor.

SAMPLE

286 patients who had smoked within six months of the screening survey were eligible for a smoking-cessation intervention.

METHODS

Descriptive statistics and bivariate and multivariate logistic regression were used to determine the independent predictors of smokers' participation in an intervention study.

MAIN RESEARCH VARIABLES

Perceived difficulty quitting (as a construct of self-efficacy), health behaviors (i.e., smoking and problem drinking), clinical characteristics (i.e., depression and cancer site and stage), and demographic variables.

FINDINGS

Forty-eight percent of those eligible participated. High perceived difficulty quitting was the only statistically significant predictor of participation, whereas problem drinking, lower depressive symptoms, and laryngeal cancer site approached significance.

CONCLUSIONS

Special outreach may be needed to reach patients with head and neck cancer who are overly confident in quitting, problem drinkers, and patients with laryngeal cancer.

IMPLICATIONS FOR NURSING

Oncology nurses are in an opportune position to assess patients' perceived difficulty quitting smoking and motivate them to enroll in cessation programs, ultimately improving quality of life, reducing risk of recurrence, and increasing survival for this population.

Postgraduate education for doctors in smoking cessation

INTRODUCTION AND AIMS

Smoking cessation advice from doctors helps improve quit rates but the opportunity to provide this advice is often missed. Postgraduate education is one strategy to improve the amount and quality of cessation support provided. This paper describes a sample of postgraduate education programs for doctors in smoking cessation and suggests future directions to improve reach and quality.

DESIGN AND METHODS

Survey of key informants identified through tobacco control listserves supplemented by a review of the published literature on education programs since 2000. Programs and publications from Europe were not included as these are covered in another paper in this Special Issue.

RESULTS

Responses were received from only 21 key informants from eight countries. Two further training programs were identified from the literature review. The following components were present in the majority of programs: 5 As (Ask, Advise, Assess, Assist and Arrange) approach (72%), stage of change (64%), motivational interviewing (72%), pharmacotherapies (84%). Reference to clinical practice guidelines was very common (84%). The most common model of delivery of training was face to face. Lack of interest from doctors and lack of funding were identified as the main barriers to uptake and sustainability of training programs.

DISCUSSION AND CONCLUSIONS

Identifying programs proved difficult and only a limited number were identified by the methods used. There was a high level of consistency in program content and a strong link to clinical practice guidelines. Key informants identified limited reach into the medical profession as an important issue. New approaches are needed to expand the availability and uptake of postgraduate education in smoking cessation

Promoting tobacco dependence treatment in nursing education

ISSUES

There are 17.3 million nurses worldwide, the largest group of health-care professionals, and they have great potential to address the epidemic of tobacco use and its related morbidity and mortality. However, the evidence indicates that the educational preparation of nurses for tobacco control remains inadequate.

APPROACH

This paper provides an overview of the efficacy of nurses in the delivery of smoking cessation interventions, existing tobacco control content in nursing educational programs, model curricula, teaching resources and strategies for reducing barriers to curricular change.

KEY FINDINGS

Despite the efficacy of nursing intervention for tobacco cessation, lack of appropriate knowledge and/or skill presents a major problem for implementation. An important factor fostering this lack of preparation is limited tobacco control content in current nursing educational programs. Barriers to enhancing and building this curricula include lack of preparation of educators, low priority for this content in an already overloaded curricula, negative attitudes, continued smoking by nursing students and/or faculty and lack of tested curricula. The availability of new tobacco control resources, including those specifically tailored for nurses can assist educators in teaching this content and nurses in implementing interventions.

IMPLICATIONS

Research and changes in policy are needed to ensure that nursing education includes essential content on tobacco control.

CONCLUSION

Nurses can be effective in delivering tobacco cessation interventions. Efforts are needed to promote curriculum that ensures that all nursing students and practicing nurses receive tobacco control content and are competent in the delivery of interventions; and to disseminate resources to nursing educators

Berlin's medical students' smoking habits, knowledge about smoking and attitudes toward smoking cessation counseling

BACKGROUND

Diseases associated with smoking are a foremost cause of premature death in the world, both in developed and developing countries. Eliminating smoking can do more to improve health and prolong life than any other measure in the field of preventive medicine. Today's medical students will play a prominent role in future efforts to prevent and control tobacco use.

METHODS

A cross-sectional, self-administered, anonymous survey of fifth-year medical students in Berlin, Germany was conducted in November 2007. The study explored the prevalence of smoking among medical students. We assessed their current knowledge regarding tobacco dependence and the effectiveness of smoking cessation methods. Students' perceived competence to counsel smokers and promote smoking cessation treatments was also explored. Analyses were based on responses from 258 students (86.6% response rate).

RESULTS

One quarter of the medical students surveyed were current smokers. The smoking rate was 22.1% among women, 32.4% among men. Students underestimated smoking-related mortality and the negative effect of smoking on longevity. A considerable number of subjects erroneously assumed that nicotine causes coronary artery disease. Students' overall knowledge of the effectiveness of smoking cessation methods was inadequate. Only one third of the students indicated that they felt qualified to counsel patients about tobacco dependence.

CONCLUSIONS

This study reveals serious deficiencies in knowledge and counseling skills among medical students in our sample. The curriculum of every medical school should include a tobacco module. Thus, by providing comprehensive training in nicotine dependence interventions to medical students, smokers will have access to the professional expertise they need to quit smoking.

Trends in smoking and quitting in China from 1993 to 2003: National Health Service Survey data

OBJECTIVE

China has about 350 million smokers, more commonly men. Using data from National Health Service Surveys conducted in 1993, 1998 and 2003, we (i) estimated trends in smoking prevalence and cessation according to sociodemographic variables and (ii) analysed cessation rates, quitting intentions, reasons for quitting and reasons for relapsing.

METHODS

Data were collected from approximately 57 000 households and 200 000 individuals in each survey year. Household members > 15 years of age were interviewed about their smoking habits, quitting intentions and attitudes towards smoking. We present descriptive data stratified by age, sex, income level and rural versus urban residence.

FINDINGS

In China, current smoking in those > 15 years old declined 60-49% in men and 5-3.2% in women over 1993-2003. The decline was more marked in urban areas. However, heavy smoking (≥ 20 cigarettes daily) increased substantially overall and doubled in men. The average age of uptake also dropped by about 3 years. In 2003, 7.9% of smokers reported intending to quit, and 6% of people who had ever smoked reported having quit. Of former smokers, 40.6% quit because of illness, 26.9% to prevent disease and 10.9% for financial reasons.

CONCLUSION

Smoking prevalence declined in China over the study period, perhaps due to the combined effect of smoking cessation, reduced uptake in women and selective mortality among men over 40 years of age. However, heavy smoking increased. People in China rarely quit or intend to quit smoking, except at older ages. Further tobacco control efforts are urgently needed, especially in rural areas.