Community interventions for reducing smoking among adults

Male Youth Tobacco Usage Pattern in Banned Smoking Area in Comparison With Non-banned Smoking Area: A Cross-Sectional Study

OBJECTIVES

This study aimed to assess the impact of smoking bans in schools on smoking prevalence and behavior among Saudi male youth aged 13-15 years.

METHODS

A cross-sectional comparative study was conducted involving students from two intermediate schools in Jeddah - one with a smoking ban and the other without. Data collection utilized the Global Youth Tobacco Survey questionnaire, and statistical analysis was performed using SPSS version 21.0.

RESULTS

The study had a 93.9% response rate, with 659 students participating. Notably, a lower percentage of ever-smoking was observed in the banned area compared to the non-banned area (39.6% vs. 50.9%; p=0.002). Current smoking rates were also lower in the banned area (14.2% vs. 23.8%; p=0.014). Family and peer influences on smoking were reduced in the banned area, and more students discussed the harmful effects of smoking with family (72.8% vs. 59.8%; p=0.003). Students in the non-banned area found it easier to access cigarettes. A significantly higher percentage of students in the banned area were resolute in not smoking if offered a cigarette by their best friend (65.0% vs. 59.2%; p=0.006). Students in the non-banned area reported higher exposure to cigarette smoke at home and in other places compared to those in the banned area (15.8% vs. 10.8%; p=0.008), respectively. A higher percentage of smokers in the banned area expressed a desire to quit smoking, though the difference was not statistically significant. More anti-smoking media messages were reported in the banned area (35.6% vs. 33.6%; p=0.004). Fewer respondents in the banned area had items with cigarette brand logos (13.6% vs. 19.9%; p=0.03).

CONCLUSION

The findings underscore the effectiveness of smoking bans in schools in reducing smoking prevalence among students. This suggests a broader societal shift in attitudes toward smoking, highlighting the need for comprehensive bans as part of public health strategies. However, there remains a need for targeted interventions to address the complexities of smoking behavior in both banned and non-banned areas.

Factors affecting smoking initiation and cessation among adult smokers in Fiji: A qualitative study

INTRODUCTION

Smoking as a public health challenge is globally considered the main risk factor of many non-communicable diseases (NCDs). Knowing factors contributing to smoking commencement and cessation is the necessary step to develop prevention strategies to combat this issue. To date, no study has been conducted in Fiji, therefore this study aimed to explore the reasons adult smokers initiate smoking and cessation in Fiji.

METHODS

A qualitative study was conducted among 35 current smokers who were interviewed between 1 May and 31 July 2020 in Suva, Fiji. Three health centers were chosen randomly to collect data and purposive sampling was applied to reach study participants. A semi-structured, open-ended questionnaire was used to guide the interviews. The content of in-depth interviews was transcribed and data were analyzed using content and thematic analysis.

RESULTS

The results of this study showed that most of the participants were male (57%), I-taukei (77%), single (54%), had attained tertiary education level (69%), were of Christian religion (77%), and unemployed (63%). Two main themes were identified including: ‘factors affecting smoking initiation’ and ‘factors affecting smoking cessation’. ‘Peer pressure’, ‘smoking myth’, ‘smoking as a fun’, ‘unpleasant event in life’ and ‘smoking establishes friendships’ were factors affecting initiation of smoking; while ‘knowledge on smoking harms’, ‘financial constraints’, ‘desire to improve health’, ‘constant request from family members’, ‘desire to save time’, ‘religious factors’ and ‘cultural factors’, were factors affecting smoking cessation among smokers.

CONCLUSIONS

This study highlights the main factors affecting smoking among adult smokers in Fiji. Considering these factors in future health planning will help policy makers and decision makers to develop tailored interventions to combat this health issue.

Powering population health research: Considerations for plausible and actionable effect sizes

Evidence for Action (E4A), a signature program of the Robert Wood Johnson Foundation, funds investigator-initiated research on the impacts of social programs and policies on population health and health inequities. Across thousands of letters of intent and full proposals E4A has received since 2015, one of the most common methodological challenges faced by applicants is selecting realistic effect sizes to inform calculations of power, sample size, and minimum detectable effect (MDE). E4A prioritizes health studies that are both (1) adequately powered to detect effect sizes that may reasonably be expected for the given intervention and (2) likely to achieve intervention effects sizes that, if demonstrated, correspond to actionable evidence for population health stakeholders. However, little guidance exists to inform the selection of effect sizes for population health research proposals. We draw on examples of five rigorously evaluated population health interventions. These examples illustrate considerations for selecting realistic and actionable effect sizes as inputs to calculations of power, sample size and MDE for research proposals to study population health interventions. We show that plausible effects sizes for population health interventions may be smaller than commonly cited guidelines suggest. Effect sizes achieved with population health interventions depend on the characteristics of the intervention, the target population, and the outcomes studied. Population health impact depends on the proportion of the population receiving the intervention. When adequately powered, even studies of interventions with small effect sizes can offer valuable evidence to inform population health if such interventions can be implemented broadly. Demonstrating the effectiveness of such interventions, however, requires large sample sizes.

How To Support Smoking Cessation In Primary Care And The Community: A Systematic Review Of Interventions For The Prevention Of Cardiovascular Diseases

Introduction

Smoking is a major risk factor for cardiovascular diseases (CVDs) and for many types of cancers. Despite recent policies, 1.1 billion people are active smokers and tobacco is the leading cause of mortality and illness throughout the world. The aim of this work was to identify smoking cessation interventions which could be implemented in primary care and/or at a community level.

Methods

A systematic review of CVDs prevention guidelines was realized using the ADAPTE Process. These were identified on G-I-N and TRIP databases. Additionally, a purposive search for national guidelines was successfully undertaken. Guidelines focusing on non-pharmacological lifestyle interventions, published or updated after 2011, were included. Exclusion criteria were specific populations, management of acute disease and exclusive focus on pharmacological or surgical interventions. After appraisal with the AGREE II tool, high-quality guidelines were included for analysis. High-grade recommendations and the supporting bibliographic references were extracted. References had to be checked in detail where sufficient information was not available in the guidelines.

Results

Nine hundred and ten guidelines were identified, 47 evaluated with AGREE II and 26 included. Guidelines recommended that patients quit smoking and that health care professionals provided advice to smokers but failed to propose precise implementation strategies for such recommendations. Only two guidelines provided specific recommendations. In the guideline bibliographic references, brief advice (BA) and multiple session strategies were identified as effective interventions. These interventions used Prochaska theory, motivational interviewing or cognitive-behavioral therapies. Self-help documentation alone was less effective than face-to-face counseling. Community-based or workplace public interventions alone did not seem effective.

Discussion

Behavioral change strategies were effective in helping patients to give up smoking. BA alone was less effective than multiple session strategies although it required fewer resources. Evidence for community-based interventions effectiveness was weak, mainly due to the lack of robust studies.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH METHODS

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in November 2016.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series.Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included.Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes.The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, or odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality (MB, LS, RTM). One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of the included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow-up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among seven campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the eight studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign. Another (California) showed positive results during the period of adequate funding and implementation and in final evaluation since the beginning of the programme. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow-up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Smoking prevalence differs by location of residence among Ghanaians in Africa and Europe: The RODAM study

BACKGROUND

Although the prevalence of smoking is low in Ghana, little is known about the effect of migration on smoking. Comparing Ghanaians living in their country of origin to those living in Europe offers an opportunity to investigate smoking by location of residence and the associations between smoking behaviours and migration-related factors.

METHODS

Data on a relatively homogenous group of Ghanaians living in London (n = 949), Amsterdam (n = 1400), Berlin (n = 543), rural Ghana (n = 973) and urban Ghana (n = 1400) from the cross-sectional RODAM (Research on Obesity & Diabetes in African Migrants) study were used. Age-standardized prevalence rates of smoking by location of residence and factors associated with smoking among Ghanaian men were estimated using prevalence ratios (PR: 95% CIs).

RESULTS

Current smoking was non-existent among women in rural and urban Ghana and London but was 3.2% and 3.3% in women in Amsterdam and Berlin, respectively. Smoking prevalence was higher in men in Europe (7.8%) than in both rural and urban Ghana (4.8%): PR 1.91: 95% CI 1.27, 2.88, adjusted for age, marital status, education and employment. Factors associated with a higher prevalence of smoking among Ghanaian men included European residence, being divorced or widowed, living alone, Islam religion, infrequent attendance at religious services, assimilation (cultural orientation), and low education.

CONCLUSION

Ghanaians living in Europe are more likely to smoke than their counterparts in Ghana, suggesting convergence to European populations, although prevalence rates are still far below those in the host populations.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.

Perseverative Cognition and Health Behaviors: A Systematic Review and Meta-Analysis

Recent developments in stress theory have emphasized the significance of perseverative cognition (worry and rumination) in furthering our understanding of stress-disease relationships. Substantial evidence has shown that perseverative cognition (PC) is associated with somatic outcomes and numerous physiological concomitants have been identified (i.e., cardiovascular, autonomic, and endocrine nervous system activity parameters). However, there has been no synthesis of the evidence regarding the association between PC and health behaviors. This is important given such behaviors may also directly and/or indirectly influence health and disease outcomes (triggered by PC). Therefore, the aim of the current review was to synthesize available studies that have explored the relationship between worry and rumination and health behaviors (health risk: behaviors which, if performed, would be detrimental to health; health promoting: behaviors which, if performed, would be beneficial for health). A systematic review and meta-analyses of the literature were conducted. Studies were included in the review if they reported the association between PC and health behavior. Studies identified in MEDLINE or PsycINFO (k = 7504) were screened, of which 19 studies met the eligibility criteria. Random-effects meta-analyses suggested increased PC was generally associated with increased health risk behaviors but not health promoting behaviors. Further analyses indicated that increases in rumination (r = 0.122), but not reflection (r = −0.080), or worry (r = 0.048) were associated with health risk behaviors. In conclusion, these results showed that increases in PC are associated with increases in health risk behaviors (substance use, alcohol consumption, unhealthy eating, and smoking) that are driven primarily through rumination. These findings provide partial support for our hypothesis that in Brosschot et al.'s (2006) original perseverative cognition hypothesis, there may be scope for additional routes to pathogenic disease via poorer health behaviors.

A randomized controlled trial of a faith-placed, lay health advisor delivered smoking cessation intervention for rural residents

INTRODUCTION

Rural US residents smoke at higher rates than urban or suburban residents. We report results from a community-based smoking cessation intervention in Appalachian Kentucky.

STUDY DESIGN

Single-blind, group-randomized trial with outcome measurements at baseline, 17 weeks and 43 weeks.

SETTING/PARTICIPANTS

This faith-placed CBPR project was located in six counties of rural Appalachian Kentucky. A total of 590 individual participants clustered in 28 churches were enrolled in the study.

INTERVENTION

Local lay health advisors delivered the 12-week Cooper/Clayton Method to Stop Smoking program, leveraging sociocultural factors to improve the cultural salience of the program for Appalachian smokers. Participants met with an interventionist for one 90 min group session once per week incorporating didactic information, group discussion, and nicotine replacement therapy.

MAIN OUTCOME MEASURES

The primary outcome was self-reported smoking status. Secondary outcomes included Fagerström nicotine dependence, self-efficacy, and decisional balance.

RESULTS

With post-intervention data from 92% of participants, those in intervention group churches (N = 383) had 13.6 times higher odds of reporting quitting smoking one month post-intervention than participants in attention control group churches (N = 154, p < 0.0001). In addition, although only 3.2% of attention control group participants reported quitting during the control period, 15.4% of attention control participants reported quitting smoking after receiving the intervention. A significant dose effect of the 12-session Cooper/Clayton Method was detected: for each additional session completed, the odds of quitting smoking increased by 26%.

CONCLUSIONS

The Cooper/Clayton Method, delivered in rural Appalachian churches by lay health advisors, has strong potential to reduce smoking rates and improve individuals' health.

Identifying effective behavioural components of Intervention and Comparison group support provided in SMOKing cEssation (IC-SMOKE) interventions: a systematic review protocol

BACKGROUND

Systematic reviews of behaviour change interventions for smoking cessation vary in scope, quality, and applicability. The current review aims to generate more accurate and useful findings by (1) a detailed analysis of intervention elements that change behaviour (i.e. behaviour change techniques (BCTs)) and potential moderators of behaviour change (i.e. other intervention and sample characteristics) and (2) assessing and controlling for variability in support provided to comparison groups in smoking cessation trials.

METHODS

A systematic review will be conducted of randomized controlled trials of behaviour change interventions for smoking cessation in adults (with or without pharmacological support), with a minimum follow-up of 6 months, published after 1995. Eligible articles will be identified through the Cochrane Tobacco Addiction Group Specialized Register. Study authors will be asked for detailed descriptions of smoking cessation support provided to intervention and comparison groups. All data will be independently coded by two researchers. The BCT taxonomy v1 (tailored to smoking cessation interventions) and template for intervention description and replication criteria will be used to code intervention characteristics. Data collection will further include sample and trial characteristics and outcome data (smoking cessation rates). Multilevel mixed-effects meta-regression models will be used to examine which BCTs and/or BCT clusters delivered to intervention and comparison groups explain smoking cessation rates in treatment arms (and effect sizes) and what key moderators of behaviour change are. Predicted effect sizes of each intervention will be computed assuming all interventions are compared against comparison groups receiving the same levels of behavioural support (i.e. low, medium, and high levels). Multi-disciplinary advisory board members (policymakers, health care providers, and (ex-)smokers) will provide strategic input throughout the project to ensure the review's applicability to policy and practice.

DISCUSSION

By capturing BCTs in intervention and comparison groups, this systematic review will provide more accurate estimates of the effectiveness of smoking cessation interventions, the most promising BCTs and/or BCT clusters associated with smoking cessation rates in intervention and comparison arms, and important moderators of behaviour change. The results could set new standards for conducting meta-analyses of behaviour change interventions and improve research, service delivery, and training in the area of smoking cessation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015025251.

Health Promotion Methods for Smoking Prevention and Cessation: A Comprehensive Review of Effectiveness and the Way Forward

Tobacco smoking is one of the greatest causes of mortality in the world, responsible for over 5 million deaths per annum. The prevalence of smoking is over 1 billion people, with the majority coming from low or middle income countries. Yet, the incidence of smoking varies vastly between many countries. Some countries have been able to decline the smoking and tobacco related morbidity and mortality through the introduction of health promotion initiatives and effective policies in order to combat tobacco usage. However, on the other hand, in some countries, the incidence of smoking is increasing still further. With the growing body of evidence of detriment of tobacco to health, many control policies have been implemented as health promotion actions. Such methods include taxation of smoking, mass advertising campaigns in the media, peer education programs, community mobilization, motivational interviewing, health warnings on tobacco products, marketing restrictions, and banning smoking in public places. However, the review of the effectiveness of various health promotion methods used for smoking prevention and cessation is lacking. Therefore, the aim of this review is to identify and critically review the effectiveness of health promotion methods used for smoking prevention and cessation. All available studies and reports published were considered. Searches were conducted using PubMed, MEDLINE, Ovid, Karger, ProQuest, Sage Journals, Science Direct, Springer, Taylor and Francis, EMBASE, CINAHL, and Cochrane and Wiley Online Library. Various relevant search terms and keywords were used. After considering the inclusion and exclusion criteria, we selected 23 articles for the present review.

Stages of change, determinants, and mortality for smoking cessation in adult Taiwanese screenees

We aimed to investigate the associations between three smoking-related constructs (pros and cons of smoking, temptation to smoke, and self-efficacy of resisting smoking) and stage of change (precontemplation, contemplation, preparation, and action) based on the transtheoretical model among smokers attending a community-based screening program. We also assessed their effects on long-term all-cause mortality. A prospective cohort study, with an average of 7 years of follow-up, was conducted by enrolling 454 male smoking screenees. The comparisons of the mean score of each variable pertaining to three smoking-related constructs across four stages of smoking cessation were assessed by analysis of variance. The impacts of both smoking-related constructs and smoking cessation stage measured at baseline on 7-year mortality were assessed by using proportional hazards regression model. The differences in the mean scores of pros and cons of smoking, temptation to smoke, and self-efficacy of resisting smoking across four stages of smoking cessation were statistically significant (P < 0.01). The precontemplation group and the contemplation group as opposed to the action group increased the risk for all-cause mortality, but the size of effect was not statistically significant (P = 0.39) when age, duration of smoking, and three smoking- related constructs were controlled. Those with a lower social aspect of self-efficacy were approximately threefold [adjusted hazard ratio = 3.22 (95 % CI 1.26-8.21)] risk for all-cause death compared with those with a higher one. Three smoking-related constructs were highly associated with smoking cessation stage, and low self-efficacy was independently predictive of long-term mortality among male smokers attending a community-based screening program.

Overview of systematic reviews on the health-related effects of government tobacco control policies

BACKGROUND

Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.

METHODS

An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.

RESULTS

Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.

CONCLUSION

When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.

The Economic Impact of Smoking and of Reducing Smoking Prevalence: Review of Evidence

BACKGROUND

Tobacco smoking is the cause of many preventable diseases and premature deaths in the UK and around the world. It poses enormous health- and non-health-related costs to the affected individuals, employers, and the society at large. The World Health Organization (WHO) estimates that, globally, smoking causes over US$500 billion in economic damage each year.

OBJECTIVES

This paper examines global and UK evidence on the economic impact of smoking prevalence and evaluates the effectiveness and cost effectiveness of smoking cessation measures.

STUDY SELECTION

SEARCH METHODS We used two major health care/economic research databases, namely PubMed and the National Institute for Health Research (NIHR) database that contains the British National Health Service (NHS) Economic Evaluation Database; Cochrane Library of systematic reviews in health care and health policy; and other health-care-related bibliographic sources. We also performed hand searching of relevant articles, health reports, and white papers issued by government bodies, international health organizations, and health intervention campaign agencies. SELECTION CRITERIA The paper includes cost-effectiveness studies from medical journals, health reports, and white papers published between 1992 and July 2014, but included only eight relevant studies before 1992. Most of the papers reviewed reported outcomes on smoking prevalence, as well as the direct and indirect costs of smoking and the costs and benefits of smoking cessation interventions. We excluded papers that merely described the effectiveness of an intervention without including economic or cost considerations. We also excluded papers that combine smoking cessation with the reduction in the risk of other diseases. DATA COLLECTION AND ANALYSIS The included studies were assessed against criteria indicated in the Cochrane Reviewers Handbook version 5.0.0. OUTCOMES ASSESSED IN THE REVIEWPrimary outcomes of the selected studies are smoking prevalence, direct and indirect costs of smoking, and the costs and benefits of smoking cessation interventions (eg, "cost per quitter", "cost per life year saved", "cost per quality-adjusted life year gained," "present value" or "net benefits" from smoking cessation, and "cost savings" from personal health care expenditure).

MAIN RESULTS

The main findings of this study are as follows: The costs of smoking can be classified into direct, indirect, and intangible costs. About 15% of the aggregate health care expenditure in high-income countries can be attributed to smoking. In the US, the proportion of health care expenditure attributable to smoking ranges between 6% and 18% across different states. In the UK, the direct costs of smoking to the NHS have been estimated at between £2.7 billion and £5.2 billion, which is equivalent to around 5% of the total NHS budget each year. The economic burden of smoking estimated in terms of GDP reveals that smoking accounts for approximately 0.7% of China's GDP and approximately 1% of US GDP. As part of the indirect (non-health-related) costs of smoking, the total productivity losses caused by smoking each year in the US have been estimated at US$151 billion.The costs of smoking notwithstanding, it produces some potential economic benefits. The economic activities generated from the production and consumption of tobacco provides economic stimulus. It also produces huge tax revenues for most governments, especially in high-income countries, as well as employment in the tobacco industry. Income from the tobacco industry accounts for up to 7.4% of centrally collected government revenue in China. Smoking also yields cost savings in pension payments from the premature death of smokers.Smoking cessation measures could range from pharmacological treatment interventions to policy-based measures, community-based interventions, telecoms, media, and technology (TMT)-based interventions, school-based interventions, and workplace interventions.The cost per life year saved from the use of pharmacological treatment interventions ranged between US$128 and US$1,450 and up to US$4,400 per quality-adjusted life years (QALYs) saved. The use of pharmacotherapies such as varenicline, NRT, and Bupropion, when combined with GP counseling or other behavioral treatment interventions (such as proactive telephone counseling and Web-based delivery), is both clinically effective and cost effective to primary health care providers.Price-based policy measures such as increase in tobacco taxes are unarguably the most effective means of reducing the consumption of tobacco. A 10% tax-induced cigarette price increase anywhere in the world reduces smoking prevalence by between 4% and 8%. Net public benefits from tobacco tax, however, remain positive only when tax rates are between 42.9% and 91.1%. The cost effectiveness ratio of implementing non-price-based smoking cessation legislations (such as smoking restrictions in work places, public places, bans on tobacco advertisement, and raising the legal age of smokers) range from US$2 to US$112 per life year gained (LYG) while reducing smoking prevalence by up to 30%-82% in the long term (over a 50-year period).Smoking cessation classes are known to be most effective among community-based measures, as they could lead to a quit rate of up to 35%, but they usually incur higher costs than other measures such as self-help quit-smoking kits. On average, community pharmacist-based smoking cessation programs yield cost savings to the health system of between US$500 and US$614 per LYG.Advertising media, telecommunications, and other technology-based interventions (such as TV, radio, print, telephone, the Internet, PC, and other electronic media) usually have positive synergistic effects in reducing smoking prevalence especially when combined to deliver smoking cessation messages and counseling support. However, the outcomes on the cost effectiveness of TMT-based measures have been inconsistent, and this made it difficult to attribute results to specific media. The differences in reported cost effectiveness may be partly attributed to varying methodological approaches including varying parametric inputs, differences in national contexts, differences in advertising campaigns tested on different media, and disparate levels of resourcing between campaigns. Due to its universal reach and low implementation costs, online campaign appears to be substantially more cost effective than other media, though it may not be as effective in reducing smoking prevalence.School-based smoking prevalence programs tend to reduce short-term smoking prevalence by between 30% and 70%. Total intervention costs could range from US$16,400 to US$580,000 depending on the scale and scope of intervention. The cost effectiveness of school-based programs show that one could expect a saving of approximately between US$2,000 and US$20,000 per QALY saved due to averted smoking after 2-4 years of follow-up.Workplace-based interventions could represent a sound economic investment to both employers and the society at large, achieving a benefit-cost ratio of up to 8.75 and generating 12-month employer cost savings of between $150 and $540 per nonsmoking employee. Implementing smoke-free workplaces would also produce myriads of new quitters and reduce the amount of cigarette consumption, leading to cost savings in direct medical costs to primary health care providers. Workplace interventions are, however, likely to yield far greater economic benefits over the long term, as reduced prevalence will lead to a healthier and more productive workforce.

CONCLUSIONS

We conclude that the direct costs and externalities to society of smoking far outweigh any benefits that might be accruable at least when considered from the perspective of socially desirable outcomes (ie, in terms of a healthy population and a productive workforce). There are enormous differences in the application and economic measurement of smoking cessation measures across various types of interventions, methodologies, countries, economic settings, and health care systems, and these may have affected the comparability of the results of the studies reviewed. However, on the balance of probabilities, most of the cessation measures reviewed have not only proved effective but also cost effective in delivering the much desired cost savings and net gains to individuals and primary health care providers.

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.

Short-Term Smoking Cessation in English Resident Adults of Bangladeshi Origin: A Service Review

INTRODUCTION

Cigarette smoking in English residents of Bangladeshi origin, particularly men, exceeds national estimates. Cessation outcomes and potential predictors of successful cigarette smoking cessation in this group await identification.

METHODS

This service review reports cessation outcomes and predictors of success for 324 adult English resident Bangladeshi origin smokers recruited into a project providing a specialist tobacco cessation service. Interview measures included sociodemographics, tobacco use and dependence. Cessation data (self-reported and validated) at 4 weeks was also collected. Cessation rate and predictors of successful cessation, modeled using multiple logistic regressions, are reported.

RESULTS

Clients' mean age was 45.59 (SD = 13.83) years. Thirty-three (10%) were females. Mean level of small area deprivation was 56.98 (SD = 5.37). Initial mean expired air carbon monoxide score was 11.66 parts per million (SD = 7.17). Thirty-eight per cent used combination nicotine replacement therapy (NRT) with behavioral support. Sixty-nine percent reported successful smoking cessation after 4 weeks, validated with carbon monoxide (mean =1.23 parts per million, SD = 1.32). Predictors of successful cessation were use of combined NRT with behavioral support (OR = 1.82, 95% CI = 1.07, 3.09), and community recruitment (OR = 1.85, 95% CI = 1.07, 3.22).

CONCLUSIONS

English adult smokers of Bangladeshi origin resident in a highly disadvantaged locality, accessing community outreach services to help them quit and using NRT have validated short-term success rates greater than that locality's general population who access National Health Service Stop Smoking Services to quit.

The Smoking Cessation Trust Program of Louisiana: The Pediatrician's Role in Identifying and Referring Eligible Caregivers

BACKGROUND

A pilot study was conducted to determine whether the caregivers of children being seen at the Ochsner for Children health center were eligible for and using services provided by the Smoking Cessation Trust (SCT).

METHODS

The study population consisted of pediatric patients' caregivers who visit the Ochsner for Children health center. Caregivers were offered a questionnaire to assess their age, sex, relationship to the child, medical insurance, smoking status, and prior cessation attempts and aids. Data about 3 other caregivers were also requested from the visiting caregiver.

RESULTS

Of the 84 caregivers assessed, 26 (30.95%) smoked, of whom 12 (46.15%) began smoking prior to 1988 and were eligible for SCT services. The cohort of eligible caregivers included 4 grandmothers (33.33%), 2 grandfathers (16.67%), and 3 fathers (25.00%). Smoking prevalence in our cohort was higher than the national average (31% vs 18%). During the previous 12 months, 3 of 12 (25.00%) SCT-eligible caregivers had tried to quit smoking. Four (33.33%) SCT-eligible caregivers were interested in smoking cessation.

CONCLUSION

Pediatricians are in a unique position to screen, counsel, and refer caregivers who smoke to the SCT.

Supporting pregnant Aboriginal and Torres Strait Islander women to quit smoking: views of antenatal care providers and pregnant indigenous women

To assess support for 12 potential smoking cessation strategies among pregnant Australian Indigenous women and their antenatal care providers. Cross-sectional surveys of staff and women in antenatal services providing care for Indigenous women in the Northern Territory and New South Wales, Australia. Respondents were asked to indicate the extent to which each of a list of possible strategies would be helpful in supporting pregnant Indigenous women to quit smoking. Current smokers (n = 121) were less positive about the potential effectiveness of most of the 12 strategies than the providers (n = 127). For example, family support was considered helpful by 64 % of smokers and 91 % of providers; between 56 and 62 % of smokers considered advice and support from midwives, doctors or Aboriginal Health Workers likely to be helpful, compared to 85-90 % of providers. Rewards for quitting were considered helpful by 63 % of smokers and 56 % of providers, with smokers rating them more highly and providers rating them lower, than most other strategies. Quitline was least popular for both. This study is the first to explore views of pregnant Australian Indigenous women and their antenatal care providers on strategies to support smoking cessation. It has identified strategies which are acceptable to both providers and Indigenous women, and therefore have potential for implementation in routine care. Further research to explore their feasibility in real world settings, uptake by pregnant women and actual impact on smoking outcomes is urgently needed given the high prevalence of smoking among pregnant Indigenous women.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, stillbirth, low birthweight and preterm birth and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this fifth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2013), checked reference lists of retrieved studies and contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, randomised cross-over trials, and quasi-randomised controlled trials (with allocation by maternal birth date or hospital record number) of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, and subgroup analyses and sensitivity analysis were conducted in SPSS.

MAIN RESULTS

Eighty-six trials were included in this updated review, with 77 trials (involving over 29,000 women) providing data on smoking abstinence in late pregnancy.In separate comparisons, counselling interventions demonstrated a significant effect compared with usual care (27 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.75), and a borderline effect compared with less intensive interventions (16 studies; average RR 1.35, 95% CI 1.00 to 1.82). However, a significant effect was only seen in subsets where counselling was provided in conjunction with other strategies. It was unclear whether any type of counselling strategy is more effective than others (one study; RR 1.15, 95% CI 0.86 to 1.53). In studies comparing counselling and usual care (the largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy (eight studies; average RR 1.06, 95% CI 0.93 to 1.21). However, a clear effect was seen in smoking abstinence at zero to five months postpartum (10 studies; average RR 1.76, 95% CI 1.05 to 2.95), a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77), and a significant effect at 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), but not in the longer term. In other comparisons, the effect was not significantly different from the null effect for most secondary outcomes, but sample sizes were small.Incentive-based interventions had the largest effect size compared with a less intensive intervention (one study; RR 3.64, 95% CI 1.84 to 7.23) and an alternative intervention (one study; RR 4.05, 95% CI 1.48 to 11.11).Feedback interventions demonstrated a significant effect only when compared with usual care and provided in conjunction with other strategies, such as counselling (two studies; average RR 4.39, 95% CI 1.89 to 10.21), but the effect was unclear when compared with a less intensive intervention (two studies; average RR 1.19, 95% CI 0.45 to 3.12).The effect of health education was unclear when compared with usual care (three studies; average RR 1.51, 95% CI 0.64 to 3.59) or less intensive interventions (two studies; average RR 1.50, 95% CI 0.97 to 2.31).Social support interventions appeared effective when provided by peers (five studies; average RR 1.49, 95% CI 1.01 to 2.19), but the effect was unclear in a single trial of support provided by partners.The effects were mixed where the smoking interventions were provided as part of broader interventions to improve maternal health, rather than targeted smoking cessation interventions.Subgroup analyses on primary outcome for all studies showed the intensity of interventions and comparisons has increased over time, with higher intensity interventions more likely to have higher intensity comparisons. While there was no significant difference, trials where the comparison group received usual care had the largest pooled effect size (37 studies; average RR 1.34, 95% CI 1.25 to 1.44), with lower effect sizes when the comparison group received less intensive interventions (30 studies; average RR 1.20, 95% CI 1.08 to 1.31), or alternative interventions (two studies; average RR 1.26, 95% CI 0.98 to 1.53). More recent studies included in this update had a lower effect size (20 studies; average RR 1.26, 95% CI 1.00 to 1.59), I(2)= 3%, compared to those in the previous version of the review (50 studies; average RR 1.50, 95% CI 1.30 to 1.73). There were similar effect sizes in trials with biochemically validated smoking abstinence (49 studies; average RR 1.43, 95% CI 1.22 to 1.67) and those with self-reported abstinence (20 studies; average RR 1.48, 95% CI 1.17 to 1.87). There was no significant difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however the effect was unclear in three dissemination trials of counselling interventions where the focus on the intervention was at an organisational level (average RR 0.96, 95% CI 0.37 to 2.50). The pooled effects were similar in interventions provided for women with predominantly low socio-economic status (44 studies; average RR 1.41, 95% CI 1.19 to 1.66), compared to other women (26 studies; average RR 1.47, 95% CI 1.21 to 1.79); though the effect was unclear in interventions among women from ethnic minority groups (five studies; average RR 1.08, 95% CI 0.83 to 1.40) and aboriginal women (two studies; average RR 0.40, 95% CI 0.06 to 2.67). Importantly, pooled results demonstrated that women who received psychosocial interventions had an 18% reduction in preterm births (14 studies; average RR 0.82, 95% CI 0.70 to 0.96), and infants born with low birthweight (14 studies; average RR 0.82, 95% CI 0.71 to 0.94). There did not appear to be any adverse effects from the psychosocial interventions, and three studies measured an improvement in women's psychological wellbeing.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy, and reduce low birthweight and preterm births.

Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews

BACKGROUND AND AIMS

The Cochrane Collaboration is an international not-for-profit organization which produces and disseminates systematic reviews of health-care interventions. This paper is the first in a series of annual updates of Cochrane reviews on tobacco addiction interventions. It also provides an up-to-date overview of review findings in this area to date and summary statistics for cessation reviews in which meta-analyses were conducted.

METHODS

In 2012, the Group published seven new reviews and updated 13 others. This update summarizes and comments on these reviews. It also summarizes key findings from all the other reviews in this area.

RESULTS

New reviews in 2012 found that in smokers using pharmacotherapy, behavioural support improves success rates [risk ratio (RR) 1.16, 95% confidence interval (CI) = 1.09-1.24], and that combining behavioural support and pharmacotherapy aids cessation (RR 1.82, 95% CI = 1.66-2.00). Updated reviews established mobile phones as potentially helpful in aiding cessation (RR 1.71, 95% CI = 1.47-1.99), found that cytisine (RR 3.98, 95% CI = 2.01-7.87) and low-dose varenicline (RR 2.09, 95% CI = 1.56-2.78) aid smoking cessation, and found that training health professionals in smoking cessation improves patient cessation rates (RR 1.60, 95% CI = 1.26-2.03). The updated reviews confirmed the benefits of nicotine replacement therapy, standard dose varenicline and providing cessation treatment free of charge. Lack of demonstrated efficacy remained for partner support, expired-air carbon monoxide feedback and lung function feedback.

CONCLUSIONS

Cochrane systematic review evidence for the first time establishes the efficacy of behavioural support over and above pharmacotherapy, as well as the efficacy of cytisine, mobile phone technology, low-dose varenicline and health professional training in promoting smoking cessation.

Ngāti and healthy: translating diabetes prevention evidence into community action

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a major health issue in New Zealand Māori. Clinical trials have demonstrated potential for the prevention of T2DM, but whether community public health programmes aiming to prevent diabetes are effective is untested.

OBJECTIVE

To describe the planning and design of an intervention aiming to translate T2DM prevention clinical trial evidence into a community-wide population health intervention in a high risk predominantly Māori community.

APPROACH

Community concerns about the diabetes burden were heard by the local diabetes nurse, herself a tribal member, and discussed with a locally raised academic. Project planning ensued. The intervention and its evaluation were designed using a participatory community development model. The planned intervention had three components: community-wide health promotion initiatives conveying healthy lifestyle messages, community education and monitoring for identified high-risk individuals and their extended families, and a structural strategy aimed at adapting local environments to support lifestyle changes. The evaluation plan involved interrupted time series surveys coupled with formative and process evaluations rather than a randomised control trial design.

DISCUSSION

Consulting communities, validating community concerns and prioritising cultural and ethical issues were key steps. Time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team were united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of our ethically and culturally appropriate non-randomised control trial evaluation design. The pre-intervention survey demonstrated high rates of diabetes (13%), insulin resistance (33%) and risk factors, and provided evidence for positive, as opposed to negative, lifestyle intervention messages.

CONCLUSION

Community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, but require a high level of commitment from the health sector and buy-in from the community. Adequate commitment, leadership, planning and resources are essential.

Contextual determinants of health behaviours in an aboriginal community in Canada: pilot project

BACKGROUND

Rapid change in food intake, physical activity, and tobacco use in recent decades have contributed to the soaring rates of obesity, type 2 diabetes and cardiovascular disease (CVD) in Aboriginal populations living in Canada. The nature and influence of contextual factors on Aboriginal health behaviours are not well characterized.

METHODS

To describe the contextual determinants of health behaviours associated with cardiovascular risk factors on the Six Nations reserve, including the built environment, access and affordability of healthy foods, and the use of tobacco.In this cross-sectional study, 63 adults from the Six Nations Reserve completed the modified Neighbourhood Environment Walkability Scale (NEWS), questionnaire assessing food access and availability, tobacco pricing and availability, and the Environmental Profile of Community Health (EPOCH) tool.

RESULTS

The structured environment of Six Nations Reserve scored low for walkability, street connectivity, aesthetics, safety, and access to walking and cycling facilities. All participants purchased groceries off-reserve, although fresh fruits and vegetables were reported to be available and affordable both on and off-reserve. On average $151/week is spent on groceries per family. Ninety percent of individuals report tobacco use is a problem in the community. Tobacco is easily accessible for children and youth, and only three percent of community members would accept increased tobacco taxation as a strategy to reduce tobacco access.

CONCLUSIONS

The built environment, access and affordability of healthy food and tobacco on the Six Nations Reserve are not perceived favourably. Modification of these contextual factors described here may reduce adverse health behaviours in the community.

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.

Effectiveness of community-based comprehensive healthy lifestyle promotion on cardiovascular disease risk factors in a rural Vietnamese population: a quasi-experimental study

Background

Health promotion is a key component for primary prevention of cardiovascular disease (CVD). This study evaluated the impact of healthy lifestyle promotion campaigns on CVD risk factors (CVDRF) in the general population in the context of a community-based programme on hypertension management.

Methods

A quasi-experimental intervention study was carried out in two rural communes of Vietnam from 2006 to 2009. In the intervention commune, a hypertensive-targeted management programme integrated with a community-targeted health promotion was initiated, while no new programme, apart from conventional healthcare services, was provided in the reference commune. Health promotion campaigns focused on smoking cessation, reducing alcohol consumption, encouraging physical activity and reducing salty diets. Repeated cross-sectional surveys in local adult population aged 25 years and over were undertaken to assess changes in blood pressure (BP) and behavioural CVDRFs (smoking, alcohol consumption, physical inactivity and salty diet) in both communes before and after the 3-year intervention.

Results

Overall 4,650 adults above 25 years old were surveyed, in four randomly independent samples covering both communes at baseline and after the 3-year intervention. Although physical inactivity and obesity increased over time in the intervention commune, there was a significant reduction in systolic and diastolic BP (3.3 and 4.7 mmHg in women versus 3.0 and 4.6 mmHg in men respectively) in the general population at the intervention commune. Health promotion reduced levels of salty diets but had insignificant impact on the prevalence of daily smoking or heavy alcohol consumption.

Conclusion

Community-targeted healthy lifestyle promotion can significantly improve some CVDRFs in the general population in a rural area over a relatively short time span. Limited effects on a context-bound CVDRF like smoking suggested that higher intensity of intervention, a supportive environment or a gender approach are required to maximize the effectiveness and maintain the sustainability of the health intervention.

Defining and understanding success at smoking reduction: a mixed-methods study

Much is known about the outcomes of different smoking reduction and cessation programs. However there is a lack of information about the degree to which such programs can achieve successes after initial failures. This study evaluated the patterns of success and failure during a smoking reduction intervention with a sample of 164 adult smokers (mean age 62; mean baseline smoking rate 21.2 cigarettes per day) who wanted to reduce their smoking but were not ready to attempt cessation. Success was defined by both self-reported number of cigarettes smoked assessed during counseling calls and carbon monoxide levels at 3 and 12 month follow-ups. There was a strong relationship between initial success/failure and eventual outcome using both assessment methods, and a moderate relationship between success categorization using the different methods (r=.43). Qualitative contextual data identified that types of travel, work and family environmental barriers experienced differed across success categories. This research confirms the importance of initial success in changing addictive behaviors and suggests directions for future research; including ways to enhance initial success, and the suggestion that more study is needed regarding the generalizability of these findings across settings and behaviors.

Estimation of the burden of cardiovascular disease attributable to modifiable risk factors and cost-effectiveness analysis of preventative interventions to reduce this burden in Argentina

BACKGROUND

Cardiovascular disease (CVD) is the primary cause of mortality and morbidity in Argentina representing 34.2% of deaths and 12.6% of potential years of life lost (PYLL). The aim of the study was to estimate the burden of acute coronary heart disease (CHD) and stroke and the cost-effectiveness of preventative population-based and clinical interventions.

METHODS

An epidemiological model was built incorporating prevalence and distribution of high blood pressure, high cholesterol, hyperglycemia, overweight and obesity, smoking, and physical inactivity, obtained from the Argentine Survey of Risk Factors dataset. Population Attributable Fraction (PAF) of each risk factor was estimated using relative risks from international sources. Total fatal and non-fatal events, PYLL and Disability Adjusted Life Years (DALY) were estimated. Costs of event were calculated from local utilization databases and expressed in international dollars (I$). Incremental cost-effectiveness ratios (ICER) were estimated for six interventions: reducing salt in bread, mass media campaign to promote tobacco cessation, pharmacological therapy of high blood pressure, pharmacological therapy of high cholesterol, tobacco cessation therapy with bupropion, and a multidrug strategy for people with an estimated absolute risk > 20% in 10 years.

RESULTS

An estimated total of 611,635 DALY was lost due to acute CHD and stroke for 2005. Modifiable risk factors explained 71.1% of DALY and more than 80% of events. Two interventions were cost-saving: lowering salt intake in the population through reducing salt in bread and multidrug therapy targeted to persons with an absolute risk above 20% in 10 years; three interventions had very acceptable ICERs: drug therapy for high blood pressure in hypertensive patients not yet undergoing treatment (I$ 2,908 per DALY saved), mass media campaign to promote tobacco cessation amongst smokers (I$ 3,186 per DALY saved), and lowering cholesterol with statin drug therapy (I$ 14,432 per DALY saved); and one intervention was not found to be cost-effective: tobacco cessation with bupropion (I$ 59,433 per DALY saved)

CONCLUSIONS

Most of the interventions selected were cost-saving or very cost-effective. This study aims to inform policy makers on resource-allocation decisions to reduce the burden of CVD in Argentina.

Stacked Deck: an effective, school-based program for the prevention of problem gambling

School-based prevention programs are an important component of problem gambling prevention, but empirically effective programs are lacking. Stacked Deck is a set of 5-6 interactive lessons that teach about the history of gambling; the true odds and "house edge"; gambling fallacies; signs, risk factors, and causes of problem gambling; and skills for good decision making and problem solving. An overriding theme of the program is to approach life as a "smart gambler" by determining the odds and weighing the pros versus cons of your actions. A total of 949 grade 9-12 students in 10 schools throughout southern Alberta received the program and completed baseline and follow-up measures. These students were compared to 291 students in 4 control schools. Four months after receiving the program, students in the intervention group had significantly more negative attitudes toward gambling, improved knowledge about gambling and problem gambling, improved resistance to gambling fallacies, improved decision making and problem solving, decreased gambling frequency, and decreased rates of problem gambling. There was no change in involvement in high risk activities or money lost gambling. These results indicate that Stacked Deck is a promising curriculum for the prevention of problem gambling.

The effectiveness of interventions to change six health behaviours: a review of reviews

BACKGROUND

Several World Health Organisation reports over recent years have highlighted the high incidence of chronic diseases such as diabetes, coronary heart disease and cancer. Contributory factors include unhealthy diets, alcohol and tobacco use and sedentary lifestyles. This paper reports the findings of a review of reviews of behavioural change interventions to reduce unhealthy behaviours or promote healthy behaviours. We included six different health-related behaviours in the review: healthy eating, physical exercise, smoking, alcohol misuse, sexual risk taking (in young people) and illicit drug use. We excluded reviews which focussed on pharmacological treatments or those which required intensive treatments (e.g. for drug or alcohol dependency).

METHODS

The Cochrane Library, Database of Abstracts of Reviews of Effectiveness (DARE) and several Ovid databases were searched for systematic reviews of interventions for the six behaviours (updated search 2008). Two reviewers applied the inclusion criteria, extracted data and assessed the quality of the reviews. The results were discussed in a narrative synthesis.

RESULTS

We included 103 reviews published between 1995 and 2008. The focus of interventions varied, but those targeting specific individuals were generally designed to change an existing behaviour (e.g. cigarette smoking, alcohol misuse), whilst those aimed at the general population or groups such as school children were designed to promote positive behaviours (e.g. healthy eating). Almost 50% (n = 48) of the reviews focussed on smoking (either prevention or cessation). Interventions that were most effective across a range of health behaviours included physician advice or individual counselling, and workplace- and school-based activities. Mass media campaigns and legislative interventions also showed small to moderate effects in changing health behaviours.Generally, the evidence related to short-term effects rather than sustained/longer-term impact and there was a relative lack of evidence on how best to address inequalities.

CONCLUSIONS

Despite limitations of the review of reviews approach, it is encouraging that there are interventions that are effective in achieving behavioural change. Further emphasis in both primary studies and secondary analysis (e.g. systematic reviews) should be placed on assessing the differential effectiveness of interventions across different population subgroups to ensure that health inequalities are addressed.

Population-based smoking cessation strategies: a summary of a select group of evidence-based reviews

OBJECTIVE

The objective of this report was to provide the Ministry of Health Promotion (MHP) with a summary of existing evidence-based reviews of the clinical and economic outcomes of population-based smoking cessation strategies.

BACKGROUND

Tobacco use is the leading cause of preventable disease and death in Ontario, linked to approximately 13,000 avoidable premature deaths annually - the vast majority of these are attributable to cancer, cardiovascular disease, and chronic obstructive lung disease. (1) In Ontario, tobacco related health care costs amount to $6.1 billion annually, or about $502 per person (including non-smokers) and account for 1.4% of the provincial domestic product. (2) In 2007, there were approximately 1.7 to 1.9 million smokers in Ontario with two-thirds of these intending to quit in the next six months and one-third wanting to quit within 30 days. (3) In 2007/2008, Ontario invested $15 million in cessation programs, services and training. (4) In June 2009, the Ministry of Health Promotion (MHP) requested that MAS provide a summary of the evidence base surrounding population-based smoking cessation strategies. PROJECT SCOPE: The MAS and the MHP agreed that the project would consist of a clinical and economic summary of the evidence surrounding nine population-based strategies for smoking cessation including: Mass media interventionsTelephone counsellingPost-secondary smoking cessation programs (colleges/universities)Community-wide stop-smoking contests (i.e. Quit and Win)Community interventionsPhysician advice to quitNursing interventions for smoking cessationHospital-based interventions for smoking cessationPharmacotherapies for smoking cessation, specifically:Nicotine replacement therapiesAntidepressantsAnxiolytic drugsOpioid antagonistsClonidineNicotine receptor partial agonistsReviews examining interventions for Cut Down to Quit (CDTQ) or harm reduction were not included in this review. In addition, reviews examining individual-level smoking cessation strategies (i.e. self-help interventions, counselling, etc.), web-based smoking cessation interventions, and smoking cessation strategies for special population groups outside of those identified from reviews included in this analysis were excluded from the scope. Information on cessation programs or strategies in other provinces or an evaluation of current population-based programs in Ontario was also not included in the scope. STATUS IN ONTARIO: In 2005, the McGuinty government launched the Smoke-Free Ontario Strategy, focusing on initiatives aimed at young people to encourage them not to smoke, protection from exposure to second-hand smoke, and programs to help smokers quit. There are currently many smoking cessation programs funded across the province and in 2007/2008, Ontario invested $15 million in cessation programs, services and training. Ontario Health Insurance Plan (OHIP) fee codes for physician advice to quit also exist. EVIDENCE-BASED ANALYSIS:

RESEARCH QUESTION

What are the efficacy and cost-effectiveness of the selected population-based strategies for smoking cessation?

LITERATURE SEARCH

A preliminary scan of Medline was conducted to identify major systematic reviews, meta-analyses, and health technology assessments (HTAs) in the area of smoking cessation. Based on the availability of a number of Cochrane Reviews on the topic of smoking cessation, a more systematic search of the literature was not conducted. For the economic analysis, a literature search was conducted of relevant databases for recently published article reviews, HTAs, and Cochrane Reviews of the nine identified population-based smoking cessation strategies. This analysis is limited as it is a summary of existing reviews and not a systematic review.

OUTCOMES OF INTEREST

The primary outcome of interest for the clinical summary was abstinence from smoking at 6 months follow up; additional outcomes were examined where available. The primary outcomes of interest for the economic analysis were cost-effectiveness ratios.

SUMMARY OF FINDINGS

The evidence suggests that pharmacotherapy, physician advice to quit, nursing interventions, hospital-based interventions, and proactive telephone counselling are effective and cost-effective in the short-term.There is poor quality data around other population-based smoking cessation strategies including mass media campaigns, community interventions, quit and win contests, access to 'quitlines', and interventions for university and college campuses, making evaluation of their effectiveness and cost-effectiveness difficult.Based on pooled summary estimates of effect and safety data, the most effective strategies are varenicline, buproprion, and nicotine replacement therapies, followed by physician advice to quit and nursing interventions (in non-hospitalized smokers without cardiovascular disease).

How confident should we be that smoking cessation treatments work?

AIM

To determine (i) the concordance among recent meta-analyses about which treatments for smoking cessation are efficacious; (ii) the similarity of odds ratios (ORs) across meta-analyses; and (iii) among the validated treatments, the proportion of studies that found higher quit rates.

METHODS

Computerized literature search for meta-analyses during the last 5 years in PubMed and PsychInfo. Data were extracted from summary tables of overall effect of validated treatments.

RESULTS

Fourteen meta-analyses agreed 100% on the presence/absence of efficacy of 17 proven treatments. The ORs differed by <0.5 in 72/76 of the comparisons of meta-analyses. Among 37 comparisons in 33 comparisons, >85% of the studies reported numerical superiority for the active treatment.

CONCLUSIONS

The efficacy of treatments for smoking cessation are extremely reliable. This argues for inclusion of treatment as an essential feature of tobacco control and clinical practice and argues for reimbursement of smoking cessation treatments on a par with other medical and behavioral disorders.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used.

MAIN RESULTS

Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes.There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I(2) > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I(2) = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse.Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power.

AUTHORS' CONCLUSIONS

Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and preterm birth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.

Do lifestyle interventions work in developing countries? Findings from the Isfahan Healthy Heart Program in the Islamic Republic of Iran

OBJECTIVE

To assess the effects of a comprehensive, integrated community-based lifestyle intervention on diet, physical activity and smoking in two Iranian communities.

METHODS

Within the framework of the Isfahan Healthy Heart Program, a community trial was conducted in two intervention counties (Isfahan and Najaf-Abad) and a control area (Arak). Lifestyle interventions targeted the urban and rural populations in the intervention counties but were not implemented in Arak. In each community, a random sample of adults was selected yearly by multi-stage cluster sampling. Food consumption, physical exercise and smoking behaviours were quantified and scored as 1 (low-risk) or 0 (other) at baseline (year 2000) and annually for 4 years in the intervention areas and for 3 years in the control area. The scores for all behaviours were then added to derive an overall lifestyle score.

FINDINGS

After 4 years, changes from baseline in mean dietary score differed significantly between the intervention and control areas (+2.1 points versus -1.2 points, respectively; P < 0.01), as did the change in the percentage of individuals following a healthy diet (+14.9% versus -2.0%, respectively; P < 0.001). Daily smoking had decreased by 0.9% in the intervention areas and by 2.6% in the control area at the end of the third year, but the difference was not significant. Analysis by gender revealed a significant decreasing trend in smoking among men (P < 0.05) but not among women. Energy expenditure for total daily physical activities showed a decreasing trend in all areas, but the mean drop from baseline was significantly smaller in the intervention areas than in the control area (-68 metabolic equivalent task (MET) minutes per week versus -114 MET minutes per week, respectively; P < 0.05). Leisure time devoted to physical activities showed an increasing trend in all areas. A significantly different change from baseline was found between the intervention areas and the control area in mean lifestyle score, even after controlling for age, sex and baseline values.

CONCLUSION

The results suggest that community-based lifestyle intervention programmes can be effective in a developing country setting.

Explicit incorporation of equity considerations into economic evaluation of public health interventions

Health equity is one of the main avowed objectives of public health policy across the world. Yet economic evaluations in public health (like those in health care more generally) continue to focus on maximizing health gain. Health equity considerations are rarely mentioned. Health economists rely on the quasi-egalitarian value judgment that ‘a QALY is a QALY’ – that is QALYs are equally weighted and the same health outcome is worth the same no matter how it is achieved or to whom it accrues. This value judgment is questionable in many important circumstances in public health. For example, policy-makers may place rather little value on health outcomes achieved by infringing individual liberties or by discriminating on the basis of age, sex, or race. Furthermore, there is evidence that a majority of the general public wish to give greater weight to health gains accruing to children, the severely ill, and, to a lesser extent, the socio-economically disadvantaged. This paper outlines four approaches to explicit incorporation of equity considerations into economic evaluation in public health: (i) review of background information on equity, (ii) health inequality impact assessment, (iii) analysis of the opportunity cost of equity, and (iv) equity weighting of health outcomes. The first three approaches can readily be applied using standard methods of health technology assessment, where suitable data are available; whereas approaches for generating equity weights remain experimental. The potential benefits of considering equity are likely to be largest in cases involving: (a) interventions that target disadvantaged individuals or communities and are also relatively cost-ineffective and (b) interventions to encourage lifestyle change, which may be relatively ineffective among ‘hard-to-reach’ disadvantaged groups and hence may require re-design to avoid increasing health inequalities.

Changing health behaviour of young women from disadvantaged backgrounds: evidence from systematic reviews

Observational evidence suggests that improving the diets of women of child-bearing age from disadvantaged backgrounds might be an important component of public health strategies aimed at reducing the burden of chronic disease in their offspring. The development of an intervention to improve the nutrition of young women needs to be informed by a systematic collation of evidence. Such a systematic collation of evidence from systematic reviews of interventions directed at changing health behaviours including diet, breast-feeding, physical activity and smoking has been conducted. Of 1847 potentially-relevant abstracts, fourteen systematic reviews met inclusion criteria. Four aspects of intervention design were identified that were effective at changing one or more of the health behaviours considered in the present review: the use of an educational component; provision of continued support after the initial intervention; family involvement; social support from peers or lay health workers. The findings of the present review suggest that interventions to change the health behaviour of women of child-bearing age from disadvantaged backgrounds will require an educational approach and should provide continued support after the initial intervention. Family involvement and social support from peers may also be important features of interventions that aim to improve diet.

Population tobacco control interventions and their effects on social inequalities in smoking: placing an equity lens on existing systematic reviews

Background

With smoking increasingly confined to lower socio-economic groups, the tobacco control community has been urged to identify which population-level tobacco control interventions work in order to help tackle smoking-related health inequalities. Systematic reviews have a crucial role to play in this task. This overview was therefore carried out in order to (i) summarise the evidence from existing systematic reviews of population-level tobacco control interventions, and (ii) assess the need for a new systematic review of primary studies, with the aim of assessing the differential effects of such interventions.

Methods

Systematic review methods were used to evaluate existing systematic reviews that assessed a population-level tobacco control intervention and which reported characteristics of included participants in terms of at least one socio-demographic or socio-economic factor.

Results

Nineteen systematic reviews were included. Four reviews assessed interventions aimed at the population level alone, whilst fifteen included at least one primary study that examined this type of intervention. Four reviews assessed youth access restrictions, one assessed the effects of increasing the unit price of tobacco, and six assessed smoking bans or restrictions. Of the eight remaining reviews, six assessed multi-component community based interventions, in which the population-level interventions were part of a wider tobacco control programme, and two assessed the impact of smoking bans or restrictions in reducing exposure to environmental tobacco smoke. We found tentative evidence that the effect of increasing the unit price of tobacco products may vary between ethnic and socio-economic groups, and between males and females. However, differences in the context and the results of different reviews made it difficult to draw any firm conclusions. Few identified reviews explicitly attempted to examine differences in intervention effects between socio-demographic groups. Therefore on the basis of these reviews the potential for smoking bans, and youth access restrictions to decrease social inequalities in smoking remains unknown.

Conclusion

There is preliminary evidence that increases in the unit price of tobacco may have the potential to reduce smoking related health inequalities. There is a need for equity effects to be explicitly evaluated in future systematic reviews and in primary research assessing the effects of population tobacco control interventions.

'People pull the rug from under your feet': barriers to successful public health programmes

BACKGROUND

A community public health programme, 'Breathing Space', aimed to tackle smoking in a low income area in Scotland. This paper draws on the qualitative process evaluation of a community-based initiative 'Breathing Space', which set out to tackle smoking in a low income area of Scotland, in order to explore user perceptions of key factors affecting implementation, and in particular to explore the implications of participant knowledge and expertise for programme stability and continuity.

METHODS

The overall evaluation of Breathing Space used a quasi-experimental design and incorporated a detailed process evaluation. The process evaluation aimed to document development and implementation of the programme using a range of qualitative methods, including observation, in-depth interviews, focus groups and documentary analysis. The paper draws upon 59 semi-structured in-depth interviews which were carried out as part of the process evaluation.

FINDINGS

Staff numbers from the multi-agency partnership dwindled across the lifecouof the programme and respondents identified lack of continuity as a key issue. While staff changes are an anticipated problem in programme implementation, here we draw on concepts of technicality and indeterminacy to explore the different aspects of public health programmes which are forfeited when individuals leave. The paper argues that, while technical components of public health programmes (such as the importance of staff complement and continuity) are widely recognised, it is the more indeterminate aspects, including the loss of key theoretical understanding underpinning the programme, which most affect programme delivery. Indeed, the paper suggests that, where inadequate planning and resources threaten the continuity of indeterminate knowledge, the success of public health programmes may be especially jeopardised.

CONCLUSION

Community-based programmes which rely strongly on partnership processes would benefit from early consideration of the potential risks associated with both expected and unexpected stakeholder change. Building in appropriate contingency plans is necessary for sustaining the theory and culture of the programme. Evaluations of innovative community development initiatives may benefit from a formative approach.

Helping hospital patients quit: what the evidence supports and what guidelines recommend

OBJECTIVE

The study aimed to critically appraise the extent and strength of systematic review evidence for, and guideline recommendations regarding hospital smoking cessation interventions.

METHODS

Systematic reviews of smoking cessation interventions were identified via an electronic search of the Cochrane Library. Meta-analyses from Cochrane reviews were categorised as those that incorporated only studies of hospital based interventions, and those which incorporated interventions which were not hospital based. Smoking cessation guidelines for hospital health professionals were identified via a search of the World Wide Web.

RESULTS

The review found that evidence from meta-analyses restricted to hospital studies was insufficient to evaluate a number of specific intervention strategies and at times conflicted with the findings of meta-analyses without such restrictions. The majority of guidelines recommended the provision of brief advice, counseling, nicotine replacement therapy despite the absence of clear supporting evidence.

CONCLUSIONS

Further hospital-based research addressing specific cessation strategies is required. Furthermore, smoking cessation guidelines for hospital based health professionals should more specifically reflect evidence from this setting.

Nonpharmacologic therapy for smoking cessation: characteristics and efficacy of current approaches

This article reviews the most common nonpharmacologic approaches used to support smoking cessation and, where possible, provides estimates of their efficacy in controlled clinical trials. Virtually all of the approaches that have been systematically evaluated to date have demonstrated modest efficacy in increasing quit rates. A cornerstone of effective treatment is tobacco dependence counseling, for which there is a dose-response relation between the intensity of counseling (total minutes of contact) and its effectiveness. New approaches in which treatment is tailored to individual patient characteristics appear promising for the future but require further study. Also, new technologies that permit delivery of smoking interventions to a wider range of patients could have a significant impact on reducing smoking prevalence worldwide in the future. Overall, the clinical literature strongly endorses combining nonpharmacologic interventions with pharmacotherapy to optimize support for smokers who are trying to quit.

Smoking Cessation for Women: Evidence of the Effectiveness of Nursing Interventions

The association between cigarette smoke and disease is direct; cigarette smoking is a major cause of disease in the United States. More than 400,000 people die each year as a result of cigarette smoke. Smoking is responsible for almost 90% of all cases of lung cancer. Smoking cessation reduces the risk of lung cancer within five years. Cessation also may reduce the risk of other cancers, such as cancer of the head and neck, pancreas, and esophagus. Smoking causes skin wrinkling and sexual dysfunction, which can be mediated by smoking cessation. Even after a diagnosis of cancer, smoking cessation improves the odds of survival and reduces the risk of developing a second cancer.

Efficacy of a computer-based hearing test and tailored hearing protection intervention

Advances in computer technology and accessibility enable researchers to provide individually tailored interventions for behavioral change. Using multimedia technology, this study developed and tested a computer-based hearing test and a tailored intervention. The purpose of this study was to evaluate, using a randomized experimental design, the efficacy of the intervention to increase workers' use of hearing protection. The tailored intervention developed by the research team showed more significant short-term effect measured immediately after the intervention than the control intervention. For the long-term effect measured 1 year after the intervention, both tailored and control groups showed significant increase in their reported use (7% vs. 6%) from preintervention to postintervention, but no significant difference between the two groups. The change accomplished in this study was small progress toward the desired level of 100% use of hearing protection to prevent noise-induced hearing loss. This finding showed that changing workers' hearing protection behavior is difficult.

The role of public policies in reducing smoking prevalence in California: results from the California tobacco policy simulation model

Tobacco control policies are examined utilizing a simulation model for California, the state with the longest running comprehensive program. We assess the impact of the California Tobacco Control Program (CTCP) and surrounding price changes on smoking prevalence and smoking-attributable deaths. Modeling begins in 1988 and progresses chronologically to 2004, and considers four types of policies (taxes, mass media, clean air laws, and youth access policies) independently and as a package. The model is validated against existing smoking prevalence estimates. The difference in trends between predicted smoking rates from the model and other commonly used estimates of smoking prevalence for the overall period were generally small. The model also predicted some important changes in trend, which occurred with changes in policy. The California SimSmoke model estimates that tobacco control policies reduced smoking rates in California by an additional 25% relative to the level that they would have been if policies were kept at their 1988 level. By 2004, the model attributes 59% of the reduction to price increases, 28% of the overall effect to media policies, 11% to clean air laws, and only a small percent to youth access policies. The model estimates that over 5000 lives will be saved in the year 2010 alone as a result of the CTCP and industry-initiated price increases, and that over 50,000 lives were saved over the period 1988-2010. Tobacco control policies implemented as comprehensive tobacco control strategies have significantly impacted smoking rates. Further tax increases should lead to additional lives saved, and additional policies may result in further impacts on smoking rates, and consequently on smoking-attributable health outcomes in the population.

Neighbourhood and individual socioeconomic inequalities in smoking: the role of physical neighbourhood stressors

OBJECTIVE

To explore the association between physical neighbourhood stressors and smoking, and the contribution of these stressors to neighbourhood and individual socioeconomic inequalities in smoking.

METHODS

Data were analysed of participants of the baseline measurement of the Dutch GLOBE study (1991), aged 20 years and older, who lived in 79 neighbourhoods of the city of Eindhoven (n = 9062). The neighbourhood socioeconomic environment was assessed from aggregated self reported information of participants' education and occupation level, and employment status. Neighbourhood stressors included were the physical quality (decay), required police attention, noise pollution from traffic, and population density in neighbourhoods. Current smokers were distinguished from previous and never smokers.

RESULTS

Compared with those living in the most advantaged neighbourhoods, residents living in the socioeconomically most disadvantaged neighbourhoods were more likely to smoke (adjusted for age, sex, education, occupation, and employment status) (OR = 1.24, 95% CI 1.05 to 1.46). An increase in a summary neighbourhood stressor score was associated with smoking, independently of the neighbourhood socioeconomic environment (OR = 1.57, 95% CI 1.11 to 2.21, in the neighbourhoods with the highest stress score). Adjustment for the score substantially reduced the odds ratio for living in the socioeconomic most disadvantaged neighbourhoods (OR = 1.03, 95% CI 0.84 to 1.28, for those in the most disadvantaged neighbourhoods). Neighbourhood stressors contributed 10% to the increased probability of smoking in the lowest educated persons.

CONCLUSIONS

Physical neighbourhood stressors are related to smoking and contribute substantially to neighbourhood inequalities in smoking over and above individual level characteristics.

In defense of the randomized controlled trial for health promotion research

The overwhelming evidence about the role lifestyle plays in mortality, morbidity, and quality of life has pushed the young field of modern health promotion to center stage. The field is beset with intense debate about appropriate evaluation methodologies. Increasingly, randomized designs are considered inappropriate for health promotion research. We have reviewed criticisms against randomized trials that raise philosophical and practical issues, and we will show how most of these criticisms can be overcome with minor design modifications. By providing rebuttal to arguments against randomized trials, our work contributes to building a sound methodological base for health promotion research.

Self-reported smoking cessation interventions were not associated with quitting in older women

OBJECTIVE

To determine the extent to which smoking cessation interventions are used in the community and their relative success in older women.

STUDY DESIGN AND SETTING

Prospective cohort study located in 23 general practices in England, Scotland. and Wales and including 3,622 women aged 60 to 79 years at recruitment from the British Women's Heart and Health Study.

RESULTS

Of the 370 smokers at baseline, 77 (21%) had stopped smoking at 3 years, reducing the prevalence of smoking from 10.2% to 8.8%. Women who were light smokers (<10 per day) at baseline were more likely to have quit than heavier smokers. The most common interventions reported by women who smoked at baseline were advice from a general practitioner (GP), family or friend's advice, and use of nicotine replacement, but 42% of the women reported having no intervention to help them to stop smoking. None of the individual interventions were associated with increased odds of quitting smoking over the follow-up period. Women reported finding a GP's advice, referral to a clinic, and nicotine replacement more useful than complementary treatments (acupuncture and hypnotherapy) or advice from family and friends.

CONCLUSION

Smoking cessation rates in this study were in line with national targets and surveys. Self-reports of ever receiving interventions were not associated with quitting smoking among these older women. Different and innovative approaches to smoking cessation may need to be developed, and evaluated in future randomized clinical trials, for individuals who have smoked for a long period of time and for whom other smoking cessation interventions have not proved successful.

Applicability and transferability of interventions in evidence-based public health

The context in which public health programmes operate can play an important role in influencing their implementation and effectiveness. An intervention that has been shown to be effective in one setting may turn out to be ineffective somewhere else, even supposing it can be implemented there. Therefore, systematic reviews of public health interventions should appraise the applicability of the intervention process and the transferability of the intervention effectiveness to other localities. However, applicability and transferability appraisal is seldom reported in systematic reviews of public health and health promotion interventions. This paper aims to introduce an innovative approach to bridging this gap. A list of attributes that may impact on applicability and transferability can be developed, based on knowledge of the proposed intervention. Then the applicability and transferability of the intervention to the local setting can be rated, and given a score, based on knowledge of the local setting. This approach provides a useful tool for evaluating public health interventions and provides a reliable basis for informed decision making in resource-poor settings, where rigorous primary studies are lacking and where very limited resources put a high demand on evidence-based approaches to health promotion.

Cost effectiveness of a community based research project to help women quit smoking

OBJECTIVE

To estimate the cost effectiveness of a four year, multifaceted, community based research project shown previously to help women quit smoking.

DESIGN

A quasi-experimental matched control design.

SETTING

Two counties in Vermont and two in New Hampshire, USA.

SUBJECTS

Women aged 18-64 years.

METHODS

Costs were the grant related expenditures converted to 2002 US dollars. Survey results at the end of the intervention were used to estimate the numbers of never smokers, former smokers, light smokers, and heavy smokers in the intervention and comparison counties, and 1986 life tables for populations of US women categorised by smoking status to estimate the gain in life expectancy.

MAIN OUTCOME MEASURES

Cost effectiveness ratios, as dollars per life-year saved, for the intervention only and for total grant costs (intervention, evaluation and indirect costs).

RESULTS

The cost effectiveness ratio for the intervention, in 2002 US dollars per life-year saved, discounted at 3%, was 1156 dollars (90% confidence interval (CI) 567 dollars to infinity), and for the total grant, 4022 dollars (90% CI 1973 dollars to infinity). When discounted at 5%, these ratios were 1922 dollars (90% CI 1024 dollars to 15,647 dollars), and 6683 dollars (90% CI 3555 dollars to 54,422 dollars), respectively.

CONCLUSION

The cost effectiveness ratios of this research project are economically attractive, and are comparable with other smoking cessation interventions for women. These observations should encourage further research and dissemination of community based interventions to reduce smoking.

Complex interventions: how "out of control" can a randomised controlled trial be?

Complex interventions are more than the sum of their parts, and interventions need to be better theorised to reflect this

Utilization and impact of cigarette pack covers illustrated with antismoking messages

The authors tested whether smokers would use cigarette pack covers illustrated with antismoking messages. In 2001, visitors to a smoking cessation Web site ordered cigarette pack covers and answered a follow-up questionnaire 52 days later. Participants received by mail cardboard boxes designed to contain cigarette packs and illustrated with antismoking messages. Participants were 393 smokers living in France, Belgium, and Switzerland. Participants used their boxes for 21 days out of a possible 28 days, and 31% were still using them at follow-up. Almost one third (32%) said that the boxes often prompted discussions about smoking. The boxes that were submitted to pretests were preferred to the boxes that were not pretested. The authors concluded that the boxes were welcomed by smokers and enabled the display of antismoking messages for 3 weeks in their immediate environments. The intervention had no impact on smoking cessation, but this was not its primary objective.