Compliance with physician advice to quit smoking: a review of the literature

Antecedents and Consequences of Smoking Cessation Intention in the Context of the Global COVID-19 Infodemic

A growing body of scientific studies has been published to inform responses to the ongoing coronavirus pandemic, and some have claimed that cigarette smoking has a beneficial or mixed effect on the prevention and treatment of COVID-19. The presentation of such findings, unfortunately, has created an infodemic. This study integrated the theory of planned behavior and the health belief model and incorporated findings on addiction from the medical literature to predict cessation intention and support for tobacco control measures in the context of the COVID-19 infodemic. The study found that cessation intention partially mediated the effect of perceived severity and fully mediated the effects of perceived benefits, self-efficacy, and addiction on support for control measures. In addition, a positively-valenced message of the effect of smoking on the prevention and treatment of COVID-19 vs. a mixedly-valenced message was significant in predicting cessation intention, and the positively-valenced message of smoking indirectly predicted support for tobacco control measures. Perceived susceptibility, barriers, and subjective norms, however, exerted neither direct nor indirect effects on the two outcome variables.

Is Oral Biopsy Associated With Change in Tobacco or Alcohol Use?

PURPOSE

Tobacco and alcohol remain the predominant risk factors for oral cancer, but the relation between having an oral biopsy and cessation of these risk factors is unknown. Therefore, this investigation examined whether there might be an association between oral biopsy and change in risk factor use.

MATERIALS AND METHODS

A survey was sent to a cohort consisting of a consecutive sample of subjects identified in the University of North Carolina Oral Pathology database. The predictor variable was oral biopsy diagnosis, with 3 levels consisting of hyperkeratosis, dysplasia, or carcinoma. The outcome variable was change in risk factor use, coded as "no change in usage," "decreased usage" or "quit." Other study variables included age, gender, and race. The proportional odds model was used to assess the effect of explanatory variables on change in use, and the P value was set at .05.

RESULTS

The response rate was 37.4% for a total sample of 605 subjects. White non-Hispanics composed 85% of respondents and women composed 49.5%, with no significant difference among diagnostic categories. The global test for change in cigarette use was significant, with age contributing to variability in behavioral change. Although not statistically significant, larger percentages of patients with more severe diagnoses quit cigarettes and alcohol following biopsy. The youngest respondents were 3.7 times more likely not to quit before biopsy or to continue to smoke following biopsy (95% confidence interval, 1.98-6.91).

CONCLUSION

The results of this study suggest that oral biopsy provides an ideal opportunity to focus on risk factor cessation. Different diagnoses provide objective data on which to base a discussion about carcinogenesis and the roles played by the risk factors in this process. Differences in risk factor cessation associated with demographics emphasize the need for all clinicians to address cessation with all patients.

Advice given by community members to pregnant women: a mixed methods study

Background

Smoking and excess weight gain during pregnancy have been shown to have serious health consequences for both mothers and their infants. Advice from friends and family on these topics influences pregnant women’s behaviors. The purpose of our study was to compare the advice that community members give pregnant women about smoking versus the advice they give about pregnancy weight gain.

Methods

A survey was sent via text messaging to adults in a diverse, low-income primary care clinic in 2015. Respondents were asked what advice (if any) they have given pregnant women about smoking or gestational weight gain and their comfort-level discussing the topics. Descriptive statistics were used to characterize the sample population and to determine response rates. Open-ended responses were analyzed qualitatively using grounded theory analysis with an overall convergent parallel mixed methods design.

Results

Respondents (n = 370) were 77 % female, 40 % black, and 25 % reported education of high school or less. More respondents had spoken to pregnant women about smoking (40 %, n = 147) than weight gain (20 %, n = 73). Among individuals who had not discussed either topic (n = 181), more reported discomfort in talking about weight gain (65 %) compared to smoking (34 %; p < 0.0001). Advice about smoking during pregnancy (n = 148) was frequently negative, recommending abstinence and identifying smoking as harmful for baby and/or mother. Advice about weight gain in pregnancy (n = 74) revealed a breadth of messages, from reassurance about all weight gain (“Eat away” or “It’s ok if you are gaining weight”), to specific warnings against excess weight gain (“Too much was dangerous for her and the baby.”).

Conclusions

Many community members give advice to pregnant women. Their advice reveals varied perspectives on the effects of pregnancy weight gain. Compared to a nearly ubiquitous understanding of the harms of smoking during pregnancy, community members demonstrated less awareness of and willingness to discuss the harms of excessive weight gain. Beyond educating pregnant women, community-level interventions may also be important to ensure that the information pregnant women receive supports healthy behaviors and promotes the long-term health of both moms and babies.

Socioeconomic differences in smoking cessation: the role of social participation

Objectives: The aim of this study was to investigate whether psychosocial resources explain socioeconomic differences in smoking cessation and its maintenance. Methods: A subpopulation of 11,837 individuals from the Malmö Diet and Cancer Study interviewed in 1992-94, age range 45-64 years, was investigated in this cross-sectional study. A multivariate logistic regression model was used to assess relative risks of having stopped smoking, adjusting for age, country of origin, previous/ current diseases, and marital status. Results: An odds ratio of 1.9 (1.4-2.5; 95% CI) for men and 2.0 (1.4-2.7; 95% CI) for women of having stopped smoking was found for higher non-manual employees when compared with unskilled manual workers. A decrease in these odds ratios was found when social participation was introduced into the model. The other three social network and social support variables were non-significant. Conclusion: High social participation is a predictor of maintenance of smoking cessation. It seems possible to interpret parts of the socioeconomic differences in smoking cessation and its maintenance as a consequence of differing social network resources and social capital between socioeconomic groups.

Intention to quit smoking: role of personal and family member cancer diagnosis

Individuals who have ever experienced a cancer diagnosis and their family members may be priority audiences for health improving interventions. Guided by the heuristic model of the 'teachable moment' and using data from the 2003 National Cancer Institute's Health Information National Trends Survey, we explored whether having a lifetime history of cancer or having a family member with a lifetime history of cancer was associated with intention to quit smoking. Results showed that having a personal lifetime history of cancer was not associated with intention to quit, while having a family member with a lifetime history of cancer was (χ(2) = 7.08, P < 0.01). Path analysis showed that individual perceived risk of cancer mediated the relationship between having a family member with a history of cancer and quitting intention: smokers who had a family member with a history of cancer in addition to an elevated level of perceived cancer risk were 36% more likely to report intending to quit. These preliminary data suggest that family members of cancer patients may be a viable target population for smoking cessation interventions, especially when they have heightened levels of perceived cancer risk. An adequately powered, controlled trial is needed to fully evaluate this hypothesis.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Faculty development in tobacco cessation: training health professionals and promoting tobacco control in developing countries

ISSUES

Cessation programs are essential components of comprehensive tobacco control. Health-care providers, especially physicians, have major responsibility for role modeling and promoting cessation. For successful, sustainable cessation training programs, countries need health-care professionals with knowledge and skills to deliver and teach tobacco cessation.

APPROACH

Review literature relevant to faculty development in tobacco cessation and discuss its strategic potential in tobacco control.

KEY FINDINGS

Faculty development is essential for sustainable tobacco cessation training programs, and a potentially powerful strategy to shift professional and societal norms towards cessation and support of comprehensive tobacco control in countries with normative tobacco use and underdeveloped tobacco control programs.

IMPLICATIONS

Medical faculty are in a key position to influence tobacco cessation and control programs because of their roles as educators and researchers, receptivity to innovation and, influence on competencies and standards for medical education and practice. Faculty development programs must consider the number and type of faculty, and tobacco cessation curricula needed. Faculty development fosters the ability to institutionalise cessation education for students and community practitioners. Academic faculty are often leaders in their professional disciplines, influential in establishing clinical practice standards, and technical experts for government and other key health organisations.

CONCLUSION

Training health-care professional faculty to become knowledgeable and committed to tobacco cessation opens opportunities to promote cessation and shift professional and societal norms away from tobacco use.

Surgeons underestimate their patients' desire for preoperative information

Background

Provision of adequate patient information may contribute to a “satisfying” surgical treatment. The patient’s views on successful transfer of information concerning operative characteristics may not be in concert with the surgeon’s. The aim of the present study was to determine opinions of both surgeons and patients about issues of surgical information.

Methods

A group of surgeons (n = 24) and surgical patients (n = 125) responded to a questionnaire that included 80 topics involving domains of information on disease, physical examination, preoperative period, anesthesia, operation, postoperative period, self care, and general hospital issues. Both groups were asked for their opinion on what they considered important and useful preoperative information for patients. Questions were scored with a visual analog scale. The reliability of the questionnaire was calculated with Cronbach’s alpha. Differences in opinions between surgeons and patients were analyzed with Student’s t-test.

Results

The Cronbach’s alpha of the questionnaire was high (0.91), indicating its high reliability. Patients scored significantly higher (p < 0.001) in most domains, including preoperative period, anaesthesia, operation, postoperative period, self care, and general hospital information. Women demonstrated a significantly higher need for information than men did. These findings were independent of patient age or complexity of operation. In contrast, surgeons thought that their patients desired more extensive information on cause, effect, and prognosis of the disease itself (p < 0.001).

Conclusion

Surgeons generally underestimate their patients’ desire for receiving extensive information prior to a surgical procedure of any complexity. Surgeons should develop strategies to bridge this informational mismatch.

Smoking cessation practices of Dutch general practitioners, cardiologists, and lung physicians

STUDY OBJECTIVES

To assess and compare the smoking cessation practices and smoking behavior of Dutch general practitioners (GPs), cardiologists, and lung physicians.

METHODS

We conducted questionnaire surveys among a random sample of 2000 Dutch GPs, all Dutch cardiologists (N=594), and all Dutch lung physicians (N=375).

RESULTS

In total, 834 GPs (41.7%), 300 cardiologists (50.5%), and 258 lung physicians (68.8%) filled out and returned the questionnaire. The prevalence of current smokers was 8.2% among GPs, 4.3% among cardiologists, and 3.5% among lung physicians. Of the pharmacological aids for smoking cessation, physicians recommended bupropion most frequently, followed by nicotine patches and nicotine gum. More lung physicians recommended the use of these three aids (67.0%, 36.3% and 18.2%, respectively) than GPs (65.7%, 18.7% and 9.8%, respectively), and than cardiologists (31.6%, 19.7% and 13.2%, respectively). A higher proportion of lung physicians (69.3%) had referred at least one smoker to a nurse for smoking cessation treatment than cardiologists (25%), and than GPs (11.3%).

CONCLUSIONS

Based on this national survey, one may conclude that the prevalence of current smoking among Dutch physicians is relatively low and has further decreased since 1988. Dutch GPs, cardiologists, and lung physicians mainly use interventions for smoking cessation that are easy to administer and are not very time consuming. Furthermore, more lung physicians than GPs and cardiologists recommend the use of bupropion, nicotine patch, and nicotine gum. When designing interventions for smoking cessation, one should take into account that physicians are often reluctant to provide interventions which demand much time. Therefore, intensive counseling of smokers who want to quit smoking may be more feasible for trained non-physicians, such as nurses.

Prevalence of psychoactive drug use among medical students in Rio de Janeiro

BACKGROUND

Drug use and abuse may hamper learning capabilities and the development of technical skills in medical students and, therefore, the quality of care offered to patients. The aim of this investigation was to estimate the prevalence of psychoactive drug use among medical students of public universities in Rio de Janeiro, Brazil, and to identify characteristics associated with substance use.

METHOD

This was a cross-sectional investigation designed to include all medical students of four universities. The final sample included 1,054 students. Patterns of licit and illicit drug use (at least once in lifetime drug use, drug use in the last 30 days (LTD) and CAGE) before and during medical school were assessed by a multiple-choice, self-administered anonymous questionnaire.

RESULTS

Alcohol abuse was more prevalent among male students from higher income families. Alcohol LTD use was more prevalent among male students with college-educated parents. Tobacco, cannabis and inhalant lifetime use was more prevalent among males and tranquillizer use among females. Tobacco, cannabis and tranquillizer lifetime use was more prevalent among students with divorced or dead parents. Inhalant lifetime use was more prevalent among students from higher income families. Students who had college-educated, divorced or dead parents or evidenced tobacco, cocaine or inhalant lifetime use were more prevalent among cannabis users. Male students from higher income families had higher prevalence of cocaine lifetime use.

CONCLUSION

Substance use in this group of medical students is not widespread compared to rates reported for developed countries. Preventive efforts should focus on alcohol and cannabis use by medical students.

Characteristics of patients with COPD in three motivational stages related to smoking cessation

OBJECTIVE

To characterize patients with chronic obstructive pulmonary disease (COPD) in different motivational stages related to smoking cessation.

METHODS

633 smoking COPD patients from 67 general practices participated in a cross-sectional study. The patients were compared with respect to health indicators, demographics, self-efficacy, nicotine dependence, attitudes, and action plans.

RESULTS

In line with previous Dutch results, smokers in precontemplation associated significantly fewer advantages with smoking cessation than smokers contemplating quitting and preparing to quit. Preparers had significantly higher self-efficacy expectations about quitting than the other smokers. Patients preparing to quit suffered from more COPD complaints than precontemplators. Smokers contemplating quitting and preparing to quit developed more plans to turn intentions to quit into action.

CONCLUSION

More than 50% of the smokers with COPD are amenable to smoking cessation support. Preparers and contemplators did not differ as much as previous studies found. It would be advantageous to tailor COPD counseling to two distinct groups (unmotivated smokers and smokers motivated to quit), to discuss the advantages of quitting with unmotivated smokers, and to increase self-efficacy, and action planning for smokers motivated to quit.

PRACTICE IMPLICATIONS

COPD patients are amenable to counseling to quit smoking. Addressing COPD complaints may contribute to greater motivation.

The incidence of smoking and risk factors for smoking initiation in medical faculty students: cohort study

BACKGROUND

Medical education requires detailed investigation because it is a period during which the attitudes and behaviors of physicians develop. The purpose of this study was to calculate the yearly smoking prevalence and incidence rates of medical faculty students and to identify the risk factors for adopting smoking behaviour.

METHODS

This is a cohort study in which every student was asked about their smoking habits at the time of first registration to the medical faculty, and was monitored every year. Smoking prevalence, yearly incidence of initiation of smoking and average years of smoking were calculated in analysis.

RESULTS

At the time of registration, 21.8% of the students smoked. At the end of six years, males had smoked for an average of 2.6 +/- 3.0 years and females for 1.0 +/- 1.8 years (p < 0.05). Of the 93 medical students who were not smokers at the time of registration, 30 (32.3%) were smokers at the end of the 6 years of the course.

CONCLUSION

The first 3 years of medical education are the most risky period for initiation of smoking. We found that factors such as being male, having a smoking friend in the same environment and having a high trait anxiety score were related to the initiation of smoking. Targeted smoking training should be mandatory for students in the Medical Faculty.

Healthcare providers' treatment of college smokers

About 28% of college students smoke tobacco, and many will continue smoking into adulthood. Although little is known about how to help college students quit smoking, 1 promising strategy is healthcare providers' advice. To estimate their life-time receipt of brief advice and to identify characteristics that predict who may receive that advice, 348 college students completed a survey about their smoking and related practices. Seventy-seven percent of the smokers (73% of the students) were asked about smoking. Of those smokers, 57% were advised to quit, 22% were given advice about quitting, 5% were helped with setting a quit date, and 4% were offered follow-up. Occasional smokers were less likely than daily smokers to be advised to quit. Although 36.2% of the smokers did not report their smoking accurately, smokers who were accurate were more likely to be advised to quit and to be given advice about quitting.

Smoking Prevalence, Behaviour and Nicotine Addiction among Coal Workers in Zonguldak, Turkey

To assess the smoking status of coal workers, as coal dust exposure and concomitant cigarette smoking contribute to the increased prevalence of pulmonary interstitial fibrosis, chronic obstructive pulmonary disease and other pulmonary diseases. A survey was conducted to determine the smoking prevalence, behaviour and nicotine addiction in coal workers. The target population consisted of 475 underground coal workers who lived in Zonguldak city of Turkey, and we reached 389 of them. Each subject completed a detailed smoking history questionnaire (included 56 question). Chest X-rays and pulmonary function tests were performed to evaluate patients' related diseases and complications. Smoking status of the workers was as follows; Sixty-nine never smokers (17.7%), 62 ex-smokers (15.9%) and 258 current smokers (66.3%). The mean age of starting smoking was similar among ex and current smokers (15.9 +/- 4.2 versus 15.0 +/- 4.0). The most common reason for starting smoking was smoking interest (50%) and friends' influence (15.5%). The most frequent reason stated for successful smoking cessation was experience of smoking-related symptoms or development of a medical condition (51%). The most important reason given by current smokers for smoking cessation attempts was increased chance of developing lung cancer, pneumoconiosis and other diseases (22.9%). Nicotine addiction was assessed by the Fagerstroem test. Mild (0-3 points), moderate (4-6) and severe (7 or more) addiction ratios were found to be 39.1%, 44.2% and 16.7% respectively. Ex-smokers had the highest prevalence of large and small airway obstruction on spirometry. Smoking prevalence is high in coal workers living in Zonguldak city of Turkey. Most of the smokers know that smoking is dangerous and want to quit smoking. A detailed smoking history during medical surveillance may help the occupational physician to develop a system in which such individuals can be referred to comprehensive smoking cessation programs.

Hospital initiatives in promoting smoking cessation: a survey of Internet and hospital-based programs targeted at consumers

STUDY OBJECTIVES

This study assesses how often local US hospitals provide smoking cessation information in the following two ways: via hospital Web sites; and via routing incoming phone calls to their hospital switchboards to an in-house smoking cessation clinic.

DESIGN

Random survey of US hospitals.

SETTING

US hospital Web pages and telephone switchboards.

PATIENTS OR PARTICIPANTS

One hundred two randomly selected US hospitals.

INTERVENTIONS

One hundred two hospital Web sites were randomly selected across the United States. The site was searched for the topic of smoking cessation. In the second phase of the survey, the main switchboard number of the same 102 hospitals was anonymously called and the "stop smoking clinic" was asked for.

MEASUREMENTS AND RESULTS

The overall results indicate that among the hospital Web sites surveyed, only 30% contained information relating to smoking cessation programs. The phone survey of hospital switchboards showed that 47% had a smoking cessation program available via phone inquiry, while 53% did not.

CONCLUSIONS

Of the US hospital Web sites visited, only 30% contained information on smoking cessation. The yield of finding the desired information was increased by the presence of an intrasite search option, which is a low-cost enhancement to any complex Web site. The relatively low cost of promoting healthy behaviors such as smoking cessation on a hospital Web site should be used more widely. Surprisingly, the phone survey of hospitals showed that the lower technology route of providing smoking cessation information to patients via a patient-initiated phone call is only available in 47% of hospitals. Both the Internet and phone-based switchboard referrals could be more widely and effectively used. Joint Commission on Accreditation of Healthcare Organizations guidelines would be one avenue of increasing the availability of smoking cessation information at hospital switchboards and Web sites.

Correlates of tobacco use among smokers and recent quitters diagnosed with cancer

Smoking after a cancer diagnosis shortens survival time, increases risk of recurrence and the development of another primary tumor, reduces treatment efficacy, and increases treatment complications. Nevertheless, many patients who smoked prior to their illness continue to smoke after diagnosis and treatment. The development of effective smoking cessation interventions for cancer patients has been slowed by the lack of data concerning psychological correlates of smoking in this population. This study, with 74 cancer patients, showed that smoking and lower readiness to quit was associated with: having relatives at home who smoke, a longer time between diagnosis and assessment, completion of medical treatment, greater nicotine dependence, lower self-efficacy, quitting pros, and risk perceptions, and higher quitting cons, fatalistic beliefs, and emotional distress. Thus, smoking cessation treatments for cancer patients should include pharmacotherapy, relapse prevention, and counseling designed to facilitate self-efficacy, quitting pros, and risk awareness and to reduce the quitting cons, fatalism, and distress.

Processes of change related to smoking behavior among cancer patients

PURPOSE

The purpose of this study was to examine the degree to which transtheoretical model processes of change (methods and strategies for cessation) were associated with smoking status and quitting behavior (ie, intentions and attempts to quit) among patients with head and neck or lung cancer. The relationship between medical variables and processes of change was also explored.

DESCRIPTION OF STUDY

Twenty-nine smokers and 45 abstainers who were recruited from treatment clinics within a comprehensive cancer center completed a brief survey. Multivariate analysis of variance and Pearson correlation procedures were used to evaluate hypothesized relationships.

RESULTS

As hypothesized, quitters used behavioral processes such as counter-conditioning and reinforcement management significantly more than smokers and used self-reevaluation, an experiential process, significantly less than smokers. Contrary to the hypothesis, however, quit attempts and intentions were associated with both experiential (ie, consciousness raising and self-reevaluation) and behavioral (ie, reinforcement management and self-liberation) processes of change. Use of the processes of change was not influenced by medical variables, including cancer type, illness phase, disease stage, type of current medical treatment, and duration of illness.

CLINICAL IMPLICATIONS

These findings suggest that behavioral counseling to promote smoking cessation for patients with cancer should involve assisting the patient to do the following: develop an awareness of the health risks related to continued smoking; devise and use alternative behaviors; implement the use of reinforcement strategies for cessation successes; and develop a sense of confidence and commitment about quitting as well as healthy lifestyle values. These strategies are discussed within the context of models and guidelines for smoking cessation in clinical practice.

Study of smoking behavior in asbestos workers

BACKGROUND

Asbestos exposure and concomitant cigarette smoking markedly increase the risk of lung cancer and contribute to the prevalence and severity of pulmonary interstitial fibrosis.

METHODS

A cross-sectional survey of 214 asbestos workers was initiated to determine the prevalence of smoking and their readiness to quit smoking using the stage of change theory.

RESULTS

The study was comprised of 61 never smokers (28.5%), 118 ex-smokers (55.1%), and 35 current smokers (16.4%). Reasons for smoking cessation in ex-smokers included perception of ill-health (51%) and knowledge of smoking-asbestos hazards (3.4%). Stage of change of current smokers revealed: precontemplation (26.5%), contemplation (35%), preparation (29%), and action (8.8%). Current smokers had the highest prevalence of small airway obstruction on spirometry.

CONCLUSIONS

A detailed smoking history during medical surveillance activities will enable the occupational physician to identify asbestos workers who have difficulty quitting and to develop a system in which such individuals can be referred to comprehensive smoking cessation programs.

A free smoking intervention clinic initiated by medical students

OBJECTIVE

To describe a medical student-run smoking intervention clinic, report initial outcomes, and assess medical student competence in smoking intervention counseling.

PATIENTS AND METHODS

Volunteer medical students of Mayo Medical School in Rochester, Minn, staffed a free smoking intervention clinic in conjunction with the Salvation Army Free Acute Care Clinic between December 1997 and January 1999. Patients received a comprehensive intervention for smoking that comprised counseling, frequent follow-up contact, and pharmacologic therapy, including bupropion and nicotine replacement. Eighty-eight patients seen during the first 13 months of the clinic's operation and 30 medical student volunteer counselors were included in the study. Patients were contacted via telephone to assess 6-month self-reported smoking abstinence. Medical student counselors completed a self-assessment questionnaire surveying competence before and after working in the clinic.

RESULTS

The 6-month self-reported smoking abstinence rate was 18% (95% confidence interval, 11%-28%). Twelve of 14 medical students completing the survey reported improved competence in smoking intervention counseling.

CONCLUSIONS

A comprehensive smoking intervention program provided by medical students yielded smoking abstinence rates comparable to other treatment programs. Medical students believed they improved their smoking cessation counseling skills.

Effect of the spine practitioner on patient smoking status

STUDY DESIGN

A prospective evaluation of the smoking habits of new spine patients was performed during a 4-year interval.

OBJECTIVE

To assess what effect the spine health care provider has on a patient's ongoing nicotine addiction.

SUMMARY OF BACKGROUND DATA

The negative effects of smoking and nicotine for the spine patient are well defined.

METHODS

Spine patients (N = 10,901) were queried as to their smoking habits during their new patient consultation; 3041 current smokers were identified. Data were obtained during 20,835 follow-up visits. Some of the smokers (n = 1632) were seen in follow-up visits and evaluated for their cigarette usage. Two different approaches were applied to assist the patient to stop smoking: 1) chart identification, reinforcement at each visit, continued education, written handout, practitioner assigning high priority, and 2) occasional mentioning, lower priority.

RESULTS

The number of smokers who quit smoking was 35.6% in the high priority group versus 19.5% in the lower priority group. There was also a difference in the number of patients who decreased their smoking (67% vs. 38%). The fear that confronting a patient who smoked would cause the patient to leave the practice was not realized. Other factors that predicted successful cessation were fewer packs per day, fewer years smoking, and older age. The effect of the practitioner was independent of these other variables as determined by a logistic regression analysis.

CONCLUSION

Patients will respond better if the practitioner assigns a priority and works with the patient to educate them about ways to address this particular substance abuse. Just asking about the patient's smoking status had a dramatic effect on smoking status. All spine practitioners should do all in their power to help their patients overcome their nicotine addiction.

Contemporary smoking cessation

BACKGROUND

Tobacco smoking is the single most preventable cause of death in the United States today. Oncologists are in a unique position to affect the health and economic burdens of smoking by encouraging cessation among their patients who smoke.

METHODS

The authors describe and review the effectiveness of current smoking cessation interventions as well as strategies that can be used to encourage cessation among patients. Three types of smoking cessation interventions are described: minimal (or self-help) interventions, behavioral interventions, and pharmacotherapy. The effectiveness of combinations of these types of treatments is also discussed.

RESULTS

Oncology professionals can improve their patients' chances for success by implementing various cost-effective and easily executed smoking cessation interventions. Advice from a physician to quit smoking has resulted in long-term quit rates of up to 10.2%, and nicotine transdermal patches, nicotine gum, inhalers, and nasal sprays are also effective.

CONCLUSIONS

Oncologists are encouraged to adopt the "4As" treatment protocol recommended by the National Cancer Institute: ask patients about their smoking status, advise them to quit, assist by recommending pharmacotherapy, counseling, and psychosocial self-help materials, and arrange follow-up.

Motivating smoking cessation among dental patients: smokers' interest in biomarker testing for susceptibility to tobacco-related cancers

This study examined interest in receiving biomarker testing for tobacco-related cancer susceptibility among 148 smokers seeking routine oral health care in a public dental clinic. Patients completed a brief, self-report survey assessing their smoking history, tobacco-related illness history, readiness to quit smoking, perceived risk and worry about cancer, and their interest in being tested for genetic susceptibility for tobacco-related cancers. Participants were socioeconomically and ethnically diverse, and were primarily long-standing, nicotine-dependent smokers. Most reported (83%) interest in biomarker feedback, and most (86%) understood that a certain genetic make-up could place them at increased risk for tobacco-related cancers. Those participants who felt that quitting smoking would reduce future cancer risk, were at least in the contemplation stage of quitting readiness, felt more worried and more at risk for developing cancer, women and younger smokers were more interested in genetic testing (all ps < 0.20). Multivariate logistic regression analyses indicated that gender and risk perceptions were associated with interest in testing. The public dental clinic setting holds potential for innovative smoking cessation interventions using personalized risk feedback.

The importance of self-efficacy in cardiovascular risk factor change

SUBJECTS AND DESIGN

The study was based on the total patient sample (n = 110) of a randomized controlled trial comparing two intervention methods advising cardiovascular high-risk men of lifestyle changes in general practice. Behaviour and risk factor changes during the one-year intervention study were analysed using multiple regression and logistic regression analyses with the above-mentioned independent variables.

SETTING

Twenty-two general practice centres in the county of Hordaland, western Norway.

RESULTS

Self-efficacy of increased physical exercise was the only variable significantly related to exercise change. Age and self-efficacy were statistical significant predictors of smoking cessation success. None of the independent variables was statistically significantly related to blood pressure or cholesterol change. Educational level related negatively, although statistically insignificantly, with total risk change.

CONCLUSION

The study confirms the importance of self-efficacy in both human behaviour and motivation for behaviour change.

OBJECTIVES

The objectives of the study were to explore the impact of possible predictors for cardiovascular risk behaviour change, predictors such as education, age, self-efficacy, doctors' interpersonal skills, and number of appointments.

Health care access and seven-year change in cigarette smoking. The CARDIA Study

OBJECTIVES

To determine associations among health care access, cigarette smoking, and change in cigarette smoking status over 7 years.

METHODS

A cohort of 4,086 healthy young adults was followed from 1985-1986 through 1992-1993. Participants were recruited from four urban sites balanced on gender, race (African Americans and whites), education (high school or less, and more than high school), and age (18-23 and 24-30). Outcome measures were smoking status at Year 7, as well as 7-year rates of smoking cessation and initiation.

RESULTS

For each of three access barriers reported at Year 7 (lack of health insurance, lack of regular source of medical care, and expense), participants experiencing the barrier had a higher prevalence of smoking, quit smoking less frequently, and started smoking more frequently; e.g., only 15% of participants with health insurance lapses quit smoking over the 7-year period, compared with 26% of those with insurance (P < 0.001). Results were similar for each race/gender stratum, and persisted after adjustment for usual markers of socioeconomic status: education, income, employment, and marital status.

CONCLUSIONS

Health care access was associated with lower prevalence of smoking and beneficial 7-year changes in smoking, independent of socioeconomic status. The possibility that this is a causal relationship has implications in the prevention of cardiovascular disease, cancer and multiple other smoking-related diseases, and deserves further exploration.

U.S. women physicians' residential radon testing practices

INTRODUCTION

These analyses were designed to elucidate U.S. physicians' perception of residential radon risk, as measured by the prevalence of residential radon testing using a representative sample of U.S. women physicians from the Women Physicians' Health Study database. In addition, characteristics of women physicians who were more likely to have conducted a residential radon test were identified.

METHODS

A random sample (n = 4,501 respondents) of U.S. women physicians aged 30 to 70 was obtained in the Women Physicians' Health Study. Analyses were conducted using SUDAAN.

RESULTS

The overall prevalence of residential radon testing among respondents was 18%, 2- to 6-fold higher than any estimate of residential radon testing in the general population. The strongest relationship with radon testing observed through logistic regression was with marital status; age, ethnicity, and region of residence were also related.

CONCLUSION

The study demonstrates that although U.S. women physicians are more likely to have conducted a personal residential radon test than the general population, 82% report not having done so. Increasing the awareness of physicians about the health risks associated with prolonged radon exposure will be essential if they are to play a role in addressing this important public health problem.

Smoking cessation: principles and practice based upon the AHCPR Guideline, 1996. Agency for Health Care Policy and Research

Cigarette smoking remains the leading preventable cause of morbidity and premature mortality in the United States. Although the vast majority of smokers come in contact with the health care system on a regular basis, clinical smoking cessation interventions happen infrequently and in a non-systematic manner. In 1996, the Agency for Health Care Policy and Research (AHCPR) "Smoking Cessation Clinical Practice Guideline" provided detailed clinical practice recommendations based on a review of some 3,000 articles in the research literature and dozens of supporting meta-analyses. This article presents a simple four-step model for clinical smoking cessation interventions, including systematic identification of smoking status, brief cessation advice from clinicians, assessment of patient motivation, and detailed assistance for those willing to stop smoking. It also provides the empirical basis for the AHCPR Guideline recommendations.

Compliance with cardiovascular disease prevention strategies: a review of the research

The efficacy of cardiovascular risk-reduction programs has been established. However, the extent to which risk-reduction interventions are effective may depend on adherence. Non-compliance, or non-adherence, may occur with any of the recommended or prescribed regimens and may vary across the treatment course. Compliance problems, whether occurring early or late in the treatment course, are clinically significant, as adherence is one mediator of the clinical outcome. This article, which is based on a review of the empirical literature of the past 20 years, addresses compliance across four regimens of cardiovascular risk reduction: pharmacological therapy, exercise, nutrition, and smoking cessation. The criteria for inclusion of a study in this review were: (a) focus on cardiovascular disease risk reduction; (b) report of a quantitative measure of compliance behavior; and (c) use of a randomized controlled design. Forty-six studies meeting these criteria were identified. A variety of self-report, objective, and electronic measurement methods were used across these studies. The interventions employed diverse combinations of cognitive, educational, and behavioral strategies to improve compliance in an array of settings. The strategies demonstrated to be successful in improving compliance included behavioral skill training, self-monitoring, telephone/mail contact, self-efficacy enhancement, and external cognitive aids. A series of tables summarize the intervention strategies, compliance measures, and findings, as well as the interventions demonstrated to be successful. This review reflects the progress made over two decades in compliance measurement and research and, further, advances made in the application of behavioral strategies to the promotion of cardiovascular risk reduction.

Predictors of smoking cessation following physicians' counseling

BACKGROUND

The purpose of this study was, to identify predictors of quitting following general practitioners' (GP) anti-smoking counseling.

METHODS

We studied determinants (characterized following the Precede framework) of successful quitting (1 year sustained abstinence, biochemically confirmed at 6- and 12-month follow-up) among 861 smokers randomized to the intervention groups based on repeated counseling (RC), RC + spirometric testing, and RC + nicotine gum, in a smoking cessation trial carried out in Turin, Italy.

RESULTS

GPs' intervention worked best for male (OR = 2.30; 95% CI, 1.13-4.52) and married (OR = 3.63; 95% CI, 1.37-9.59) smokers, for smokers who had maintained abstinence for at least 1 month in the past (OR = 6.78; 95% CI, 1.56-29.52) or at their first quit attempt (OR = 10.91; 95% CI, 2.37-50.13), and for those who spontaneously reduced their coffee consumption (OR = 3.30; 95% CI, 1.59-6.82); heavy smokers (> = 20 cig/day OR = 0.48; 95% CI, 0.24-0.93) and those living with other smokers (> = 1 smokers in the household: OR = 0.44; 95% CI, 0.22-0.90) were less likely to give up. Previous antismoking advice by the GP represented a strong barrier to success for healthy smokers (OR = 0.19; 95% CI, 0.07-0.52), but not for those reporting symptoms of shortness of breath (OR = 0.63; 95% CI, 0.39-9.20). There were no interactions between predictors and treatment conditions.

CONCLUSIONS

Assessment of factors influencing quitting would allow GPs to tailor their message to address existing barriers and to help patients utilize their resources for change.

Physicians and smoking cessation. Development of survey measures

Data from a mailed survey to primary care physicians (N = 122) were used to construct and evaluate psychosocial scales related to performance of smoking cessation counseling. Scales measuring counseling barriers, self-efficacy, and motivation demonstrated considerable promise with excellent or reasonable internal consistency. The correlation for each scale with performance of cessation counseling and with stage of change was statistically significant. Physicians who report they are currently assisting patients had higher performance and self-efficacy rating. Physicians who had participated in formal smoking cessation training had higher self-efficacy; however, their scores on the Barriers, Motivation, and Performance Scales did not differ. Further study with a representative group is encouraged.

Smoking Survey of Dental Clinic Patients in the Saudi Military Hospital

A survey of 200 dental clinic patients in Saudi Arabia's only military hospital. An appropriate health education smoking prevention program is described based on knowledge, attitude, and behavior derived from the survey and existing anti-smoking educational programs in the United States.

Patterns of smoking among inner-city teenagers: smoking has a pediatric age of onset

OBJECTIVES

(1) To test the hypothesis that the prevalence of smoking among African-American teenagers is lower than among whites and Hispanic inner-city senior high school students; (2) to assess the patterns of smoking among inner-city teenagers; and (3) to ascertain the relationship between smoking status and their knowledge, attitudes, beliefs, and behaviors.

METHODS

All students attending inner-city senior high schools in two cities in New Jersey were included in the survey (n = 8,900). Response Rate was 85%; 89% of respondents were minority teenagers.

RESULTS

The overall point prevalence rate of cigarette smoking was 9%. Almost all smoking began before the age of 16 years. The factors that significantly (p < .001) contributed to the initiation of cigarette smoking were: peer influence, self-initiation, and the influence of relatives' cigarette smoking. The factors that were stated to play a major role in progression to regular smoking were: perceptions that smoking relieves stress and feelings of induced pleasure while smoking. In addition, smokers were significantly (p < .0005) less knowledgeable about smoke-related diseases than exsmokers or nonsmokers. Over two-thirds of smokers and exsmokers believed that it is the physician's responsibility to advise patients to quit smoking and the majority of the current smokers contemplated quitting smoking. The data support the hypothesis that smoking prevalence among African-American teenagers is significantly lower than among white and Hispanic teenagers who attended the senior high school and resided in the inner city.

CONCLUSION

These data suggest that multidimensional antismoking strategies are needed to address the smoking among predominately minority teenagers. This includes supportive messages from physicians, relatives, friends along with public policy to act as motivating factors to discourage early smoking.

Prevention of lung cancer: the key is to stop smoking

OBJECTIVES

To review current approaches to primary prevention of lung cancer and to screening for precarcinogenic or preclinical asymptomatic disease.

DATA SOURCES

Research studies, review articles, and government reports relating to prevention of lung cancer and strategies for smoking cessation.

CONCLUSIONS

Because almost 90% of lung cancer cases can be attributed to tobacco, reduction of smoking is the appropriate focus of lung cancer prevention efforts. Lung cancer chemoprevention remains an experimental approach and large scale screening for lung cancer is of limited value.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are in a strategic position to prevent smoking initiation and to influence successful smoking cessation through education, information on the multiple modalities to assist behavioral change, and ongoing reinforcement.

Arterial hypertension: lessons from patient education

The face of hypertension has been changing rapidly over the last few decades, from a serious disease to a cardiovascular risk factor. Patient education has been instrumental in bringing about tremendous improvements in hypertension-related mortality, morbidity, life expectancy, and life quality. Patient education has evolved from an adjunct to medical therapy to an intervention in its own right. In this process patient education tasks and techniques themselves have undergone remarkable developments, driven by evolving patient needs due to medical progress. The same is true for the roles of patients and health care providers. Dealing with hypertension is a behavior change process which demands serious learning efforts from all parties involved, patients, health practitioners and health care administrators alike. This paper focuses therefore on patient education for preventive behavior change and risk factor management. Special emphasis will be placed on processes and tools for effective patient education.

Behavioral anti-smoking trial in chronic obstructive pulmonary disease patients

Smoking causes chronic obstructive pulmonary disease (COPD), but few controlled studies have tested anti-smoking treatments in COPD. With procedures likely to attract unmotivated persons we recruited 49 quite-ill, smoking COPD patients. During one or two daily home visits for 85 days, breath carbon monoxide (CO) and self-reports of daily smoking were obtained. Patients, given quit dates and nicotine gum (2-mg pieces, up to 30 per day), were assigned randomly to three groups: Experimentals were reinforced with lottery tickets for CO < 10 ppm. Cigarette Self Report (CSR) patients were reinforced for reporting no smoking that day. Controls received non-contingent payments. Each group's mean CO level fell at the quit date. Thereafter, reinforced patients maintained significantly lower CO levels than Controls. Although many more 24-h abstentions occurred in the intervention period than in baseline, few patients sustained abstinence; the groups did not differ in that regard. Outcome was predicted by decisions to throw away cigarettes when intervention began, but not by motivation scales nor Fagerstrom dependence scores. Pay schedules apparently exaggerated self-reports of reduced smoking. Although results are statistically significant, there is still no proven, practical treatment for smoking in advanced COPD.

Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke

OBJECTIVE

To assess the effect of expanding the vital signs to include smoking status.

DESIGN

We prospectively conducted exit interviews with patients at a general internal medicine clinic in Madison, Wisconsin, during a 16-month period from 1991 to 1993.

METHODS

Patients were surveyed briefly before (N = 870) and after (N = 994) the implementation of a simple institutional change in clinical practice. This change involved training the staff in how to use progress notepaper with a vital sign stamp that included smoking status (current, former, or never) along with the traditional vital signs. Included in the survey were questions about whether the patient smoked, whether the patient was asked that day about smoking status (by a clinician or other staff), and, for smokers, whether they were urged to quit smoking and given specific advice on how to do so.

RESULTS

After expansion of the vital signs, patients were much more likely to report inquiries about their smoking status on the day of a clinic visit (an increase from approximately 58% at baseline to 81% at intervention; P < 0.0001). The vital sign intervention was associated with significant increases in the percentage of smokers who reported that their clinician advised them that day to quit smoking (from approximately 49% at baseline to 70% during the intervention; P < 0.01) and in the percentage who reported that their clinician gave them specific advice that day on how to stop smoking (from approximately 24% at baseline to 43% during the intervention; P < 0.01).

CONCLUSION

Expanding the vital signs to include smoking status was associated with a dramatic increase in the rate of identifying patients who smoke and of intervening to encourage and assist with smoking cessation. This simple, low-cost intervention may effectively prompt clinicians to inquire about use of tobacco and offer recommendations to smokers.

Reducing tobacco smoke in the environment of the child with asthma: a cotinine-assisted, minimal-contact intervention

Children with asthma who are exposed to environmental tobacco smoke are at increased risk for adverse health consequences. An experimental design was used to evaluate a minimal-contact intervention aimed at modifying parents' smoking behavior in their homes. All subjects received counseling on the health effects of passive smoking and advice to quit smoking inside the home. Treatment subjects were also mailed the results of a urine cotinine test on their child and a self-help manual. More treatment (35%) than control (17%) subjects reported smoking outside their homes at posttest (and their children's cotinine levels were lower), but this difference was not statistically significant.

Predictors of successful smoking cessation following advice from nurses in general practice

At follow-up of 751 subjects receiving a brief nurse-administered anti-smoking intervention in general practice, 135 subjects (18%) reported stopping smoking, of whom 44 (6%) reported sustained cessation for one year. The demographic, social and attitudinal characteristics of these subjects were compared with 616 subjects who continued to smoke. The most important predictors of cessation were intention to stop (OR 5.1, 95% CI 2.1-12.0), personal rating of likelihood of cessation (OR 4.9, 95% CI 2.8-8.5), nurse rating of likelihood of cessation (OR 4.0, 95% CI 2.2-7.4), and smoking habit of partner (1.9, 95% CI 1.3-2.9). As practice nurses are able to distinguish likely quitters from those who are not motivated and less likely to succeed, it is important to decide whether it is more cost effective to target support at the motivated or to spend more time encouraging less motivated. The most challenging, but possibly the most rewarding, task is to try to reduce the high proportion of new ex-smokers who relapse. Although 41.1% (95% CI 28.1, 58.0) of those expressing a definite intention to stop smoking gave up, only 17.9% (95% CI 8.9, 30.4) achieved sustained cessation. However, as sustained cessation is strongly predicted by social variables, such as marital status and time spent in the company of smokers, preventing relapse may not be easy to achieve through medical intervention alone.

Quitting smoking: reasons for quitting and predictors of cessation among medical patients

OBJECTIVE

To describe why medical patients quit smoking and the methods they use.

DESIGN

Cross-sectional and prospective cohort design. Patient smokers were enrolled in a study of physician counseling about smoking. One year later, 2,581 of the patients were asked about quit attempts and methods used. Of those, 245 former smokers whose quitting had been biologically validated were interviewed about why and how they had quit.

SETTING

Offices of internists and family practitioners in private practice and a health maintenance organization.

SUBJECTS

Consecutive sample of ambulatory patients who smoked.

MEASUREMENTS AND MAIN RESULTS

Baseline questionnaires included demographic data, smoking history, and symptoms and diagnoses related to smoking. After one year, subjects were interviewed about smoking status and methods used in attempting to quit. Cessation was confirmed by biochemical testing. Those who had quit were asked about reasons for quitting. Seventy-seven percent of successful quitters gave health-related reasons for quitting and the quitters ranked "harmful to health" as the most important reason for quitting. In a multivariate analysis, those who had a college education, who had social pressures to quit, and who had greater confidence in being able to quit were more likely to have quit smoking one year later, while those who smoked their first cigarette within 15 minutes of awakening and who had more diagnoses related to smoking were less likely to have quit smoking one year later. Participation in a treatment program and having been counseled by a physician or nurse practitioner were positively related to successful quitting, while use of filters or mouthpieces was negatively related.

CONCLUSIONS

Concerns about health are the most common reason patients give for quitting, and addiction is the most important barrier to quitting. Education, social pressure, provider advice, and formal programs, but not over-the-counter devices, appear to increase the chances that smokers will quit.

Methods of smoking cessation

Smoking-cessation treatment consists of three phases: preparation, intervention, and maintenance. Preparation aims to increase the smoker's motivation to quit and to build confidence that he or she can be successful. Intervention can take any number of forms (or a combination of them) to help smokers to achieve abstinence. Maintenance, including support, coping strategies, and substitute behaviors, is necessary for permanent abstinence. Although most smokers who successfully quit do so on their own, many use cessation programs at some point during their smoking history. Moreover, many people act on the advice of a health professional in deciding to quit. Some are also aided by a smoking-cessation kit from a public or voluntary agency, a book, a tape, or an over-the-counter product. Still others receive help from mass-media campaigns, such as the Great American Smokeout, or community programs. Counseling, voluntary and commercial clinics, nicotine replacement strategies, hypnosis, acupuncture, and behavioral programs are other methods used by smokers to break the habit. Programs that include multiple treatments are more successful than single interventions. The most cost-effective strategy for smoking cessation for most smokers is self-care, which includes quitting on one's own and might also include acting on the advice of a health profession or using an aid such as a quit-smoking guide. Heavier, more addicted smokers are more likely to seek out formal programs after several attempts to quit. Many people can quit smoking, but staying off cigarettes requires maintenance, support, and additional techniques, such as relapse prevention. Physicians, dentists, and other health professionals can provide important assistance to their patients who smoke. Quit rates can be improved if clinicians provide more help (e.g., counseling, support) than just simple advice and warnings. Clinicians also play an important role in providing nicotine replacement products such as nicotine gum or transdermal patches. These products are particularly useful for smokers who show evidence of strong physiologic addiction to nicotine. Attitudes toward smoking have shifted dramatically. In the 1950s, fewer than 50% of American adults believed that cigarette smoking caused lung cancer. In 1986, this proportion had increased to 92%. A majority of the public favors policies restricting smoking in public places and worksites. Half of all Americans who ever smoked had stopped smoking by 1988. Of those who continue to smoke, more than 70% report that they would like to quit. By increasing their knowledge about smoking-cessation methods, health professionals can support and encourage the large majority of smokers who want to quit.

Evaluation of a self-help dietary intervention in a primary care setting

BACKGROUND

Dietary intervention to reduce fat consumption and increase fiber consumption has been recommended by the National Cancer Institute, but there is little evidence concerning the effectiveness of self-help materials. The purpose of this study was to evaluate such self-help materials, introduced by a nurse in a primary care setting.

METHODS

A randomized controlled trial involving 242 subjects was conducted in two primary care clinics in Chapel Hill, NC, in 1987. Changes in fat and fiber consumption in the intervention and control groups during the 3-month interval between interviews were compared using analysis of covariance.

RESULTS

The estimated reduction in fat was 3.8g larger for the intervention group than for the control group, but the confidence interval included zero. For those individuals who had some responsibility for meal preparation there was a larger difference (-6.9g) in favor of the intervention group, although the difference using calorie-adjusted values was -3.8g with a 95% confidence interval (-7.1, -0.4). The differences for fiber change were smaller.

CONCLUSIONS

We found significant small but consistent differential changes associated with a minimal self-help intervention, but we cannot rule out the possibility of some response bias. Nonetheless, this study demonstrates that the use of self-help materials for dietary change is feasible, and may be effective.