Systematic Review of Clinician-Reported Barriers to Provision of Smoking Cessation Interventions in Hospital Inpatient Settings

Smoking data quality of primary care practices in comparison with smoking data from the New Zealand Māori and Pacific abdominal aortic aneurysm screening programme: an observational study

BACKGROUND

Quality smoking data is crucial for assessing smoking-related health risk and eligibility for interventions related to that risk. Smoking information collected in primary care practices (PCPs) is a major data source; however, little is known about the PCP smoking data quality. This project compared PCP smoking data to that collected in the Māori and Pacific Abdominal Aortic Aneurysm (AAA) screening programme.

METHODS

A two stage review was conducted. In Stage 1, data quality was assessed by comparing the PCP smoking data recorded close to AAA screening episodes with the data collected from participants at the AAA screening session. Inter-rater reliability was analysed using Cohen's kappa scores. In Stage 2, an audit of longitudinal smoking status was conducted, of a subset of participants potentially misclassified in Stage 1. Data were compared in three groups: current smoker (smoke at least monthly), ex-smoker (stopped > 1 month ago) and never smoker (smoked < 100 cigarettes in lifetime).

RESULTS

Of the 1841 people who underwent AAA screening, 1716 (93%) had PCP smoking information. Stage 1 PCP smoking data showed 82% concordance with the AAA data (adjusted kappa 0.76). Fewer current or ex-smokers were recorded in PCP data. In the Stage 2 analysis of discordant and missing data (N = 313), 212 were enrolled in the 29 participating PCPs, and of these 13% were deceased and 41% had changed PCP. Of the 93 participants still enrolled in the participating PCPs, smoking status had been updated for 43%. Data on quantity, duration, or quit date of smoking were largely missing in PCP records. The AAA data of ex-smokers who were classified as never smokers in the Stage 2 PCP data (N = 27) showed a median smoking cessation duration of 32 years (range 0-50 years), with 85% (N = 23) having quit more than 15 years ago.

CONCLUSIONS

PCP smoking data quality compared with the AAA data is consistent with international findings. PCP data captured fewer current and ex-smokers, suggesting ongoing improvement is important. Intervention programmes based on smoking status should consider complementary mechanisms to ensure eligible individuals are not missed from programme invitation.

Knowledge, attitudes and practices of Irish doctors regarding stop smoking care and electronic cigarettes

BACKGROUND

Smoking continues to cause harm on a huge scale in Ireland. Doctors can help this harm through providing safe, effective and clinically sound stop smoking care, but the needs of Irish doctors in this area are largely uncharted.

AIMS

We assessed the knowledge, attitudes and practices of Irish doctors regarding stop smoking care and electronic cigarettes.

METHODS

An Internet-based cross-sectional survey was administered to members of the Royal College of Physicians in Ireland and the Irish College of General Practitioners. Descriptive statistics for key parameters were derived and factors associated with more consistent practice of brief intervention, a key component of stop smoking care, were analysed using chi-square testing.

RESULTS

There were 250 responses (58.7% female, 53.0% aged under 45 years, 55.1% graduated in medicine before 2000 and 57.2% worked in general practice). Most (84.9%) reported often or always asking about patient's smoking behaviour, and most (86.1%) reported often or always advising patients to stop. However, providing or arranging effective stop smoking care was weak and less consistently practised, and while most (91.4%) saw it as a responsibility, few doctors (28.5%) agreed they were sufficiently trained in this area of clinical care. Confidence in the knowledge of e-cigarettes was poor.

CONCLUSIONS

While there is a strong reservoir support and areas of good reported practice in stop smoking care among doctors in Ireland, the development of their knowledge and skills in arranging effective care should be supported if doctors are to fulfil their huge potential role in tackling the harm caused by smoking.

Barriers to implementation of smoking cessation support among healthcare professionals in the secondary healthcare sector: A qualitative and quantitative evaluation

INTRODUCTION

Smoking cessation support (SCS) in the hospital is essential; patients often struggle to maintain quit attempts, which necessitates assistance from healthcare professionals (HCPs). However, unknown barriers can obstruct the implementation of SCS in hospitals. This study aims to uncover barriers to the implementation of SCS in psychiatric, somatic, inpatient, and outpatient hospital settings.

METHODS

In the period from June to September 2021, HCPs in a large secondary care hospital in the Region of Southern Denmark completed an online, cross-sectional study, providing sociodemographic details and listing potential barriers to SCS. They also shared additional barriers in the form of free-text responses. Descriptive statistics and thematic analysis of free-text responses were performed.

RESULTS

Of 1645 HCPs surveyed, 409 elaborated their response in the free-text field assessing unlisted barriers. Top listed barriers, reported by more than one-third of participants, included: 'lack of time' (45.1%), 'lack of patient motivation' (34.3%), and 'insufficient knowledge on how to support' (32.2%). Free-text responses revealed three barrier-related, which we grouped under the themes of: 'Concerned about the patient', 'Not part of my job', and 'Inappropriate setting'.

CONCLUSIONS

This quantitative and qualitative study identifies barriers to SCS on multiple levels in the hospital setting, i.e. on the patient, provider, and organizational levels. These results can inform healthcare organizations and professionals in the implementation of SCS in routine hospital care.

Introduction to Tobacco Cessation and Motivational Interviewing: Evaluation of a Lecture and Case-Based Learning Activity for Medical Students

Introduction Despite the fact that tobacco use continues to have significant public health impacts, most healthcare providers are not adequately trained to counsel patients on their tobacco use or to provide cessation resources. Although all healthcare providers have a role in providing tobacco cessation assistance, physicians and advanced practice providers are generally the only practitioners able to furnish tobacco cessation medications and bill insurance for their cessation services. Therefore, ensuring these practitioners are properly trained to offer tobacco cessation to their patients is critical to addressing this public health threat. In line with this goal, this study outlines the curriculum evaluation for an innovative student-facilitated tobacco cessation activity for medical students. Methods A lecture and case-based learning activity was created and piloted with a class of first-year medical students. The activity was facilitated by fourth-year medical students. Students took a pre-session survey to establish baseline experience and beliefs and a post-session survey to ascertain their confidence in applying what was covered in the session. Descriptive statistics were utilized to analyze the data. Results One hundred and twenty-eight students completed both surveys. Prior to the activity, students reported low levels of confidence in their ability to counsel patients and knowledge of cessation resources. Following the activity, more than 90% reported improvement in their ability to assess a patient's willingness to quit and counsel those ready to quit. Greater than 80% reported an improvement in their ability to counsel patients not ready to quit and to establish a quit plan. More than 90% of students reported that the session increased their self-efficacy in helping patients quit and that it was worth their time, with 96% committing to increasing their tobacco cessation efforts with their patients. Discussion Students valued the training and almost all reported that it increased their ability to help patients quit smoking. The use of student-facilitated case-based learning provided both an opportunity for students to practice cessation techniques and a low-stakes introduction to the OSCE format without the need for extensive faculty resources. Although this session was run with first-year medical students, the curriculum presented can be used for residents, nurses, and other healthcare professionals.

The learning outcomes of smoking cessation training in undergraduate nursing students: A systematic review

AIM

To systematically evaluate the effect of smoking cessation training on nursing students' learning outcomes.

DESIGN

This systematic review followed the PRISMA guidelines and was registered with PROSPERO (CRD42022373280).

METHODS

Ten electronic English and Chinese databases were searched to identify articles on nursing students' smoking cessation training from inception to October 2022. Medical Education Research Study Quality Instrument was used to assess the methodological quality of eligible studies.

RESULTS

Twelve moderate methodological quality studies (three randomized controlled trials and nine quasi-experimental studies) with 2114 undergraduate nursing students were included. Teaching strategies included didactic lectures, collaborative learning, blended learning and the service-learning approach. Eight studies showed that the training significantly increased nursing students' knowledge of smoking cessation (p < 0.05) and three of them showed a large effect size (Cohen's d: 0.83-1.31). Seven studies showed that training enhanced students' attitudes/motivation towards smoking cessation interventions significantly (p < 0.05) and two of them showed a large effect size (Cohen's d: 1.11-1.84). Nine studies reported that students' self-efficacy improved significantly after training (p < 0.05) and six of them showed a large effect size (Cohen's d: 0.98-2.18). Two one-group pre-post studies showed training significantly improved students' practice of 5 A's behavior (p < 0.05), with a small effect size (Cohen's d < 0.50).

CONCLUSIONS

This review showed that smoking cessation training had a positive and large effect on undergraduate nursing students' knowledge, attitudes/motivation and self-efficacy towards smoking cessation intervention, but the effect of changing the practice of 5 A's was modest. We noted that very few RCTs were done and most studies only used subjective measures. More robust experimental studies with long-term follow-up are warranted in evaluating nursing students' practice/behavior of smoking cessation intervention and patients' quitting outcomes. Blended and collaborative learning are recommended in smoking cessation education.

Smoking cessation interventions and implementations across multiple settings in Japan: a scoping review and supplemental survey

BACKGROUND

Smoking is the leading risk factor for death worldwide. In Japan, although several evidence-based interventions (EBIs) for smoking cessation have been disseminated or adopted, there is a gap between scientific evidence and the actual implementation. This scoping review aimed to describe the knowledge gaps in local-level smoking cessation interventions in Japan, their implementation outcomes, implementation barriers and facilitators, and the use of implementation strategies.

METHODS

This study comprised two approaches: (1) a comprehensive scoping review of primary and grey literature, and (2) a supplemental survey of organizations in the grey literature. For the scoping review, we included original studies or reports on smoking cessation interventions targeting adults aged 18 years and older, or providers of cessation support at various settings (community, workplace, school, and clinical settings) in Japan. The extracted data included basic characteristics, intervention categories, implementation outcomes, factors influencing implementation, and implementation strategies for each intervention. Responses to the supplemental survey were extracted same used for the scoping review. To gain a deeper understanding, semi-structured interviews were conducted with some of the organizations in the survey.

RESULTS

A total of 600 interventions with 691 intervention components, based on EBIs in the 2020 US Surgeon General Report, from 498 articles were included in the data extraction; 32 of the 88 organizations responded to the survey. Regarding the overall knowledge about smoking cessation intervention components, behavioral counseling, and cessation medication in clinical settings were mostly reported (34.7%). Implementation outcomes were measured in 18 articles (3.0%) and penetration was mostly reported. Regarding influential factors, "available resources," and "knowledge and beliefs about the intervention" for barriers, and "relative priority" for facilitators were mostly reported. Implementation strategies were measured in 29 articles (4.8%), and "Train and educate stakeholders" was mostly reported.

CONCLUSIONS

Most EBIs reported in the Japanese literature included smoking cessation treatments in clinical settings. While a few articles focused on the implementation indicators in Japan, significant knowledge and experience were extracted from the grey literature, especially in the workplace and community settings. Future research should focus more on implementation to reduce the knowledge gap regarding smoking cessation interventions.

Effectiveness of Medical Student Counseling for Hospitalized Patients Addicted to Tobacco (MS-CHAT): a Randomized Controlled Trial

BACKGROUND

Low-middle-income countries face an enormous burden of tobacco-related illnesses. Counseling for tobacco cessation increases the chance of achieving quit outcomes, yet it remains underutilized in healthcare settings.

OBJECTIVE

We tested the hypothesis that utilizing trained medical students to counsel hospitalized patients who use tobacco will lead to an increase in patient quit rates, while also improving medical student knowledge regarding smoking cessation counseling.

DESIGN

Investigator-initiated, two-armed, multicenter randomized controlled trial conducted in three medical schools in India.

PARTICIPANTS

Eligibility criteria included age 18-70 years, active admission to the hospital, and current smoking.

INTERVENTION

A medical student-guided smoking cessation program, initiated in hospitalized patients and continued for 2 months after discharge.

MAIN MEASURES

The primary outcome was self-reported 7-day point prevalence of smoking cessation at 6 months. Changes in medical student knowledge were assessed using a pre- and post-questionnaire delivered prior to and 12 months after training.

KEY RESULTS

Among 688 patients randomized across three medical schools, 343 were assigned to the intervention group and 345 to the control group. After 6 months of follow up, the primary outcome occurred in 188 patients (54.8%) in the intervention group, and 145 patients (42.0%) in the control group (absolute difference, 12.8%; relative risk, 1.67; 95% confidence interval, 1.24-2.26; p < 0.001). Among 70 medical students for whom data was available, knowledge increased from a mean score of 14.8 (± 0.8) (out of a maximum score of 25) at baseline to a score of 18.1 (± 0.8) at 12 months, an absolute mean difference of 3.3 (95% CI, 2.3-4.3; p < 0.001).

CONCLUSIONS

Medical students can be trained to effectively provide smoking cessation counseling to hospitalized patients. Incorporating this program into the medical curriculum can provide experiential training to medical students while improving patient quit rates.

TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov . Unique identifier: NCT03521466.

Effectiveness of eHealth Smoking Cessation Interventions: Systematic Review and Meta-Analysis

BACKGROUND

Rapid advancements in eHealth and mobile health (mHealth) technologies have driven researchers to design and evaluate numerous technology-based interventions to promote smoking cessation. The evolving nature of cessation interventions emphasizes a strong need for knowledge synthesis.

OBJECTIVE

This systematic review and meta-analysis aimed to summarize recent evidence from randomized controlled trials regarding the effectiveness of eHealth-based smoking cessation interventions in promoting abstinence and assess nonabstinence outcome indicators, such as cigarette consumption and user satisfaction, via narrative synthesis.

METHODS

We searched for studies published in English between 2017 and June 30, 2022, in 4 databases: PubMed (including MEDLINE), PsycINFO, Embase, and Cochrane Library. Two independent reviewers performed study screening, data extraction, and quality assessment based on the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. We pooled comparable studies based on the population, follow-up time, intervention, and control characteristics. Two researchers performed an independent meta-analysis on smoking abstinence using the Sidik-Jonkman random-effects model and log risk ratio (RR) as the effect measurement. For studies not included in the meta-analysis, the outcomes were narratively synthesized.

RESULTS

A total of 464 studies were identified through an initial database search after removing duplicates. Following screening and full-text assessments, we deemed 39 studies (n=37,341 participants) eligible for this review. Of these, 28 studies were shortlisted for meta-analysis. According to the meta-analysis, SMS or app text messaging can significantly increase both short-term (3 months) abstinence (log RR=0.50, 95% CI 0.25-0.75; I2=0.72%) and long-term (6 months) abstinence (log RR=0.77, 95% CI 0.49-1.04; I2=8.65%), relative to minimal cessation support. The frequency of texting did not significantly influence treatment outcomes. mHealth apps may significantly increase abstinence in the short term (log RR=0.76, 95% CI 0.09-1.42; I2=88.02%) but not in the long term (log RR=0.15, 95% CI -0.18 to 0.48; I2=80.06%), in contrast to less intensive cessation support. In addition, personalized or interactive interventions showed a moderate increase in cessation for both the short term (log RR=0.62, 95% CI 0.30-0.94; I2=66.50%) and long term (log RR=0.28, 95% CI 0.04-0.53; I2=73.42%). In contrast, studies without any personalized or interactive features had no significant impact. Finally, the treatment effect was similar between trials that used biochemically verified or self-reported abstinence. Among studies reporting outcomes besides abstinence (n=20), a total of 11 studies reported significantly improved nonabstinence outcomes in cigarette consumption (3/14, 21%) or user satisfaction (8/19, 42%).

CONCLUSIONS

Our review of 39 randomized controlled trials found that recent eHealth interventions might promote smoking cessation, with mHealth being the dominant approach. Despite their success, the effectiveness of such interventions may diminish with time. The design of more personalized interventions could potentially benefit future studies.

TRIAL REGISTRATION

PROSPERO CRD42022347104; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=347104.

A survey exploring the practices of smoking cessation support among hospital-based healthcare providers

BACKGROUND

Hospital visits constitute a 'window of opportunity' for initiating smoking cessation attempts, and healthcare providers (HCPs) play an important role in supporting patients to stop smoking. Yet, the current practices of supporting smoking cessation in the hospital setting are largely unexplored. The aim of this study was to explore practices of smoking cessation support among hospital-based HCPs.

METHODS

HCPs working in a large hospital in the secondary care sector completed an online, cross-sectional survey, including sociodemographic and work-related factors as well as 21 questions assessing practices of smoking cessation support based on the "five As" framework. Descriptive statistics were computed, and predictors of HCPs giving patients advice to stop smoking were explored using logistic regression analysis.

RESULTS

All employees (N = 3998) in the hospital received a survey link; 1645 (41.1%) HCPs with daily patient contact completed the survey. Smoking cessation support in the hospital setting was limited with regard to assessment of smoking; providing information and advice; planning and referral for further support; and follow-up on smoking cessation attempts. Almost half (44.8%) of participating HCPs with daily patient contact never or rarely advise their patients to stop smoking. Physicians were more likely than nurses to advice patients to stop smoking, and HCPs in outpatient clinics were more likely to give advice than inpatient clinic HCPs.

CONCLUSION

Smoking cessation support is very limited in the hospital-based healthcare setting. This is problematic, as hospital visits can be windows of opportunity to help patients change their health behaviour. An intensified focus on the implementation of hospital-based smoking cessation support is needed.

A Qualitative Investigation of Staff Feedback on an Online Learning Module on Smoking Cessation in a German Healthcare Company

Quitting smoking is a powerful way for patients to improve their own wellbeing and to significantly reduce the risk of health problems. Evidence shows that health professionals can effectively intervene in order to prevent and stop tobacco smoking in their patients. Online learning modules have proved to be effective in terms of transferring knowledge and skills. In an urban community hospital setting in Germany, a novel e-learning course for staff on the treatment of tobacco dependence was implemented in 2021. In this study, we analyzed free-text feedback of participants completing this online module in order to examine the feasibility and acceptance of this new format. We were able to reach a reasonable proportion of staff. Our qualitative analysis showed that most feedback was positive and described the module as well-designed and helpful. Some staff, however, expressed extremely negative views and did not see smoking cessation support as essential to their role in healthcare. We argue that in order to achieve a shift in attitude in healthcare staff, a change in German policy is required which includes the creation of smoke-free environments and the adherence to smoke-free policies on hospital sites. Furthermore, the provision of smoking cessation support in line with the WHO Framework Convention on Tobacco Control and a true understanding of the role of all healthcare professionals in promoting health of patients and staff will be essential.

Integrating Tobacco Dependence Treatment into Hospital Practice Using the Rochester Model

Purpose

Delivering evidence-based tobacco dependence treatments to hospital patients in real-world settings continues to be a challenge. To achieve long-term abstinence, a program should provide both bedside counseling and post-discharge contacts. These program features are necessary but difficult to implement due to lack of training, time and low administrative support. The Rochester Model is a tobacco treatment program using existing staff and medical students to reduce the barriers for treating hospitalized smokers.

Patients and Methods

Any smoking patient admitted to a participating hospital unit can participate. Staff nurses, mid-level providers and physicians deliver the counseling steps during the admission. Nurses hold two bedside counseling sessions, while providers give quitting advice and encourage pharmacotherapy. Nurses also contribute as unit champions and post-discharge call counselors. New York State quit line counselors combined with a University of Rochester call team fulfill the post-discharge calls. The latter call team is composed of staff nurses, respiratory therapists and medical students.

Results

The number of smoking patients screened was 2610 while 385 enrolled after a proof-of-concept period. The 7-day point prevalence quit rates using the as treated (patients contacted) analysis is 50% at 4 weeks, 42% at 3 months and 38% at 6 months. The 7-day point prevalence quit rates using the intent-to-treat (all patients) analysis is 23% at 4 weeks, 16% at 3 months and 14% at 6 months.

Conclusion

Preliminary data on the Rochester Model is showing an effective yet affordable tobacco treatment program using hospital staff and medical students. Nurses serve as bedside counselors, unit champions and post-discharge call counselors. Hospitals, even with limited resources, can implement tobacco treatment programs using existing staff.

Development and Design of E_MOTIV: A Theory-Based Adaptive E-Learning Program to Support Nurses' Provision of Brief Behavior Change Counseling

Brief counseling, when provided by adequately trained nurses, can motivate and support patient health behavior change. However, numerous barriers can impede nurses' capability and motivation to provide brief counseling. Theory-based interventions, as well as information and communication technologies, can support evidence-based practice by addressing these barriers. The purpose of this study was to document the development process of the E_MOTIV asynchronous, theory-based, adaptive e-learning program aimed at supporting nurses' provision of brief counseling for smoking cessation, healthy eating, and medication adherence. Development followed French's stepwise theory- and evidence-based approach: (1) identifying who needs to do what, differently, that is, provision of brief counseling in acute care settings by nurses; (2) identifying determinants of the provision of brief counseling; (3) identifying which intervention components and mode(s) of delivery could address determinants; and (4) developing and evaluating the program. The resulting E_MOTIV program, guided by the Theory of Planned Behavior, Cognitive Load Theory, and the concept of engagement, is unique in its adaptive functionality-personalizing program content and sequence to each learners' beliefs, motivation, and learning preferences. E_MOTIV is one of the first adaptive e-learning programs developed to support nurses' practice, and this study offers key insights for future work in the field.

Practice Current: Variability in Smoking Cessation Intervention Practice Patterns After Ischemic Stroke and Transient Ischemic Attack

People who continue to smoke after ischemic stroke and transient ischemic attack (TIA) are at increased risk for subsequent stroke and cardiovascular events. Although effective smoking cessation strategies exist, smoking rates after stroke remain high. Through case-based discussions with 3 international vascular neurology panelists, this article seeks to explore practice patterns and barriers to smoking cessation for patients with stroke/TIA. We sought to answer these questions: What are the barriers to using smoking cessation interventions for patients with stroke/TIA? Which interventions are most used for hospitalized patients with stroke/TIA? Which interventions are most used for patients who continue smoking during follow-up? Our synthesis of panelists' commentaries is complemented by the preliminary results of an online survey posed to global readership. Together, the interviews and survey results identify practice variability and barriers to smoking cessation after stroke/TIA, suggesting that there is substantial need for research and standardization.

The Use of Biomarkers to Guide Precision Treatment for Tobacco Use

This review summarizes the evidence to date on the development of biomarkers for personalizing the pharmacological treatment of combustible tobacco use. First, the latest evidence on FDA-approved medications is considered, demonstrating that, while these medications offer real benefits, they do not contribute to smoking cessation in approximately two-thirds of cases. Second, the case for using biomarkers to guide tobacco treatment is made based on the potential to increase medication effectiveness and uptake and reduce side effects. Next, the FDA framework of biomarker development is presented along with the state of science on biomarkers for tobacco treatment, including a review of the nicotine metabolite ratio, electroencephalographic event-related potentials, and other biomarkers utilized for risk feedback. We conclude with a discussion of the challenges and opportunities for the translation of biomarkers to guide tobacco treatment and propose priorities for future research.

Hospitalised Smokers' and Staff Perspectives of Inpatient Smoking Cessation Interventions and Impact on Smokers' Quality of Life: An Integrative Review of the Qualitative Literature

Aim

To identify, integrate, and appraise the evidence on hospitalised smokers' and staff perspectives of inpatient smoking cessation interventions and the impact on smokers' quality of life.

Design

The integrative review method was used to present hospitalised smokers' and staff perspectives of inpatient smoking cessation interventions. Search Method. This integrative review consisted of a comprehensive search on smoking cessation interventions that take place during an inpatient admission to hospital for adults (> age 18 years) of the following online databases: Ovid Medline, Joanna Briggs Institute, APA PsycInfo, CINAHL, Cochrane, Google Scholar, PEDro, and Scopus. The search strategy was inclusive of peer-reviewed studies limited to the English language or translated to English. A search of grey literature and manual searching of reference lists was also conducted to identify further studies not identified in the online database search. All studies that produced any qualitative data (i.e., qualitative, mixed methods, and surveys) on inpatient-initiated smoking cessation programs were included. Outcomes of interest are included but were not limited to education, counselling, and the use of pharmacotherapy. Studies undertaken in the psychiatric, adolescent, and paediatric settings were excluded.

Results

The key findings from this integrative review included positive evaluations from both patients and staff involved in inpatient smoking cessation interventions, reporting that hospitalisation was an appropriate opportunity to address smoking cessation. A number of facilitators and barriers to inpatient smoking cessation interventions included creating a supportive patient-centred environment and consideration of the cost of nicotine replacement therapy and time to deliver inpatient smoking cessation interventions. Recommendations/preferences for future inpatient smoking cessation interventions included the use of a program champion and ongoing education to demonstrate the effectiveness of the intervention, and despite the cost of nicotine replacement therapy being identified as a potential barrier, it was identified as a preference for most patients. Although quality of life was only evaluated in two studies, statistically significant improvements were identified in both.

Conclusion

This qualitative integrative review provides further insight into both clinician and patient participants' perspectives on inpatient smoking cessation interventions. Overall, they are seen to produce positive benefits, and staff training appears to be an effective means for service delivery. However, insufficient time and lack of resources or expertise appear to be consistent barriers to the delivery of these services, so they should be considered when planning the implementation of an inpatient smoking cessation intervention.

Smoking cessation interventions and implementations in Japan: a study protocol for a scoping review and supplemental survey

INTRODUCTION

Despite various tobacco control measures in Japan, smoking remains a leading cause of mortality. This manuscript outlines proposed methodology for scoping review that aims to describe the knowledge gaps for local-level smoking cessation interventions in Japan, their implementation barriers and facilitators, and the use of implementation strategies.

METHODS AND ANALYSIS

A scoping review will be conducted using the updated guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for Scoping Reviews to systematically search peer-reviewed journal articles and grey literature to identify studies on smoking cessation interventions in Japan. The six-stage scoping review model will involve (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting data; (5) collating, summarising and reporting the results; and (6) consultation exercise. Since there is little information available on the implementation context in the literature, we will use grey literature to identify organisations implementing smoking cessation interventions and conduct a cross-sectional survey among them to supplement the information gap. Based on a literature review, findings will be organised on smoking cessation interventions in local settings (ie, communities, workplaces, schools and hospitals) at the population, provider and individual levels in Japan to understand knowledge gaps. We will adopt the consolidated framework for implementation research to identify implementation barriers and facilitators, and the expert recommendations for implementing change to identify implementation strategies.

ETHICS AND DISSEMINATION

This study does not require ethical committee approval. The scoping review method will be robust in searching available smoking cessation interventions in Japan. The findings of this study will be compiled as case studies of best practices on smoking cessation interventions and disseminated to relevant stakeholders at the public and private levels through publications, presentations in conferences and stakeholder meetings.

Brief opportunistic interventions by general practitioners to promote smoking cessation: A conversation analytic study

Very brief opportunistic interventions for smoking cessation are effective, cost-saving for health systems, and universally recommended in guidelines. However, evidence suggests that clinicians are reluctant to intervene, citing interactional difficulties. Only one UK study has specifically examined smoking discussions, within naturally occurring primary care consultations. However smoking cessation treatment was not available at the time. We examined existing datasets amounting to 519 video-recordings of GP consultations in England for instances of talk about smoking. We used conversation analytic methods to assess patients' responses to doctors asking about smoking, giving advice on smoking, and offering cessation treatment. In 31 recordings it was apparent that the patient smoked, and, in 25/31 consultations, doctors initiated the topic of smoking. They did so by asking about smoking status, commonly during the history-taking phase of the consultation. In many instances, these questions led to active resistance from patients against being placed in a discreditable category, for example by minimising their smoking. This was more pronounced when GPs pursued efforts to quantify the amount smoked. Thereafter, where doctors returned to the topic of smoking, they did so typically by linking smoking to the patient's medical condition, which likewise led to resistance. Guidance recommends that GPs advise on how best to quit smoking where patients are interested in doing so, but this was only evident in a minority of consultations. Where GPs offered support for cessation, they did so using interactional practices that minimised the need for the patient to respond and thereby accept. Interactional difficulties were found to be common in consultations between GPs and people who smoke when GPs actions aligned with some VBA guidelines. Future research should examine when and how advice on how best to quit, and offers of support, should be delivered within primary care consultations.

Organization-Level Factors Associated with Changes in the Delivery of the Five A's for Smoking Cessation following the Implementation of a Comprehensive Tobacco-Free Workplace Program within Substance Use Treatment Centers

Many adults with a substance use disorder smoke cigarettes. However, tobacco use is not commonly addressed in substance use treatment centers. This study examined how provider beliefs about addressing tobacco use during non-nicotine substance use treatment, provider self-efficacy in delivering tobacco use assessments, and perceived barriers to the routine provision of tobacco care were associated with changes in the delivery of the evidence-based five A's for smoking intervention (asking, advising, assessing, assisting, and arranging) at the organizational level. The data were from 15 substance use treatment centers that implemented a tobacco-free workplace program; data were collected before and after the program's implementation. Linear regression examined how center-level averages of provider factors (1) at pre-implementation and (2) post- minus pre-implementation were associated with changes in the use of the five A's for smoking in substance use treatment patients. The results indicated that centers with providers endorsing less agreement that tobacco use should be addressed in non-nicotine substance use treatment and reporting lower self-efficacy for providing tobacco use assessments at pre-implementation were associated with significant increases in asking patients about smoking, assessing interest in quitting and assisting with a quit attempt by post-implementation. Centers reporting more barriers at pre-implementation and centers that had greater reductions in reported barriers to treatment over time had greater increases in assessing patients' interest in quitting smoking and assisting with a quit attempt by post-implementation. Overall, the centers that had the most to learn regarding addressing patients' tobacco use had greater changes in their use of the five A's compared to centers whose personnel were already better informed and trained. Findings from this study advance implementation science and contribute information relevant to reducing the research-to-practice translational gap in tobacco control for a patient group that suffers tobacco-related health disparities.

Bridging the Gap in Tobacco Cessation Services: Utilizing Community Pharmacists to Facilitate Transitions of Care in the USA

Interprofessional strategies for promoting tobacco cessation lead to enhanced quit rates among patients; however, current approaches might not effectively support patients with their quit attempts after they are discharged from the hospital. This paper explores opportunities for interprofessional collaboration between health system-based providers and community pharmacists, as one proposed approach to bridging tobacco cessation services during transitions of care. Suggested strategies include (1) increasing other healthcare professionals' awareness of legislative advances that permit pharmacists to prescribe cessation medications in some states, and (2) encouraging bi-directional communication between health system-based and community-based providers, especially via integrated electronic health records. Community pharmacists can offer a convenient solution to obtain the post-discharge medication and counseling support that patients need to increase their chances of quitting for good. Additional steps are discussed to improve broadscale capacity of this service being provided in community pharmacies.

A cluster randomized controlled trial for a multi-level, clinic-based smoking cessation program with women in Appalachian communities: study protocol for the "Break Free" program

BACKGROUND

The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program.

METHODS

The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness.

DISCUSSION

Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020).

A personalized biomedical risk assessment infographic for people who smoke with COPD: a qualitative study

Background

Chronic obstructive pulmonary disease (COPD) causes 3 million deaths each year, yet 38% of COPD patients continue to smoke. Despite proof of effectiveness and universal guideline recommendations, smoking cessation interventions are underused in practice. We sought to develop an infographic featuring personalized biomedical risk assessment through future lung function decline prediction (with vs without ongoing smoking) to both prompt and enhance clinician delivery of smoking cessation advice and pharmacotherapy, and augment patient motivation to quit.

Methods

We recruited patients with COPD and pulmonologists from a quaternary care center in Toronto, Canada. Infographic prototype content and design was based on best evidence. After face validation, the prototype was optimized through rapid-cycle design. Each cycle consisted of: (1) infographic testing in a moderated focus group and a clinician interview (recorded/transcribed) (with questionnaire completion); (2) review of transcripts for emergent/critical findings; and (3) infographic modifications to address findings (until no new critical findings emerged). We performed iterative transcript analysis after each cycle and a summative qualitative transcript analysis with quantitative (descriptive) questionnaire analysis.

Results

Stopping criteria were met after 4 cycles, involving 20 patients (58% male) and 4 pulmonologists (50% male). The following qualitative themes emerged: Tool content (infographic content preferences); Tool Design (infographic design preferences); Advantages of Infographic Messaging (benefits of an infographic over other approaches); Impact of Tool on Determinants of Smoking Cessation Advice Delivery (impact on barriers and enablers to delivery of smoking cessation advice in practice); and Barriers and Enablers to Quitting (impact on barriers and enablers to quitting). Patient Likert scale ratings of infographic content and format/usability were highly positive, with improvements in scores for 20/21 questions through the design process. Providers scored the infographic at 77.8% (“superior”) on the Suitability Assessment of Materials questionnaire.

Conclusions

We developed a user preference-based personalized biomedical risk assessment infographic to drive smoking cessation in patients with COPD. Our findings suggest that this tool could impact behavioural determinants of provider smoking-cessation advice delivery, while increasing patient quit motivation. Impacts of the tool on provider care, patient motivation to quit, and smoking cessation success should now be evaluated in real-world settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00283-1.

Imaginal Retraining Reduces Craving for Tobacco in 1-Year Controlled Follow-Up Study

INTRODUCTION

Imaginal retraining is a self-help technique that adapts the principles of approach bias modification to the imagination. Imaginal retraining has been shown to reduce craving and addictive behaviours in 3 randomized controlled trials (RCTs) on problematic alcohol consumption, overweight, and tobacco use. To date, there have been no studies evaluating the long-term efficacy of the intervention. The aim of the present study was to generate first hypotheses on the long-term efficacy of imaginal retraining in smokers in a controlled 1-year follow-up study.

MATERIALS AND METHODS

We recontacted the 345 participants who had taken part in an RCT on imaginal retraining for smokers 1 year later. The survey was carried out online and assessed craving for tobacco (primary outcome), smoking behaviour, well-being, and subjective appraisal. Individuals who applied the technique at least once during the previous year were categorized as the training group, whereas participants who never performed the training were categorized as the no-training group. Data were analysed using linear mixed models (LMMs). The study was preregistered as DRKS00021044.

RESULTS

The completion rate was 45.5%. Less than 40% used the intervention at least once in the previous 12 months. LMM analyses showed a significant reduction in craving for tobacco for the training compared to the no-training group after 1 year. No significant group differences emerged in smoking behaviour, depressive symptoms, or quality of life. Subjective appraisal of the intervention was favorable, similar to the initial study.

CONCLUSION

The present study provides preliminary support for the long-term efficacy of imaginal retraining on craving for tobacco but not on smoking behaviour, highlighting the importance of multimodal treatment concepts in smoking cessation that target a variety of maintaining factors. Future studies need to investigate the long-term efficacy of the intervention in prospective RCTs that test alternative ways of conveying the technique to improve adherence.

The referral of patients to smoking cessation counselling: perceptions and experiences of healthcare providers in general practice

Background

Few European smokers receive professional counselling when attempting to quit smoking, resulting in suboptimal success rates and poor health outcomes. Healthcare providers in general practice play an important role in referring smokers to smoking cessation counselling. We chose the Netherlands as a case study to qualitatively explore which factors play a role among healthcare providers in general practice with regard to referral for smoking cessation counselling organised both inside and outside general practice.

Methods

We conducted four focus groups and 18 telephone interviews, with a total of 31 healthcare providers who work in general practice. Qualitative content analysis was used to identify relevant factors related to referral behaviours, and each factor was linked to one of the three main components of the COM-B behaviour model (i.e., capability, opportunity and motivation) as well as the six sub-components of the model.

Results

Dutch healthcare providers in general practice typically refer smokers who want to quit to counselling inside their own general practice without actively discussing other counselling options, indicating a lack of shared decision making. The analysis showed that factors linked to the COM-B main components ‘capability’ and ‘opportunity’, such as healthcare providers’ skills and patients’ preferences, play a role in whether patients are referred to counselling inside general practice. Factors linked to all three COM-B components were found to play a role in referrals to counselling outside general practice. These included (knowledge of) the availability and quality of counselling in the region, patients’ requests, reimbursement, and sense of urgency to refer. The identified factors can both act as barriers and facilitators.

Conclusions

The findings of this research suggest that more smokers can be reached with smoking cessation counselling if implementation interventions focus on: (i) equipping healthcare providers with the knowledge and skills needed to refer patients; (ii) creating more opportunities for healthcare providers to refer patients (e.g., by improving the availability and reimbursement of counselling options); and (iii) motivating healthcare providers to discuss different counselling options with patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06618-7.

Facilitators and barriers to stakeholder engagement in advance care planning for older adults in community settings: a hybrid systematic review protocol

Background: Poor stakeholder engagement in advance care planning (ACP) poses national and international challenges, preventing maximisation of its potential benefits. Conceptualisation of advance care planning as a health behaviour highlights the need to design innovative, evidence-based strategies that will facilitate meaningful end-of-life care decision-making. Aim: To review systematically and synthesise quantitative and qualitative evidence on barriers and facilitators to stakeholders` engagement in ACP for older adults (≥ 50 years old) in a community setting. Methods: A hybrid systematic review will be conducted, identifying studies for consideration in two phases. First, databases will be searched from inception to identify relevant prior systematic reviews, and assess all studies included in those reviews against eligibility criteria (Phase 1). Second, databases will be searched systematically for individual studies falling outside the timeframe of those reviews (Phase 2). A modified SPIDER framework informed eligibility criteria. A study will be considered if it (a) included relevant adult stakeholders; (b) explored engagement in ACP among older adults (≥50 years old); (c) employed any type of design; (d) identified enablers and/or barriers to events specified in the Organising Framework of ACP Outcomes; (e) used either quantitative, qualitative, or mixed methods methodology; and (f) evaluated phenomena of interest in a community setting (e.g., primary care or community healthcare centres). Screening, selection, bias assessment, and data extraction will be completed independently by two reviewers. Integrated methodologies will be employed and quantitative and qualitative data will be combined into a single mixed method synthesis. The Behaviour Change Wheel will be used as an overarching analytical framework and to facilitate interpretation of findings. The Joanna Briggs Institute (JBI) Reviewers` Manual and PRISMA-P guidelines have been used to inform this protocol development. Registration: This protocol has been submitted for registration on PROSPERO, registration number CRD42020189568 and is awaiting review.

Hospital staff perspectives on the provision of smoking cessation care: a qualitative description study

OBJECTIVE

To explore the perspectives of hospital staff regarding the provision of smoking cessation care.

STUDY DESIGN

A qualitative description study using focus group discussions.

STUDY SETTING

Data were collected across metropolitan regional and rural hospitals in Victoria, Australia, between November and December 2019.

PARTICIPANTS

Clinical and non-clinical hospital staff.

RESULTS

Five focus groups were conducted across four hospitals. Staff (n=38) across metropolitan regional and rural hospitals shared similar views with regards to barriers and facilitators of smoking cessation care. Four themes were present: (1) Clinical Setting wherein views about opportunity and capacity to embed smoking cessation care, relevant policies and procedures and guidelines were discussed; (2) Knowledge consisted of the need for training on the provision of pharmacotherapy and behavioural interventions, and awareness of resources; (3) Consistency represented the need for a consistently applied approach to smoking cessation care by all staff and included issues of staff smoking; and (4) Appropriateness consisted of questions around how smoking cessation care can be safely delivered in the context of challenging patient groups and different settings.

CONCLUSIONS

Staff across metropolitan regional and rural hospitals experience similar views and identified shared barriers in implementing smoking cessation care. Responding to staff concerns and providing support to address smoking with patients will help to foster a consistent approach to cessation care. Clear practice guidelines for multidisciplinary clinical roles need to underpin staff training in communication skills, include priorities around smoking cessation care, and provide the authorising environment in which clinical staff actively provide smoking cessation care.

Lacking willpower? A latent class analysis of healthcare providers' perceptions of smokers' responsibility for smoking

OBJECTIVE

Healthcare providers' (HCPs) perceptions of smokers' responsibility for smoking may affect implementation of smoking cessation care (SCC), but are understudied. This study examined Dutch HCPs' perceptions of smokers' responsibility for smoking, and how many and which subgroups exist with regard to these perceptions.

METHODS

Observational cross-sectional study among physicians and other HCPs (N = 570). Latent class analysis was used to analyse data.

RESULTS

Results showed two latent classes of HCPs: a majority (77 %) that appeared to hold smokers themselves more accountable for their smoking, and a minority (23 %) that seemed more inclined to believe that people smoked as a consequence of factors such as addiction, and smoking initiation when people were young and could not foresee consequences. The two-class model showed excellent certainty in classification. Class membership was associated with age, working experience, and smoking status. The majority class experienced more barriers to SCC than the minority class and provided SCC tasks to fewer patients.

CONCLUSIONS

HCPs' perceptions of smokers' responsibility for smoking relate to HCP background characteristics, barriers to SCC and implementation of SCC.

PRACTICE IMPLICATIONS

New approaches to improving SCC might be needed that take HCP's perceptions of smokers' responsibility into account.

Current Activities Centered on Healthy Living and Recommendations for the Future: A Position Statement from the HL-PIVOT Network

We continue to increase our cognizance and recognition of the importance of healthy living (HL) behaviors and HL medicine (HLM) to prevent and treat chronic disease. The continually unfolding events precipitated by the coronavirus disease 2019 (COVID-19) pandemic have further highlighted the importance of HL behaviors, as indicated by the characteristics of those who have been hospitalized and died from this viral infection. There has already been recognition that leading a healthy lifestyle, prior to the COVID-19 pandemic, may have a substantial protective effect in those who become infected with the virus. Now more than ever, HL behaviors and HLM are essential and must be promoted with a renewed vigor across the globe. In response to the rapidly evolving world since the beginning of the COVID-19 pandemic, and the clear need to change lifestyle behaviors to promote human resilience and quality of life, the HL for Pandemic Event Protection (HL-PIVOT) network was established. The 4 major areas of focus for the network are: (1) knowledge discovery and dissemination; (2) education; (3) policy; (4) implementation. This HL-PIVOT network position statement provides a current synopsis of the major focus areas of the network, including leading research in the field of HL behaviors and HLM, examples of best practices in education, policy, and implementation, and recommendations for the future.

Rationale and Design of a Randomized Controlled Trial to Evaluate the Effectiveness of Medical Student Counseling for Hospitalized Patients Addicted to Tobacco (the MS-CHAT Trial)

Globally, India is the second largest consumer of tobacco. However, Indian medical students do not receive adequate training in smoking cessation counseling. Each patient hospitalization is an opportunity to counsel smokers. Medical Student Counseling for Hospitalized patients Addicted to Tobacco (MS-CHAT) is a 2-arm multicenter randomized controlled trial (RCT) that compares the effectiveness of a medical student-guided smoking cessation program initiated in inpatients and continued for two months after discharge versus standard hospital practice. Current smokers admitted to the hospital are randomized to receive either usual care or the intervention. The intervention group receives inpatient counseling and longitudinal postdischarge telephone follow-up by medical students. The control group receives counseling at the discretion of the treating physician. The primary outcome is biochemically verified 7-day point prevalence of smoking cessation at 6 months after enrollment. Changes in medical student knowledge and attitude will also be studied using a pre- and postquestionnaire delivered prior to and 12 months after training. This trial tests a unique model that seeks to provide hands-on experience in smoking cessation counseling to medical students while simultaneously improving cessation outcomes among hospitalized smokers in India.

Systematic Review of Clinician-Reported Barriers to Provision of Brief Advice for Alcohol Intake in Hospital Inpatient and Emergency Settings

Hospital inpatient and emergency care settings provide frequent opportunities for clinicians to screen and provide brief interventions to patients who engage in the harmful use of alcohol. However, these services are not always provided, with several reasons given in different studies. We aimed to systematically review clinician-reported barriers in the provision of brief alcohol screening, brief advice, and intervention specific to hospital inpatient and emergency department (ED) settings. A systematic literature review was conducted in MEDLINE, PsycINFO, and CINAHL to identify the barriers perceived by healthcare workers in the provision of alcohol screening and brief intervention. These barriers were then categorized according to the capability, opportunity, and motivation (COM-B) model of behavior change theory. Twenty-five articles were included in this study, which involved questionnaires, surveys, interviews, and conference call discussions. The most commonly cited barriers (i.e., greater than half of the studies) were related to capability (lack of knowledge cited in 60% of studies); opportunity (lack of time and resources, 76 and 52% of studies, respectively); and motivation (personal discomfort in 60% of studies). Twenty-two other barriers were reported but with lower frequency. Clinicians cite a multitude of factors that impede their delivery of alcohol screening and brief interventions in the hospital inpatient and ED settings. These barriers were explored further under the framework of the COM-B model, which allows for intervention design. As such, changes can be made at the policy, managerial, and educational levels to address these barriers and help improve the self-efficacy and knowledge of clinicians who counsel patients on alcohol use.

Evaluating the utility of a Smoking Cessation Clinical Pathway tool to promote nicotine prescribing and use among inpatients of a tertiary hospital in Brisbane, Australia

Introduction

Due to the burden of tobacco-related illnesses among hospital inpatients, an evidence-based smoking cessation brief intervention tool was developed for clinicians working in hospitals in Queensland, Australia. The tool, called the Smoking Cessation Clinical Pathway (SCCP), is used by clinicians to support inpatient smoking cessation and manage nicotine withdrawal in hospital.

Aims

To investigate the impact of completed SCCP on nicotine replacement therapy (NRT) prescribing and use, and to explore clinician involvement in smoking cessation interventions.

Methods

A retrospective review was conducted to examine data regarding SCCP responses and NRT offering, prescribing and use. The statistical significance of the results was assessed using chi-squared and Fisher's exact tests.

Results

Patients with a completed SCCP were more likely to be offered NRT (P < 0.0001). NRT prescribing on admission and discharge was higher in patients with a completed SCCP (P = 0.001 and P = 0.027). Intention to quit had no effect on whether NRT was offered (P = 0.276) and NRT acceptance was higher for patients that intended to quit smoking (P < 0.0001).

Conclusions

The SCCP prompted clinicians to offer NRT to patients, leading to increased NRT prescribing and use. These findings demonstrate the utility of the SCCP to assist clinicians to promote smoking cessation among hospital inpatients.

Facilitators and barriers to stakeholder engagement in advance care planning for older adults in community settings: a hybrid systematic review protocol

Background: Poor stakeholder engagement in advance care planning (ACP) poses national and international challenges, preventing maximisation of its potential benefits. Conceptualisation of advance care planning as a health behaviour highlights the need to design innovative, evidence-based strategies that will facilitate meaningful end-of-life care decision-making. Aim: To review systematically and synthesise quantitative and qualitative evidence on barriers and facilitators to stakeholders` engagement in ACP for older adults (≥ 50 years old) in a community setting. Methods: A hybrid systematic review will be conducted, identifying studies for consideration in two phases. First, databases will be searched from inception to identify relevant prior systematic reviews, and assess all studies included in those reviews against eligibility criteria (Phase 1). Second, databases will be searched systematically for individual studies falling outside the timeframe of those reviews (Phase 2). A modified SPIDER framework informed eligibility criteria. A study will be considered if it (a) included relevant adult stakeholders; (b) explored engagement in ACP among older adults (≥50 years old); (c) employed any type of design; (d) identified enablers and/or barriers to events specified in the Organising Framework of ACP Outcomes; (e) used either quantitative, qualitative, or mixed methods methodology; and (f) evaluated phenomena of interest in a community setting (e.g., primary care or community healthcare centres). Screening, selection, bias assessment, and data extraction will be completed independently by two reviewers. Integrated methodologies will be employed and quantitative and qualitative data will be combined into a single mixed method synthesis. The Behaviour Change Wheel will be used as an overarching analytical framework and to facilitate interpretation of findings. The Joanna Briggs Institute (JBI) Reviewers` Manual and PRISMA-P guidelines have been used to inform this protocol development. Registration: This protocol has been submitted for registration on PROSPERO and is awaiting review.

Auyeung A, Doyle F. A Systematic Review Protocol of the Barriers to Both Physical Activity and Obesity Counselling in the Secondary Care Setting as Reported by Healthcare Providers

Physical activity and obesity counselling have both been gaining increasing interest in preventive health and treatment. However, most healthcare professionals do not provide advice on these topics nearly as often as they should. There are many reasons for this. Common barriers for the provision of brief advice on physical activity and obesity in both primary and secondary care are lack of time, motivation and knowledge. Systematic reviews have been published on the barriers of physical activity and obesity counselling in the primary care setting, but there is no published work on the barriers present in secondary care. This systematic review aims to assess all published data that discuss the barriers of physical activity and obesity counselling as noted by healthcare providers in secondary care. Four databases will be searched using the same search strategy, and the findings will be compiled using the COM-B model to explore the frequency of a reported barrier. This systematic review will be beneficial not only to practicing healthcare providers, but also the educational and managerial staff of secondary care facilities, as it may highlight the need for further training to fill gaps in the provision of preventive healthcare.

Cost-effectiveness of smoking cessation programs for hospitalized patients: a systematic review

OBJECTIVE

This systematic review examined the characteristics of published cost-effectiveness analyses of inpatient smoking cessation programs and assessed the methodological quality of the selected studies, to provide policymakers with economic evidence for this type of program.

METHODS

A literature search was undertaken using a relevant database by three investigators. Only full economic evaluations with results in the form of the incremental cost-effectiveness ratio (ICER) were included. Costs were adjusted to 2016 US dollars using the Gross Domestic Product deflator and purchasing power parities. The British Medical Journal checklist was utilized to appraise the methodological quality of the included studies.

RESULTS

Nine articles were ultimately selected. The inpatient smoking cessation programs appeared to be a highly cost-effective intervention according to the recommended cost-effectiveness thresholds by the World Health Organization or individual studies. The highest ICERs among the selected studies were $5593 per additional quit, $10,550 per life year gained, and $5680 per quality-adjusted life year gained.

CONCLUSIONS

This study provides robust evidence supporting the cost-effectiveness of smoking cessation programs for hospitalized patients. In addition, the results indicated that the degree of cost-effectiveness of the inpatient smoking cessation program might not be related to either the components of the program or methodological variations in the cost-effectiveness analysis. Policymakers should provide hospitals with resources and strong incentives to promote wider implementation of the smoking cessation program.

Leverage points to improve smoking cessation treatment in a large tertiary care hospital: a systems-based mixed methods study

OBJECTIVES

To generate system insights on patient and provider levers and strategies that must be activated to improve hospital-based smoking cessation treatment.

DESIGN

Mixed methods study including a series of in-depth group model building sessions, which informed the design of an online survey completed by healthcare providers and a structured interview protocol administered at the bedside to patients who smoke.

SETTING

Large, tertiary care hospital in the Midwestern United States.

PARTICIPANTS

Group model building: 28 healthcare providers and 22 previously-hospitalised patients; Online survey: 308 healthcare providers; Bedside interviews: 205 hospitalised patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

Hypothesis-generating, participatory qualitative methods informed the examination of the following quantitative outcomes: patient interest versus provider perception of patient interest in smoking cessation and treatment; patient-reported receipt versus provider-reported offering of inpatient smoking cessation interventions; and priority ratings of importance and feasibility of strategies to improve treatment.

RESULTS

System insights included patients frequently leaving the floor to smoke, which created major workflow disruption. Leverage points included interventions to reduce withdrawal symptoms, and action ideas included nurse-driven protocols for timely administration of nicotine replacement therapy. Quantitative data corroborated system insights; for instance, 80% of providers reported that patients frequently leave the floor to smoke, leading to safety risks, missed assessments and inefficient use of staff time. Patients reported significantly lower rates of receiving any smoking cessation interventions, compared with provider reports (mean difference=17.4%-33.7%, p<0.001). Although 92% of providers cited patient interest as a key barrier, only 4% of patients indicated no interest in quitting or reducing smoking.

CONCLUSIONS

Engaging hospital providers and patients in participatory approaches to develop an implementation strategy revealed discrepant perceptions of patient interest and frequency of hospital-based treatment for smoking. These findings spurred adoption of standardised point-of-care treatment for cigarette smoking, which remains highly prevalent yet undertreated among hospitalised patients.

Group randomized trial of teaching tobacco-cessation counseling to senior medical students: a peer role-play module versus a standardized patient module

BACKGROUND

An important barrier to smoking-cessation counseling for physicians is a lack of education at the undergraduate level. Interactive methods such as peer role-play (RP) or modules utilizing standardized patients (SPs) may be effective for medical students to enhance their performance on tobacco cessation counseling. This study compared the effectiveness of a module using SPs to that of a RP module for undergraduate medical students on tobacco cessation counseling.

METHODS

This study was conducted over a single week of the family medicine clerkship. One hundred and thirteen fourth-year medical students were randomized into either the SP group or the RP group. A RP module involved a ten-minute encounter between the student doctor and the student patient followed by five minutes of feedback from the observer student using a group developed checklist. In a SP module, each student was asked to interview a SP portraying a smoker with willingness to quit. After the encounter, the SP provided five minutes of direct oral feedback to the student. In both modules, the total intervention lasted three-and-half hours and was supervised by faculty staff. Students' objective structured clinical examination (OSCE) scores were evaluated to determine their tobacco cessation counseling skills. Four evaluation periods were conducted at baseline, postintervention, post-clerkship, and before receiving the Korean medical licensing examination (KMLE). Students' smoking knowledge test scores and counseling self-confidence levels at pre- and post-intervention were also compared.

RESULTS

In both groups, post-intervention OSCE scores increased significantly compared to baseline (Cohen's d 0.87, p < 0.001 in SP group; d 0.77, p < 0.001 in RP group). However, there were no differences between the two groups. Students achieved the highest OSCE score for smoking-cessation counseling before the KMLE. After training, student self-confidence and smoking-knowledge test scores increased significantly, regardless of the type of module. Self-confidence was higher in the SP group compared with the RP group (d 0.37, p = 0.01).

CONCLUSIONS

Peer role-play may be equivalent to the SP method with regard to knowledge and skills reported during smoking-cessation counseling and SP method may be better in self-confidence. Cost and student self-confidence may be important factors when choosing among the teaching methods for smoking-cessation counseling.

Using an extended theory of planned behaviour to predict smoking cessation counsellors' intentions to offer smoking cessation support in the Taiwanese military: a cross-sectional study

OBJECTIVES

To use the extended theory of planned behaviour (TPB) to predict smoking cessation counsellors' intentions to offer smoking cessation support.

DESIGN

Cross-sectional study SETTING: Taiwanese military PARTICIPANTS: A survey of 432 smoking cessation counsellors was conducted in 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

All participants completed a self-administered questionnaire that solicited information concerning demographics, smoking behaviour, self-rated suitability for being a counsellor, the knowledge and skills learnt from training courses and the TPB construct.

RESULTS

The factors of perceived behavioural control (β=0.590, p<0.001), self-rated suitability for being a counsellor (acceptable vs not suitable, β=0.436, p=0.001; suitable vs not suitable, β=0.510, p<0.001), knowledge (β=0.298, p=0.020) and professional specialty (military doctor vs non-military doctor, β=0.198, p=0.034) were found to be correlated with intention. However, attitude, subjective norms and descriptive norms were determined to be non-significant correlates. The model explained 59.7% of the variance for the intention to offer smoking cessation support (F[12,343]=44.864, p<0.001).

CONCLUSIONS

To encourage smoking cessation counsellors to offer cessation support to smokers, policies should aim to increase their perceived behavioural control, knowledge and self-rated suitability for being a counsellor.

Smoking behaviours of Hong Kong Chinese hospitalised patients and predictors of smoking abstinence after discharge: a cross-sectional study

OBJECTIVES

Patients admitted to hospitals represent an excellent teachable moment for smoking cessation, as they are required to abstain from tobacco use during hospitalisation. Nevertheless, smoking behaviours of hospitalised patients, and factors that lead to smoking abstinence thereafter, remain relatively underexplored, particularly in a Hong Kong Chinese context. This study aimed to examine the smoking behaviours of hospitalised patients and explore factors leading to their abstaining from cigarette use after being hospitalised.

DESIGN

A cross-sectional design was employed.

SETTING

This study was conducted in three outpatient clinics in different regions in Hong Kong.

PARTICIPANTS

A total of 382 recruited Chinese patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The patients were asked to complete a structured questionnaire that assessed their smoking behaviours before, during and after hospitalisation.

RESULTS

The results indicated 23.6% of smokers smoked secretly during their hospital stay, and about 76.1% of smokers resumed smoking after discharge. Multivariate logistic regression analysis found that number of days of hospitalisation admission in the preceding year (OR 1.02; 95% CI 1.01 to 1.27; p=0.036), patients' perceived correlation between smoking and their illness (OR 1.08; 95% CI 1.01 to 1.17; p=0.032), withdrawal symptoms experienced during hospitalisation (OR 0.75; 95% CI 0.58 to 0.97; p=0.027) and smoking cessation support from healthcare professionals (OR 1.18; 95% CI 1.07 to 1.36; p=0.014) were significant predictors of smoking abstinence after discharge.

CONCLUSIONS

The results of this study will aid development of appropriate and innovative smoking cessation interventions that can help patients achieve more successful smoking abstinence and less relapse.

TRIAL REGISTRATION NUMBER

NCT02866760.

Prospective study of provided smoking cessation care in an inpatient psychiatric setting

OBJECTIVE

People with mental health difficulties (MHD) are more likely to smoke and to have smoking-related diseases, yet little research has investigated the provision of smoking cessation care in psychiatric inpatient settings. This study aimed to evaluate current levels of cessation care provided, and 3-month quit-rates, in one such setting in Ireland.

METHODS

From January to October 2016, inpatients across all 8 adult wards of St Patrick's University Hospital were recruited to participate in a baseline face-to-face survey (N = 246), assessing demographic information, smoking history and quit attempts, motivation to quit, nicotine dependence, attitudes towards cessation advice and actual care received. For baseline current smokers (n = 84) who consented, casenotes were also audited for documentation of smoking status and cessation care (n = 77/84) while quit rates were assessed at three months (n = 72/84), including a carbon monoxide test for those who reported quitting.

RESULTS

Current smoking prevalence was 34% (n = 84/246). At baseline 75% of smokers wanted to quit and 48% reported they would like cessation advice while in hospital. Few reported receiving cessation advice from any healthcare professional in the past year (13%), while just 6% had smoking cessation care clearly documented in their casenotes. The 3-month quit-rate was 17%, with a 100% pass rate for those completing an objective CO validation test.

CONCLUSION

Despite a high current smoking prevalence among psychiatric inpatients, and similar motivation and quit rates to other populations, current cessation care rates are low. Smoking cessation care needs to be prioritised in psychiatric settings.

Implementation of a Quit Smoking Programme in Community Adult Mental Health Services-A Qualitative Study

Little is known about the experiences of people with severe mental health difficulties in smoking cessation interventions. This study aimed to review the implementation of a smoking cessation programme across 16 community mental health day services. The aim was to establish the experience from both service user and facilitator perspectives and refine implementation for future groups. In-depth interviews were conducted with 20 service users and four focus groups held with 17 facilitators. Thematic analysis was used to analyse the data for emergent themes in relation to key enablers and barriers to implementation. Data from service users and facilitators revealed that implementation was enabled by an open and engaged recruitment approach; the resourcefulness of facilitators; programme materials and group-based format; combining the cessation programme with other and broader health initiatives; and participants' motivations, including health and money. Barriers included the structure of the service; the lack of a joined-up approach across the health services; literacy issues and the serial/logical process assumed by the programme. Barriers perceived as more specific to those with mental health difficulties included the use of smoking as a coping mechanism, lack of alternative activities/structure and lack of consistent determination. The tobacco free policy, implemented shortly before the programme, interestingly emerged as both a barrier and an enabler. In conclusion, although this group-based cessation programme in community mental health settings was well-received overall, a number of key barriers persist. A joined-up approach which addresses the culture of smoking in mental health settings, inconsistencies in smoking policies, and provides consistent cessation support, is needed. Care needs to be taken with the timing as overall it may not be helpful to introduce a new smoking cessation programme at the same time as a tobacco free policy.