Is some provider advice on smoking cessation better than no advice? An instrumental variable analysis of the 2001 National Health Interview Survey

Individuals with long-term illness, disability or infirmity are more likely to smoke than healthy controls: An instrumental variable analysis

Despite the prevalence of smoking cessation programs and public health campaigns, individuals with long-term illness, disability, or infirmity have been found to smoke more often than those without such conditions, leading to worsening health. However, the available literature has mainly focused on the association between long-term illness and smoking, which might suffer from the possible bidirectional influence, while few studies have examined the potential causal effect of long-term illness on smoking. This gap in knowledge can be addressed using an instrumental variable analysis that uses a third variable as an instrument between the endogenous independent and dependent variables and allows the identification of the direction of causality under the discussed assumptions. Our study analyzes the UK General Household Survey in 2006, covering a nationally representative 13,585 households. We exploited the number of vehicles as the instrumental variable for long-term illness, disability, or infirmity as vehicle numbers may be related to illness based on the notion that these individuals are less likely to drive, but that vehicle number may have no relationship to the likelihood of smoking. Our results suggested that chronic illness status causes a significantly 28% higher probability of smoking. The findings have wide implications for public health policymakers to design a more accessible campaign around smoking and for psychologists and doctors to take targeted care for the welfare of individuals with long-term illnesses.

Changes in cigarette smoking behavior among breast cancer and unaffected women - A prospective study in the MARIE cohort

BACKGROUND

Smoking cessation after a cancer diagnosis can reduce adverse cancer treatment outcomes. Whether a breast cancer diagnosis, a cancer commonly seen as unrelated to smoking cigarettes, motivates changes in smoking behavior is not fully understood. We aimed to compare long-term changes at three follow-up times of cigarette smoking behavior in women with breast cancer and baseline age- and region-matched unaffected women.

METHODS

We used longitudinal data from the population-based case-control study MARIE (Mamma Carcinoma Risk Factor Investigation). Women with breast cancer (N = 3813) and unaffected women (N = 7341) aged 50-74 years were recruited from 2002 to 2005. Analyses on changes in smoking were based on data from those who also completed follow-up 1 in 2009-2012, follow-up 2 in 2014-2016 and follow-up 3 in 2020. Multinomial logistic regression for changes (quitting, stable, or start smoking) adjusted for age, study region, education, comorbidities, living situation, and follow-up time, was applied to examine the associations between breast cancer status and changes in smoking behavior.

RESULTS

Women with breast cancer had significantly higher odds than unaffected women of quitting smoking (OR = 1.38, 95 % CI: 1.01-1.89) and lower odds of returning to smoking (OR = 0.29, 95 % CI: 0.09-0.94) at follow-up 1, but were more likely to start or return to smoking at follow-up 2 (OR = 2.11, 95 % CI 1.08-4.15). No significant group differences were found for changes in smoking behavior at follow-up 3.

CONCLUSION

Our findings indicate that short-term changes in smoking behavior can be attributed to a breast cancer diagnosis, but that over time the effect diminishes and changes in smoking no longer differ between breast cancer and breast cancer-free women. To support smoking cessation and to prevent relapse, guidelines to address smoking in cancer care, as well as comprehensive tobacco treatment services, are needed.

Quitting Smoking before and after Pregnancy: Study Methods and Baseline Data from a Prospective Cohort Study

Smoking during pregnancy and postpartum remains an important public health problem. No known prior study has prospectively examined mutual changes in risk factors and women's smoking trajectory across pregnancy and postpartum. The objective of this study was to report methods used to implement a prospective cohort (Msgs4Moms), present participant baseline characteristics, and compare our sample characteristics to pregnant women from national birth record data. The cohort study was designed to investigate smoking patterns, variables related to tobacco use and abstinence, and tobacco treatment quality across pregnancy through 1-year postpartum. Current smokers or recent quitters were recruited from obstetrics clinics. Analyses included Chi-square and independent sample t-tests using Cohen's d. A total of 62 participants (41 smokers and 21 quitters) were enrolled. Participants were Black (45.2%), White (35.5%), and multiracial (19.3%); 46.8% had post-secondary education; and most were Medicaid-insured (64.5%). Compared with quitters, fewer smokers were employed (65.9 vs 90.5%, Cohen's d = 0.88) and more reported financial strain (61.1% vs 28.6%; Cohen's d = 0.75). Women who continue to smoke during pregnancy cope with multiple social determinants of health. Longitudinal data from this cohort provide intensive data to identify treatment gaps, critical time points, and potential psychosocial variables warranting intervention.

Examining the role of healthcare access in racial/ethnic disparities in receipt of provider-patient discussions about smoking: A latent class analysis

Using insurance as a single indicator of healthcare access in examining the association between race/ethnicity and healthcare encounter-based interventions for smoking may not be adequate. In this study, we assessed the role of healthcare access using multifactorial measures in accounting for racial/ethnic disparities in the receipt of provider-patient discussions, defined as either being asked about smoking or advised to quit smoking by providers. We identified adult current smokers from the 2015 National Health Interview Survey. We first conducted a latent class analysis (LCA) to identify the underlying patterns of healthcare access measured by 13 indicators of healthcare access and utilization. We then used a propensity score - based weighting approach to examine racial/ethnic disparities in receiving provider-patient discussions about smoking or quitting in stratified groups by the distinct healthcare access clusters. Out of the 4134 adult current smokers who visited a doctor or a healthcare provider during the past 12 months, 3265 (79.90%) participants were classified as having high healthcare access and 869 (20.10%) participants as having low healthcare access. Compared to non-Hispanic whites, Hispanics had significantly lower odds of being asked about smoking (OR 0.46, 95% CI (0.27-0.77)) and being advised to quit (OR 0.57, 95% CI (0.34-0.97)) in the low access group, but neither association was significant in the high access group. In addition to increasing health insurance coverage, reducing other healthcare access barriers for Hispanics will likely facilitate provider-patient discussion and promote tobacco cessation among Hispanic smokers.

Smoking Treatment: A Report Card on Progress and Challenges

The impact of tobacco smoking treatment is determined by its reach into the smoking population and the effectiveness of its interventions. This review evaluates the reach and effectiveness of pharmacotherapy and psychosocial interventions for smoking. Historically, the reach of smoking treatment has been low, and therefore its impact has been limited, but new reach strategies such as digital interventions and health care system changes offer great promise. Pharmacotherapy tends to be more effective than psychosocial intervention when used clinically, and newer pharmacotherapy strategies hold great promise of further enhancing effectiveness. However, new approaches are needed to advance psychosocial interventions; progress has stagnated because research and dissemination efforts have focused too narrowly on skill training despite evidence that its core content may be inconsequential and the fact that its mechanisms are either unknown or inconsistent with supporting theory. Identifying effective psychosocial content and its mechanisms of action could greatly enhance the effectiveness of counseling, digital, and web interventions.

The Influence of Increasing Levels of Provider-Patient Discussion on Quit Behavior: An Instrumental Variable Analysis of a National Survey

Objective: We aimed to examine the influence of increasing levels of discussion (both asked and advised, either asked or advised but not both, and neither asked nor advised) on quit behavior. Methods: We included 4133 adult current smokers from the 2015 National Health Interview Survey. The primary outcomes were quit intent and quit attempt, and the secondary outcomes were methods used for quitting. We used an instrumental variable analysis, as well as propensity score weighted and multivariable logistic regressions. Results: Compared to no discussion, having both or only one discussion, respectively, increased quit intent (OR = 1.65, 95% CI = 1.63–1.66 and OR = 1.02, 95% CI = 0.99–1.05), quit attempt (OR = 1.76, 95% CI = 1.75–1.77 and OR = 1.60, 95% CI = 1.57–1.63). Among those who attempted to quit (n = 1536), having both or only one discussion increased the use of pharmacologic (OR = 1.99, 95% CI = 1.97–2.02 and OR = 1.56, 95% CI = 1.49–1.63) or behavioral (OR = 2.01, 95% CI = 1.94–2.08 and OR = 2.91, 95% CI = 2.74–3.08) quit methods. Conclusions: Increasing levels of provider–patient discussion encourages quit behavior, and should be an integral part of reducing the health and economic burden of smoking. Strategies that promote the adherence and compliance of providers to communicate with patients may help increase the success of smoking cessation.

Creating Standardized Tools for the Pharmacist-Led Assessment and Pharmacologic Management of Adult Canadians Wishing to Quit Smoking: A Consensus-Based Approach

Tobacco use continues to be recognized as the single most preventable cause of death worldwide. As the gatekeepers of and experts on pharmacotherapy, pharmacists play a vital role in facilitating smoking cessation. While existing frameworks have enabled pharmacists to provide smoking cessation services in Canada for many years, the way in which they are delivered vary considerably across the nation. The purpose of this initiative was to create standardized tools for the pharmacists providing cessation services to ensure all Canadians wishing to stop smoking have equal access to consistent, evidence-based care. An iterative process using repeated rounds of voting was employed to establish consensus among key opinion leaders on the most important items to include in tools for the pharmacist-led assessment and pharmacologic management of Canadian adults wishing to stop smoking. The results were used to create eight standardized documents for national use by pharmacists: a readiness to quit assessment tool, a patient consent form, a patient assessment form for past users of tobacco and/or tobacco-like products, a patient assessment form for current users of tobacco and/or tobacco-like products, a treatment algorithm, a treatment plan summary form, a prescribing documentation form, and a follow-up & monitoring documentation form. Although not described in detail in these documents, other strategies for smoking cessation (e.g., non-pharmacologic strategies (including quitting "cold turkey" and behavioural interventions), harm reduction strategies, etc.) should be considered when pharmacotherapy is inappropriate or undesired; care should be individualized based on a patient's previous experiences and current motivation. No single approach to treatment is endorsed by the authors. The consensus-based approach described here provides a suggested framework for harmonizing the pharmacist-led management of other ailments to optimize patient care.

Machine learning to identify and understand key factors for provider-patient discussions about smoking

We sought to identify key determinants of the likelihood of provider-patient discussions about smoking and to understand the effects of these determinants. We used data on 3666 self-reported current smokers who talked to a health professional within a year of the time the survey was conducted using the 2017 National Health Interview Survey. We included wide-ranging information on 43 potential covariates across four domains, demographic and socio-economic status, behavior, health status and healthcare utilization. We exploited a principled nonparametric permutation based approach using Bayesian machine learning to identify and rank important determinants of discussions about smoking between health providers and patients. In the order of importance, frequency of doctor office visits, intensity of cigarette use, length of smoking history, chronic obstructive pulmonary disease, emphysema, marital status were major determinants of disparities in provider-patient discussions about smoking. There was a distinct interaction between intensity of cigarette use and length of smoking history. Our analysis may provide some insights into strategies for promoting discussions on smoking and facilitating smoking cessation. Health care resource usage, smoking intensity and duration and smoking-related conditions were key drivers. The "usual suspects", age, gender, race and ethnicity were less important, and gender, in particular, had little effect.

The long-term outcomes of tobacco control strategies based on the cognitive intervention for smoking cessation in COPD patients

OBJECTIVE

To evaluate the long-term efficacy of tobacco control strategies based on cognitive intervention for smoking cessation in chronic obstructive pulmonary disease (COPD) patients, and to provide basis for clinical practice.

MATERIALS AND METHODS

102 COPD patients with a long-term history of smoking from the outpatient clinic were recruited in the study. These smokers were randomly divided into intervention group and control group. The intervention group received a cognitive intervention containing individual consultation, telephone follow-ups and self-help materials, etc. The prevalence of quitting smoking, acute exacerbation (AE), lung function and survival were compared in the groups in 10 years.

RESULTS

There were significant differences between the intervention group and the control group in the rate of persistent quitting smoking in half a year (17.6% vs 3.9%) (P < 0.05), the rate of quitting smoking at the 6th month (58.8% vs 33.3%) (P < 0.05). After 3 months (P < 0.01) and 6 months (P < 0.01), the difference in body weight between the intervention group and the control group was statistically significant. Intervention-group patients had fewer AE per year (P < 0.01) and higher FEV1/FVC ratio (P < 0.01) after 5-year and 10-year follow-up. Besides, the FEV1% predicted in the intervention patients was higher than that in control group after 10-year follow-up. The ages of patients in the death group were greater than those in the survival group. Death-group patients had longer smoking times, higher smoking index, and later onset of COPD symptoms. Death-group patients had lower FEV1% predicted (P < 0.05) and FEV1/FVC ratio (P < 0.01). During 10-year follow-up, 30 patient deaths were recorded (the control group: n = 48; 19 deaths, and intervention group: n = 46; 11 deaths), and patients in the control group had lower survival than those in the intervention group. (P < 0.05).

CONCLUSION

The method of quitting smoking based on cognitive intervention is an effective way for COPD patients to quit smoking successfully. Quitting smoking can slower deterioration in lung function and improve the survival of COPD patients.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR2000031239 (Chinese clinical trial registry).

Primary Care Tasks Associated with Provider Burnout: Findings from a Veterans Health Administration Survey

BACKGROUND

The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout.

OBJECTIVE

To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout.

DESIGN

Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods.

PARTICIPANTS

327 providers from 23 VA primary care practices within one VHA regional network.

MAIN MEASURES

The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables.

KEY RESULTS

In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03).

CONCLUSIONS

Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.

Is Cost of Medication for Quit Smoking Important for Smokers, Experience of Using Champix in Iranian Smoking Cessation Program 2016

Background:

Providing smoking cessation services are special importance to tobacco control programs. To date, Champix is a new expensive medication for smoking cessation available nationally. Champix has both agonist and antagonist activities and can reduce nicotine dependence and withdrawal symptoms. The purpose of this study was to evaluate the duration of using Champix based on its cost.

Methods:

This quasi-experimental study was conducted with smokers presenting to the Tanaffos Smoking Cessation Clinic in Tehran, Iran 2016. Smokers were visited by a physician 3 times at 1-week intervals for counseling. Smokers started to use Champix and stopped smoking in the 2nd week of counseling and were followed up by phone and through regular visits to the clinic at 1, 3, and 6 months postintervention. Some of them did not continue medication for 12 weeks because of its cost.

Results:

A total of 227 smokers including 133 males (58%) with a mean age of 43 years were enrolled of whom 116 (51.1%), 89 (43.6%), and 34 (20.6%) had quit smoking after 1, 3, and 6 months, respectively. Quit rates were significantly higher among those who used Champix for more than 6 weeks, and this rate was not correlated with age, sex, educational level, or nicotine dependence.

Conclusions:

Use of Champix for more than 6 weeks increases the quitting success rate compared with using for a shorter time. The cost of Champix was important for smokers and adding Champix to the list of insurance medication or getting it free of charge is needed.

Clickotine, A Personalized Smartphone App for Smoking Cessation: Initial Evaluation

Background

Tobacco smoking is the leading cause of preventable death in the United States, and the annual economic burden attributable to smoking exceeds US $300 billion. Obstacles to smoking cessation include limited access and adherence to effective cessation interventions. Technology can help overcome these obstacles; many smartphone apps have been developed to aid smoking cessation, but few that conform to the US clinical practice guideline (USCPG) have been rigorously tested and reported in the literature. Clickotine is a novel smartphone app for smoking cessation, designed to deliver the essential features of the USCPG and engineered to engage smokers by personalizing intervention components.

Objective

Our objective was to assess the engagement, efficacy, and safety of Clickotine in an initial, single-arm study. Outcomes measured were indicators of engagement with the smartphone app (number of app opens, number of interactions with the Clickotine program, and weeks active with Clickotine), cessation outcomes of 7- and 30-day self-reported abstinence from smoking, and negative health events.

Methods

We recruited US residents between 18 and 65 years of age who owned an iPhone and smoked 5 or more cigarettes daily for the study via online advertising. Respondents were prescreened for eligibility by telephone and, if appropriate, directed to a Web portal to provide informed consent, confirm eligibility, and download the Clickotine app. Participants completed study assessments via the online portal at baseline and after 8 weeks. Data were collected in Amazon S3 with no manual data entry, and access to all data was maximally restrictive, logged, and auditable.

Results

A total of 416 participants downloaded the app and constituted the intention-to-treat (ITT) sample. On average, participants opened the Clickotine app 100.6 times during the 8-week study (median 69), logged 214.4 interactions with the Clickotine program (median 178), and remained engaged with Clickotine for 5.3 weeks (median 5). Among the ITT sample, 45.2% (188/416) reported 7-day abstinence and 26.2% (109/416) reported 30-day abstinence from smoking after 8 weeks. Completer analysis focused on 365 (87.7%) of the 416 enrolled participants who completed the 8-week questionnaire revealed that 51.5% (188/365) of completers reported 7-day abstinence and 29.9% (109/365) reported 30-day abstinence. Few adverse events, mostly consistent with nicotine withdrawal symptoms, were reported and overall no safety signal was detected.

Conclusions

In this initial single-arm trial, Clickotine users appeared to demonstrate encouraging indicators of engagement in terms of the number of app opens, number of program interactions, and continued engagement over time. Clickotine users reported encouraging quit rates while reporting few adverse events. Future research is warranted to assess Clickotine’s efficacy in a randomized controlled trial.

Trial Registration

Clinicaltrials.gov NCT02656745; https://clinicaltrials.gov/ct2/show/NCT02656745 (Archived by WebCite at http://www.webcitation.org/6peTT4x60)

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults

PURPOSE

To help clinicians and care systems determine the priority for tobacco counseling in busy clinic schedules, we assessed the lifetime health and economic value of annually counseling youth to discourage smoking initiation and of annually counseling adults to encourage cessation.

METHODS

We conducted a microsimulation analysis to estimate the health impact and cost effectiveness of both types of tobacco counseling in a US birth cohort of 4,000,000. The model used for the analysis was constructed from nationally representative data sets and structured literature reviews.

RESULTS

Compared with no tobacco counseling, the model predicts that annual counseling for youth would reduce the average prevalence of smoking cigarettes during adult years by 2.0 percentage points, whereas annual counseling for adults will reduce prevalence by 3.8 percentage points. Youth counseling would prevent 42,686 smoking-attributable fatalities and increase quality-adjusted life years (QALYs) by 756,601 over the lifetime of the cohort. Adult counseling would prevent 69,901 smoking-attributable fatalities and increase QALYs by 1,044,392. Youth and adult counseling would yield net savings of $225 and $580 per person, respectively. If annual tobacco counseling was provided to the cohort during both youth and adult years, then adult smoking prevalence would be 5.5 percentage points lower compared with no counseling, and there would be 105,917 fewer smoking-attributable fatalities over their lifetimes. Only one-third of the potential health and economic benefits of counseling are being realized at current counseling rates.

CONCLUSIONS

Brief tobacco counseling provides substantial health benefits while producing cost savings. Both youth and adult intervention are high-priority uses of limited clinician time.

Health professional advice, use of medications and smoking cessation: A population-based prospective cohort study

INTRODUCTION

The mediating role of cessation medications in the association between health professional advice and quitting behaviors is unclear.

METHODS

Data were from the Ontario Tobacco Survey longitudinal study, collected between July 2005 and June 2011 in Ontario, Canada. The analytic sample included 3437 baseline smokers who were seen by health professionals during follow-up. Logistic regression with generalized estimating equations and mediation analysis techniques were used to examine the impact of advice and medications on quitting outcomes (making a quit attempt, short-term quitting 1-6months and long-term quitting>6months).

RESULTS

Those who received advice to quit smoking were more likely to use cessation medications than those who did not receive advice (21% vs. 13%, P<0.001). Receiving advice was associated with making a quit attempt (adjusted odds ratio (OR) 1.25, 95% confidence interval (CI) 1.10-1.41) and long-term quitting (adjusted OR 1.49, 95% CI 1.10-2.02), but not with short-term quitting. Use of cessation medications was associated with making a quit attempt (adjusted OR 11.83, 95% CI 9.93-14.08), short-term quitting (adjusted OR 3.69, 95% CI 2.90-4.68), and long-term quitting (adjusted OR 2.73, 95% CI 1.95-3.82). Using prescription medications was associated with a higher likelihood of quitting short-term (adjusted OR 2.43, 95% CI 2.59-3.74) and long-term (adjusted OR 2.27, 95% CI 1.23-4.17) than using NRT. Use of cessation medications was a significant mediator in the pathway from receiving advice to quitting.

CONCLUSION

Health professionals should advise smokers to quit and encourage them to use cessation medications, especially prescription medications when trying to quit.

Providers' advice concerning smoking cessation: Evidence from the Medical Expenditures Panel Survey

IMPORTANCE AND OBJECTIVE

We estimate how often adult smokers are advised to quit using a nationally representative sample of adults in the United States.

DESIGN AND PARTICIPANTS

Data are from the 2012-2013 household component of the United States (US) Medical Expenditures Panel Survey (MEPS).

MAIN OUTCOME MEASURE

Current smoking and advice to quit offered by providers.

RESULTS

Smoking was reported by 18.26% (CI 17.13%-19.38%) of 2012 MEPS respondents. Less than half of adult smokers (47.24%, CI 44.30%-50.19%) were advised to quit by their physicians although 17.57% (CI 15.37%-19.76%) had not seen a doctor in the last 12months. Advice to quit was given significantly less often to respondents classified as: aged 18-44 (40.29%), men (40.20%), less educated (42.26%), lower family income (43.51%), Hispanic (33.82%), never married (39.55%), and living outside the northeast. Smoking status at year 2 for patients who had received advice to quit was similar (85.13%: SE 1.62%) to those who had seen a physician but were not advised to quit (81.95%: SE 2.05%). Advice to quit smoking was less common than the use of common medical screening tests.

CONCLUSIONS AND RELEVANCE

Smoking cessation advice is given to less than half of current cigarette smokers and it is least likely to be given to the most vulnerable populations. Efforts to reduce smoking are deployed less often than other preventive practices. The rate of advice to quit has not changed over the last decade. Health care providers are missing an important opportunity to affect health behaviors and outcomes.

Smoking and environmental characteristics of smokers with a mental illness, and associations with quitting behaviour and motivation; a cross sectional study

Background

Persons with a mental illness are less likely to be successful in attempts to quit smoking. A number of smoking and environmental characteristics have been shown to be related to quitting behaviour and motivation of smokers generally, however have been less studied among smokers with a mental illness. This study aimed to report the prevalence of smoking characteristics and a variety of physical and social environmental characteristics of smokers with a mental illness, and explore their association with quitting behaviour and motivation.

Methods

A cross-sectional descriptive study was undertaken of 754 smokers admitted to four psychiatric inpatient facilities in Australia. Multivariable logistic regression analyses were undertaken to explore the association between smoking and environmental characteristics and recent quitting behaviour and motivation.

Results

Participants were primarily daily smokers (93 %), consumed >10 cigarettes per day (74 %), and highly nicotine dependent (51 %). A third (32 %) lived in a house in which smoking was permitted, and 44 % lived with other smokers. The majority of participants believed that significant others (68–82 %) and health care providers (80–91 %) would be supportive of their quitting smoking. Reflecting previous research, the smoking characteristics examined were variously associated with quitting behaviour and motivation. Additionally, participants not living with other smokers were more likely to have quit for a longer duration (OR 2.02), and those perceiving their psychiatrist to be supportive of a quit attempt were more likely to have had more quit attempts in the past six months (OR 2.83).

Conclusions

Modifiable characteristics of the physical and social environment, and of smoking, should be considered in smoking cessation interventions for persons with a mental illness.

Awareness, practices, and barriers regarding smoking cessation treatment among physicians in Saudi Arabia

Smoking cessation counseling and therapy provided by physicians play an important role in helping smokers quit. Awareness and practices of the clinical practice guidelines for tobacco dependence (in particular the 5A's: Ask, Assist, Assess, Advise, and Arrange) among physicians and perceived barriers for their implementation is needed to improve care for individuals who smoke/use tobacco products in Saudi Arabia. A cross-sectional self-administered survey was conducted among 124 general and family practitioners in primary health care clinics belonging to 2 major medical centers in Riyadh city, Saudi Arabia. Descriptive statistics were reported for all survey variables. Logistic regression was used to examine the predictors of physicians' use of the 5A's for smoking cessation counseling and therapy. Among the 216 contacted physicians, 124 responded (57.4%). The majority (63.7%) were males, between the ages of 40 and 49 years (52.4%), practicing full-time (95.2%), and had not received smoking cessation training during medical school education or residency training (68.6%). Approximately 85.5% reported some experience with the guidelines (heard, read, or used). Asking (71.8%) and advising (87.9%) were the most implemented for smoking cessation, while assisting (15.3%) and arranging for follow-up (17.7%) were the least implemented. Most (96.0%) did not prescribe pharmacotherapy and 53.2% reported documenting the patient's smoking status. Reported barriers were mostly lack of time (72.6%) and lack of training (66.9%). Awareness of the guidelines, physician's smoking status, perceived competence in ability to provide smoking cessation counseling and therapy, reporting the ineffectiveness of smoking cessation therapy as a barrier, and the perceived benefit of reducing patient's physical symptoms were independently statistically significant predictors of the implementation of the 5A's for smoking cessation therapy. This preliminary study showed that smoking cessation delivery, according to the clinical practice guidelines recommendation, in Saudi Arabia is inadequate. Barriers were identified regarding the delivery of smoking cessation therapy and counseling for the first time. Physician training is likely to improve compliance with implementing smoking cessation counseling and therapy.

Assessment of Different Quit Smoking Methods Selected by Patients in Tobacco Cessation Centers in Iran

BACKGROUND

Health systems play key roles in identifying tobacco users and providing evidence-based care to help them quit. This treatment includes different methods such as simple medical consultation, medication, and telephone counseling. To assess different quit smoking methods selected by patients in tobacco cessation centers in Iran in order to identify those that are most appropriate for the country health system.

METHODS

In this cross-sectional and descriptive study, a random sample of all quit centers at the country level was used to obtain a representative sample. Patients completed the self-administered questionnaire which contained 10 questions regarding the quality, cost, effect, side effects and the results of quitting methods using a 5-point Likert-type scale. Percentages, frequencies, mean, T-test, and variance analyses were computed for all study variables.

RESULTS

A total of 1063 smokers returned completed survey questionnaires. The most frequently used methods were Nicotine Replacement Therapy (NRT) and combination therapy (NRT and Counseling) with 228 and 163 individuals reporting these respectively. The least used methods were hypnotism (n = 8) and the quit and win (n = 17). The methods which gained the maximum scores were respectively the combined method, personal and Champix with means of 21.4, 20.4 and 18.4. The minimum scores were for e-cigarettes, hypnotism and education with means of 12.8, 11 and 10.8, respectively. There were significant differences in mean scores based on different cities and different methods.

CONCLUSIONS

According to smokers' selection the combined therapy, personal methods and Champix are the most effective methods for quit smoking and these methods could be much more considered in the country health system.

Quit Smoking Experts' Opinions toward Quality and Results of Quit Smoking Methods Provided in Tobacco Cessation Services Centers in Iran

Background:

One of the core responsibilities of health system is to treat tobacco dependence. This treatment includes different methods such as simple medical consultation, medication, and telephone counseling. To assess physicians’ opinions towards quality and result of different quit smoking methods provided in tobacco cessation services centers in Iran.

Methods:

In this cross-sectional and descriptive study, random sampling of all quit centers at country level was used to obtain a representative sample size of 100 physicians. Physicians completed a self-administered questionnaire which contained 10 questions regarding the quality, cost, effect, side effects, and the results of quitting methods using a 5-point Likert-type scale. Percentages, frequencies, mean, T-test, and variance analyses were computed for all study variables.

Results:

Most experts preferred to use combination quit smoking methods and then Nicotine Replacement Therapy (NRT) with 26 and 23, respectively. The least used methods were quit line and some methods without medication with 3 cases. The method which gained the maximum scores were telephone consultation, acupuncture, Willpower, Champix, combined method, and Interactive Voice Response (IVR) with the mean of 23.3, 23, 22.5, 22, 21.7 and 21.3, respectively. The minimum scores were related to e-cigarette, some methods without medication, and non-NRT medication with the mean of 12.3, 15.8 and 16.2, respectively. There were no significant differences in the mean of scores based on different cities (P = 0.256). Analysis of variance in mean scores showed significant differences in the means scores of different methods (P < 0.000).

Conclusions:

According to physicians acupuncture, personal methods and Champix are the most effective methods and these methods could be much more feasible and cost effective than other methods.

Smoking-cessation advice to patients with chronic obstructive pulmonary disease: the critical roles of health insurance and source of care

INTRODUCTION

Smoking cessation is the most effective therapeutic intervention for chronic obstructive pulmonary disease (COPD) patients. However, the proportion of smokers with COPD who have received physician advice to quit smoking is unknown. The purpose of this study is to assess the prevalence of receipt of smoking-cessation advice among adults with COPD and explore factors predicting advice receipt.

METHODS

This study employed nationally representative data from the Medical Expenditure Panel Survey (MEPS), collected in 2008-2011 on adults aged ≥20 years. Logistic regression models were conducted to estimate the likelihood of receiving provider advice. Data were analyzed in 2014.

RESULTS

Four percent (95% CI=3.8%, 4.2%) of adults reported being diagnosed with COPD. Among them, 38.5% (95% CI=36.1%, 40.8%) were current smokers. Among those who had seen a physician in the past year, 85.6% (95% CI=83.1%, 88.0%) were advised to quit smoking. Logistic regression revealed negative associations between receipt of smoking-cessation advice and having fewer healthcare visits (AOR=0.41, 95% CI=0.23, 0.72); being uninsured (AOR=0.43, 95% CI=0.22, 0.83); having no usual source of care (AOR=0.39, 95% CI=0.19, 0.80); and having no comorbid chronic diseases (AOR=0.50, 95% CI=0.29, 0.85).

CONCLUSIONS

Having no usual source of care and no health insurance are major barriers to receiving smoking-cessation advice among patients with COPD. The Patient Protection and Affordable Care Act has the potential to increase advice receipt in this high-risk population by expanding health insurance coverage and increasing the number of people with a usual source of care.

Practical clinical interventions for diet, physical activity, and weight control in cancer survivors

Answer questions and earn CME/CNE The importance of expanding cancer treatment to include the promotion of overall long-term health is emphasized in the Institute of Medicine report on delivering quality oncology care. Weight management, physical activity, and a healthy diet are key components of tertiary prevention but may be areas in which the oncologist and/or the oncology care team may be less familiar. This article reviews current diet and physical activity guidelines, the evidence supporting those recommendations, and provides an overview of practical interventions that have resulted in favorable improvements in lifestyle behavior change in cancer survivors. It also describes current lifestyle practices among cancer survivors and the role of the oncologist in helping cancer patients and survivors embark upon changes in lifestyle behaviors, and it calls for the development of partnerships between oncology providers, primary care providers, and experts in nutrition, exercise science, and behavior change to help positively orient cancer patients toward longer and healthier lives.

Patient Characteristics Associated With Smoking Cessation Interventions and Quit Attempt Rates Across 10 Community Health Centers With Electronic Health Records

OBJECTIVES

We used electronic health record (EHR) data to determine rates and patient characteristics in offering cessation interventions (counseling, medications, or referral) and initiating quit attempts.

METHODS

Ten community health centers in New York City contributed 30 months of de-identified patient data from their EHRs.

RESULTS

Of 302 940 patients, 40% had smoking status recorded and only 34% of documented current smokers received an intervention. Women and younger patients were less likely to have their smoking status documented or to receive an intervention. Patients with comorbidities that are exacerbated by smoking were more likely to have status documented (82.2%) and to receive an intervention (52.1%), especially medication (10.8%). Medication, either alone (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.5, 2.3) or combined with counseling (OR = 1.8; 95% CI = 1.5, 2.3), was associated with higher quit attempts compared with no intervention.

CONCLUSIONS

Data from EHRs demonstrated underdocumentation of smoking status and missed opportunities for cessation interventions. Use of data from EHRs can facilitate quality improvement efforts to increase screening and intervention delivery, with the potential to improve smoking cessation rates.

Health professionals' provision of lifestyle advice in the oncology context in the United Kingdom

A healthy lifestyle following a cancer diagnosis is linked with better long-term outcomes. Health professionals can play an important role in promoting healthy lifestyles after cancer, but little is known about the factors that influence whether or not they give lifestyle advice. We conducted an online survey to examine levels of, and predictors of, health professionals' provision of lifestyle advice to cancer patients in the United Kingdom. The survey included questions on awareness of lifestyle guidelines for cancer survivors, current practices with regard to giving advice on smoking, diet, exercise, weight and alcohol, and perceived barriers to giving advice. Nurses, surgeons and physicians (N=460) responded to the survey. Many (36%) were not aware of any lifestyle guidelines for cancer survivors, but 87% reported giving some lifestyle advice; although this was lower for individual behaviours and often to <50% of patients. Respondents who were aware of lifestyle guidelines were more likely to give lifestyle advice on all behaviours (all OR's>1.76, all P's<0.05). Not believing lifestyle would affect outcomes was associated with lower odds of giving lifestyle advice (all OR's<0.48, all P's<0.05). Improved survivorship education for health professionals may increase the number of patients receiving lifestyle advice, and improve their long-term outcomes.

Teachable moments and missed opportunities for smoking cessation counseling in a hospital emergency department: a mixed-methods study of patient-provider communication

BACKGROUND

While primary care medical clinics have been the most common setting for the delivery of advice about smoking cessation, the hospital emergency department (ED) is a valuable context for counseling medically underserved tobacco users. We conducted a secondary analysis based on a larger audio-recorded study of patient-provider communication about pain and analgesics in the ED. Within a sample of ED patients with back pain, the purpose of this mixed-methods study was to examine how physicians and nurse practitioners capitalize on "teachable moments" for health education to offer spontaneous smoking cessation counseling in the ED.

METHODS

Patients presenting to an academic ED with a primary complaint of back pain were invited to participate in a study of patient-provider communication. Audio-recorded encounters were transcribed verbatim. Two coders reviewed each transcript to determine whether smoking was discussed and to build a corpus of smoking-related discussions. We then developed inductively generated coding categories to characterize how providers responded when patients endorsed smoking behavior. Categories were refined iteratively to accommodate discrepancies.

RESULTS

Of 52 patient-provider encounters during which smoking was discussed, two-thirds of the patients indicated that they were smokers. Providers missed opportunities for smoking cessation counseling 70% of the time. Eleven encounters contained teachable moments for smoking cessation. We identified four primary strategies for creating teachable moments: 1) positive reinforcement, 2) encouragement, 3) assessing readiness, and 4) offering concrete motivating reasons.

CONCLUSIONS

Most providers missed opportunities to offer teachable moments for smoking cessation. In encounters that contained teachable moments, providers employed multiple strategies, combining general advice with motivation tailored to the patient's particular circumstances. Creating motivational links to enhance smoking cessation efforts may be possible with a minimal investment of ED resources.

Diabetes diagnosis and exercise initiation among older Americans

OBJECTIVE

To determine whether exercise participation increased following a new diagnosis of diabetes using a sample of U.S. individuals aged 50 and over who did not report exercise prior to diagnosis.

METHODS

We used data from the 2004-2010 Health and Retirement Study in a pre-post study design. Individuals newly-diagnosed with diabetes (N=635) were propensity score matched to a comparison group with no diabetes.

RESULTS

In the year following a reported diagnosis, 35.7% (95% confidence interval 32.0 to 39.5) of those newly diagnosed with diabetes initiated exercise as compared with 31.4% (95% confidence interval 27.9 to 35.1) for the matched cohort with no diabetes, with a between-group difference of 4.3 percentage points (95% confidence interval -0.9 to 9.4). Among individuals with fewer health risk factors at baseline, the between-group difference was 15.6 percentage points (95% confidence interval 1.58 to 29.5).

CONCLUSION

Over 35% of persons with a new diagnosis of diabetes initiated moderate or vigorous exercise in the year following their diagnosis. Among individuals with fewer health risk factors at baseline, those newly-diagnosed with diabetes were more likely to begin exercise than those without diabetes.

A comparative study on tobacco cessation methods: a quantitative systematic review

BACKGROUND

During recent years, there have been many advances in different types of pharmacological and non-pharmacological tobacco control treatments. In this study, we aimed to identify the most effective smoking cessation methods used in quit based upon a review of the literature.

METHODS

We did a search of PubMed, limited to English publications from 2000 to 2012. Two trained reviewers independently assessed titles, abstracts and full texts of articles after a pilot inter-rater reliability assessment which was conducted by the author (GH). The total number of papers and their conclusions including recommendation of that method (positive) or not supporting (negative) was computed for each method. The number of negative papers was subtracted from the number of positive ones for each method. In cases of inconsistency between the two reviewers, these were adjudicated by author.

RESULTS

Of the 932 articles that were critically assessed, 780 studies supported quit smoking methods. In 90 studies, the methods were not supported or rejected and in 62 cases the methods were not supported. Nicotine replacement therapy (NRT), Champix and Zyban with 352, 117 and 71 studies respectively were the most supported methods and e-cigarettes and non-Nicotine medications with one case were the least supported methods. Finally, NRT with 39 and Champix and education with 36 scores were the most supported methods.

CONCLUSIONS

Results of this review indicate that the scientific papers in the most recent decade recommend the use of NRT and Champix in combination with educational interventions. Additional research is needed to compare qualitative and quantitative studies for smoking cessation.

[Do we teach the smoking cessation intervention to future nurses? Result of a descriptive study]

Introduction :

Les infirmières qui ont reçu une formation en cessation tabagique ont tendance à intervenir davantage auprès des fumeurs que celles qui n’ont pas été formées. Il est démontré qu’une intervention même très brève conduit à une diminution de la prévalence du tabagisme. Or, les programmes qui préparent à l’exercice de la profession infirmière laissent actuellement peu de place à la formation en cessation tabagique. Les objectifs de la recherche sont de décrire les pratiques d’enseignement de la cessation tabagique dans les programmes de formation infirmière et de comparer en tenant compte de la formation en cessation tabagique reçue par les professeures.

Méthodologie :

Un devis descriptif-comparatif a été choisi.

Résultats :

Au total, 278 professeures (20,8 %) ont répondu à un sondage en ligne effectué à l’aide d’un questionnaire validé. Celles-ci avouent offrir en moyenne une heure en cessation tabagique par année. Les aspects physiopathologiques sont couverts au détriment de l’intervention professionnelle en cessation tabagique. Les obstacles identifiés par les professeures sont le manque de temps, de connaissances et de pertinence avec le cours enseigné. Seulement 11,9 % des sujets mentionnent avoir reçu une formation spécifique en cessation tabagique. Or ce sont ces dernières qui enseignent davantage d’éléments reliés à l’intervention en cessation tabagique.

Conclusion :

Une meilleure intégration de l’intervention en promotion de la santé, incluant la cessation tabagique, dans la formation initiale devrait amener la future infirmière à réaliser davantage d’interventions personnalisées en cessation tabagique.

Designing a quality improvement program with electronic health records: New York City's Health eQuits

Despite clear recommendations for identifying and intervening with smokers, clinical preventive practice is inconsistent in primary care. Use of electronic health records could facilitate improvement. Community health centers treating low-income and Medicaid recipients with greater smoking prevalence than the general population were recruited for a pilot program. Key design elements used to engage centers' participation include designating a project champion at each organization, confirming ability to transmit data for reporting and participation, and offering money to facilitate initial engagement; however, financial incentives did not motivate all organizations. Other methods to elicit participation and to motivate practice change included building on centers' previous experiences with similar programs, utilizing existing relationships with state cessation centers, and harnessing the "competitive" spirit-sharing both good news and areas for improvement to stimulate action. These experiences and observations may assist others in designing programs to improve clinical interventions with smokers.

Does individualized health information regarding alcohol consumption affect consumption among risky drinkers?

PURPOSE

Studies testing the effect of physician advice on alcohol consumption in a noncontrolled environment have not specifically focused on risky drinkers. Therefore, it is possible that the estimated effect of professional health advice primarily reflected moderate drinkers' responses. We assessed whether professional health advice reduced alcohol consumption among risky and binge drinkers in a real-world setting.

DESIGN

Retrospective cohort analysis.

SETTING

We used 2009 Behavioral Risk Factor Surveillance System Annual Survey Data.

SUBJECTS

Five thousand seven hundred thirty-five adult male and nonpregnant female risky drinkers, with hypertension or borderline hypertension, who reported on whether they were advised to reduce alcohol consumption.

MEASURES

Dependent variable: respondent was currently reducing alcohol use to control hypertension (1 = yes; 0 = no). Primary regressor: respondent claimed to have received advice from a health professional on reducing alcohol consumption to control hypertension (1 = yes; 0 = no).

ANALYSIS

The model was estimated using generalized maximum entropy.

RESULTS

Professional health advice increased the probability that both risky (marginal effect [ME] = .09), and binge drinkers (ME = .07) reduced their alcohol consumption.

CONCLUSION

Our findings indicate that risky drinkers can effectively be targeted with consumption advice. This has important policy implications given that society bears the largest cost for this group, whereas moderate drinkers have been found to be relatively productive and healthy.

Effectiveness of individual counseling for smoking cessation in smokers with chronic obstructive pulmonary disease and asymptomatic smokers

Few studies have examined the effect of individual counseling for smoking cessation in China. The present study evaluated the efficacy of individual counseling in patients with chronic obstructive pulmonary disease (COPD) and asymptomatic smokers. This prospective randomized study evaluated 85 smokers with COPD and 105 asymptomatic smokers with normal lung function. The individuals were randomly allocated to intervention and control groups. Subjects in the intervention group were provided with individual cognitive counseling based on face-to-face individual consultation, self-help materials and nine telephone follow-ups. Subjects in the control group were provided with simple smoking cessation advice. The smoking status for all subjects and the St. George’s Respiratory Questionnaire (SGRQ) for COPD patients were assessed at baseline, week 4 and month 6. The COPD patient exacerbations during the 6 months were recorded. In the total study population, individual counseling resulted in higher abstinence rates compared with those in the control: Intervention vs. control, 23.4 vs. 10.4% (P=0.007), respectively. Similar results were observed in the smokers with COPD: Intervention vs. control, 40.5 vs. 18.6% (P=0.027), respectively. However, for asymptomatic smokers, the effect of individual counseling was identified to be statistically insignificant: Intervention vs. control, 9.6 vs. 3.8% (P=0.230), respectively. SGRQ scores and COPD exacerbations were significantly improved in patients who abstained from smoking compared with those in the patients who failed to stop smoking. Airway obstruction, quitting motivation and individual counseling were predictors associated with smoking cessation. Airway obstruction was the most significant predictor of smoking cessation (odds ratio, 4.215; 95% confidence interval, 2.215–7.865). The results of the present study show that individual counseling is an effective method for smoking cessation, particularly in COPD patients. However, its efficacy in asymptomatic smokers requires confirmation in further studies.

Teaching Smoking Cessation to Future Nurses

Smoking cessation strategies are barely discussed in nursing education programs, even though initial education shapes how future professionals practice their profession. The aim of this research is to describe the practices, attitudes, and beliefs of nursing educators of Quebec with regard to smoking cessation strategies in initial nursing education. A descriptive design was chosen along with an online questionnaire. A total of 278 educators (20.8%) participated in the survey. Although educators recognize the importance of incorporating smoking cessation strategies into their teaching practice, they allocate an average of only one hour per year to the topic. Tobacco use is addressed mostly in terms of risk factors, with little focus on how to help patients quit. The perceived obstacles are related to false beliefs and a lack of knowledge. The results of this study demonstrate the need to raise educators’ awareness of the importance of incorporating smoking cessation strategies into classroom teaching.

Health care providers' recommendations for physical activity and adherence to physical activity guidelines among adults with arthritis

Introduction

Physical activity is beneficial for reducing pain and improving health-related quality of life among people with arthritis. However, physical inactivity is prevalent among people with arthritis. Health care providers’ recommendations act as a catalyst for changes in health behavior. However, information about the effectiveness of such recommendations is limited in the arthritis literature. We examined the association between providers’ recommendations for physical activity and adherence to physical activity guidelines for adults with arthritis and whether adults’ age influenced this association.

Methods

We used combined data of adult respondents aged 45 years or older with provider-diagnosed arthritis (N = 10,892) from the 2011 Behavioral Risk Factor Surveillance System to conduct a retrospective, cross-sectional study. We used a multivariable logistic regression model to examine the association between health care providers’ recommendations and adherence to physical activity guidelines among adults with arthritis.

Results

Adults with arthritis who received health care providers’ recommendations for physical activity were more likely (odds ratio, 1.22; 95% confidence interval, 1.12–1.32) to adhere to physical activity guidelines than those who did not, after controlling for relevant covariates. Adults’ age did not influence the association between providers’ recommendations and adherence to physical activity (odds ratio, 1.00; 95% confidence interval, 0.99–1.00), after controlling for covariates.

Conclusion

Health care providers’ recommendations are associated with adherence to physical activity guidelines among adults with arthritis. Providers should recommend physical activity to adults with arthritis.

Cigarette smoking and onset of mood and anxiety disorders

OBJECTIVES

We examined the association between regular cigarette smoking and new onset of mood and anxiety disorders.

METHODS

We used logistic regression analysis to detect associations between regular smoking and new-onset disorders during the 3-year follow-up among 34 653 participants in the longitudinal US National Epidemiologic Survey on Alcohol and Related Conditions (2001-2005). We used instrumental variable methods to assess the appropriateness of these models.

RESULTS

Regular smoking was associated with an increased risk of new onset of mood and anxiety disorders in multivariable analyses (Fdf = 5,61 = 11.73; P < .001). Participants who smoked a larger number of cigarettes daily displayed a trend toward greater likelihood of new-onset disorders. Age moderated the association of smoking with most new-onset disorders. The association was mostly statistically significant and generally stronger in participants aged 18 to 49 years but was smaller and mostly nonsignificant in older adults.

CONCLUSIONS

Our finding of a stronger association between regular cigarette smoking and increased risk of new-onset mood and anxiety disorders among younger adults suggest the need for vigorous antismoking campaigns and policy initiatives targeting this age group.

Effect of colonoscopy on colorectal cancer incidence and mortality: an instrumental variable analysis

BACKGROUND

Using population-based health services information to estimate the effectiveness of colonoscopy on colorectal cancer (CRC) outcomes is prone to selection bias.

OBJECTIVE

To determine the effect of colonoscopy on CRC incidence and mortality.

DESIGN

Population-based retrospective cohort study.

SETTING

Ontario provincial health data information.

PATIENTS

This study involved average-risk persons aged 50 to 74 years from 1996 to 2000 who were alive and free of CRC on January 1, 2001.

INTERVENTION

Colonoscopy between 1996 and 2000.

MAIN OUTCOME MEASUREMENTS

CRC incidence and mortality from 2001 to 2007.

RESULTS

The study cohort contained 1,089,998 persons, 7.9% of whom had undergone a colonoscopy between 1996 and 2000. Using primary care physician rate of discretionary colonoscopy as an instrumental variable, the receipt of colonoscopy was associated with a 0.60% (95% confidence interval [CI], 0.31%-0.78%) absolute reduction in the 7-year colorectal cancer incidence and a 0.17% (95% CI, 0.14%-0.21%) absolute reduction in the 5-year risk of death caused by CRC. This corresponds to a 48% relative decrease in CRC incidence (risk ratio [RR] 0.52; 95% CI, 0.34-0.76) and 81% decrease in mortality caused by CRC (RR 0.19, 95% CI, 0.07-0.47). In subgroup analyses, the reduction in the risk of death due to CRC was larger in women than men. The reduction in CRC incidence was larger for complete colonoscopies and for left-sided cancers.

LIMITATIONS

Instrumental variable methods estimate only the marginal effect on the population studied.

CONCLUSION

Increased use of colonoscopy procedures is associated with a reduction in the incidence and mortality of CRC in the population studied.

Medical students' attention to multiple risk behaviors: a standardized patient examination

BACKGROUND

Risk behaviors tend to cluster, particularly among smokers, with negative health effects. To optimize patients' health and wellbeing, health care providers ideally would assess and intervene upon the multiple risks with which patients may present.

OBJECTIVE

This study examined medical students' skills in assessing and treating multiple risk behaviors.

DESIGN

Using a randomized experimental design, medical students' counseling interactions were evaluated with a standardized patient presenting with sexual health concerns and current tobacco use with varied problematic drinking status (alcohol-positive or alcohol-negative).

PARTICIPANTS

One hundred and fifty-six third-year medical students.

MAIN MEASURES

Student and standardized patient completed measures evaluated student knowledge, attitudes, and clinical performance.

KEY RESULTS

Overall, most students assessed tobacco use (85%); fewer assessed alcohol use (54%). Relative to the alcohol-negative case, students seeing the alcohol-positive case were less likely to assess sexually transmitted disease history (80% vs. 91%, p = 0.042), or patients' readiness to quit smoking (41% vs. 60%, p = 0.025), and endorsed greater attitudinal barriers to tobacco treatment (p = 0.030). Patient satisfaction was significantly lower for the alcohol-positive than the alcohol-negative case; clinical performance ratings moderated this relationship.

CONCLUSIONS

When presented with a case of multiple risks, medical students performed less effectively and received lower patient satisfaction ratings. Findings were moderated by students' overall clinical performance. Paradigm shifts are needed in medical education that emphasize assessment of multiple risks, new models of conceptualizing behavior change as a generalized process, and treatment of the whole patient for optimizing health outcomes.

Impact of a bladder cancer diagnosis on smoking behavior

PURPOSE

Bladder cancer is the second most common tobacco-related malignancy. A new bladder cancer diagnosis may be an opportunity to imprint smoking cessation. Little is known about the impact of a diagnosis of bladder cancer on patterns of tobacco use and smoking cessation among patients with incident bladder cancer.

PATIENTS AND METHODS

A simple random sample of noninvasive bladder cancer survivors diagnosed in 2006 was obtained from the California Cancer Registry. Respondents completed a survey on history of tobacco use, beliefs regarding bladder cancer risk factors, and physician influence on tobacco cessation. Respondents were compared by smoking status. Those respondents smoking at diagnosis were compared with general population controls obtained from the California Tobacco Survey to determine the impact of a diagnosis of bladder cancer on patterns of tobacco use.

RESULTS

The response rate was 70% (344 of 492 eligible participants). Most respondents (74%) had a history of cigarette use. Seventeen percent of all respondents were smoking at diagnosis. Smokers with a new diagnosis of bladder cancer were almost five times as likely to quit smoking as smokers in the general population (48% v 10%, respectively; P < .001). The bladder cancer diagnosis and the advice of the urologist were the reasons cited most often for cessation. Respondents were more likely to endorse smoking as a risk factor for bladder cancer when the urologist was the source of their understanding.

CONCLUSION

The diagnosis of bladder cancer is an opportunity for smoking cessation. Urologists can play an integral role in affecting the patterns of tobacco use of those newly diagnosed.

Results From an Outreach Program for Health Systems Change in Tobacco Cessation

Introduction. Washington state has experienced a dramatic reduction in adult smoking prevalence (22.4% in 1999 to 14.8% in 2010) because of a comprehensive tobacco control effort that includes a proactive health professional education and an outreach program. The outreach program uses academic detailing and online tools to increase routine identification and treatment of tobacco users. This article summarizes outcomes from the first 2 years of the program. Method. Outcome measures include the frequency of contact with providers, changes in the percentage of callers reporting that they had heard about the Quit Line from a health professional, and changes in provider Quit Line fax referrals. Data are compared between Initial, Expanded, and Never Outreach Counties. Results. From 2008 to 2010, a total of 629 unique health care organizations and 3,989 unique health professionals received services. Between 2007 and 2010, the ratio of health professional “How Heard Abouts” to total Quit Line registrations increased by 142.6% and 95.4% in Initial and Expanded Outreach Counties, whereas Never Outreach Counties showed an 11.2% increase. Fax referrals to the Quit Line increased by 132% and 232% in Initial and Expanded Outreach Counties whereas they declined by 39% in Never Outreach Counties. Discussion. Results suggests that health professionals can be an important and reliable source of referrals to a treatment resource such as a tobacco quitline. A field-based outreach program using academic detailing principles can be used to increase treatment referrals and holds application for other chronic disease areas and quality improvement programs.

Cigarette smoking knowledge and perceptions among students in four Italian medical schools

INTRODUCTION

Tobacco smoking is the leading cause of premature death in the developed world. Advice and assistance by physicians help smokers quit, but little attention has been paid to the topic of tobacco dependence in the curricula of Italian medical schools. Consequently, few physicians follow the clinical practice guidelines for treating dependence.

METHODS

This study was conducted on 439 students at 4 Italian medical schools in 2010. Students were asked to complete a 60-item questionnaire. Two scores were computed: Score 1 assessed knowledge of the epidemiology of smoking, risks associated with smoking, and benefits of cessation. Score 2 assessed knowledge of tobacco dependence treatment guidelines and the effectiveness of treatments. A score of less than 60% indicated insufficient knowledge.

RESULTS

Medical students had limited knowledge of the epidemiology of smoking, attributable morbidity and mortality, and the benefits of cessation. This limited knowledge was reflected by the finding that 70% of students had a total Score 1 less than 60% of available points. Knowledge of clinical guidelines, perceived competence in counseling smokers, and treatment of addiction was also insufficient, as 76% of students achieved a total Score 2 of less than 60%.

CONCLUSIONS

Our data demonstrate that Italian medical students have limited knowledge about tobacco dependence, how to treat it, and the critical role of the physician in promoting cessation. Taken together with research from other countries, these findings suggest that medical schools do not offer adequate training in tobacco dependence and provide a rationale for modifying the core curriculum to include more information on tobacco dependence treatment.

Provider beliefs and practices relating to tobacco use in patients living with HIV/AIDS: a national survey

The entire online HIV Medical Association US registry was invited to complete a questionnaire regarding beliefs and practices related to smoking in persons living with HIV/AIDS (PLWHAs). 363/486 returned completed questionnaires. Respondents from 43 states reported caring for 76,570 PLWHAs. Only 22.9% had ever received formal tobacco treatment training. Respondents generally agreed that smoking is an important issue in PLWHAs, but reported low levels of cessation-promoting activities. Providers with larger patient panels, "primarily HIV" practices, and formal cessation training had higher questionnaire scores, indicating stronger beliefs in the harms of smoking, benefits of quitting, and effectiveness of cessation strategies.

Awareness and acceptability of human papillomavirus vaccine: an application of the instrumental variables bivariate probit model

Background

Although lower uptake rates of the human papillomavirus (HPV) vaccine among socioeconomically disadvantaged populations have been documented, less is known about the relationships between awareness and acceptability, and other factors affecting HPV vaccine uptake.

The current study aimed to estimate the potential effectiveness of increased HPV vaccine awareness on the acceptability of HPV vaccination in a nationally representative sample of women, using a methodology that controlled for potential non-random selection.

Methods

This study used a population-based sample from the 2007 Health Information National Trends Survey, a cross-sectional study of the US population aged 18 years or older, and focused on the subsample of 742 women who have any female children under the age of 18 years in the household. An instrumental variables bivariate probit model was used to jointly estimate HPV vaccine awareness and acceptability.

Results

The proportion of HPV vaccine acceptability among the previously aware and non-aware groups was 58% and 47%, respectively. Results from the instrumental variables bivariate probit model showed that the estimated marginal effect of awareness on acceptability was 46 percentage points, an effect that was even greater than observed.

Conclusions

Among populations who are not currently aware of the HPV vaccine, the potential impact of raising awareness on acceptability of HPV vaccination is substantial. This finding provides additional support to strengthening public health programs that increase awareness and policy efforts that address barriers to HPV vaccination.

Fax referrals, academic detailing, and tobacco quitline use: a randomized trial

BACKGROUND

Fax referral programs quickly and economically can link smokers' visiting primary care clinics to state-based telephone quitlines. Yet, it is unclear how to optimize use of this strategy.

PURPOSE

To evaluate the potential of enhanced academic detailing in clinics (i.e., on-site training, technical assistance, and performance feedback) to boost utilization of a fax referral program called Fax to Quit.

DESIGN

Participants were randomized to one of two intervention conditions.

SETTING/PARTICIPANTS

Participants were drawn from 49 primary care clinics in southeastern Wisconsin. The sample size was based on a power analysis in which the control intervention condition was estimated to generate 0.5 referrals/clinic/month and the experimental condition 2.0 referrals/clinic/month.

INTERVENTIONS

One of two fax referral program interventions was administered: the control condition Fax to Quit-Only (F2Q-Only) or the experimental condition Fax to Quit plus Enhanced Academic Detailing (F2Q+EAD).

MAIN OUTCOME MEASURES

Clinic- and clinician-specific referral and quality referral rates (those resulting in quitline enrollment) were measured for 13 months post-intervention, starting in March 2009.

RESULTS

Mean number of post-intervention referrals/clinician to the Wisconsin Tobacco Quitline was 5.6 times greater for F2Q+EAD (8.5, SD=7.0) compared to F2Q-Only (1.6, SD=3.6, p<0.001). The F2Q+EAD (4.8, SD=4.1) condition produced a greater mean number of quality referrals/clinician than did the F2Q-Only (0.86, SD=1.8, p<0.001) condition. Data were analyzed in 2010.

CONCLUSIONS

Enhanced academic detailing, which included on-site training, technical assistance, and performance feedback, increased the number of referrals more than fivefold over a fax referral program implemented without such enhanced academic detailing.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov NCT00989755.

Health professional advice for smoking and weight in adults with and without diabetes: findings from BRFSS

Health risk behaviors including smoking and weight-gain can cause and exacerbate chronic diseases like diabetes. Brief provider advice is an effective intervention to reduce risk from these behaviors. However, behavioral advice is provided more often to those who already have a chronic illness when compared with those who are at risk. The purpose of this study is to determine whether the frequency of provider advice for smoking cessation and weight loss varies between overweight or obese smokers with and without diabetes. BRFSS data from a subset of overweight and obese smokers with (n = 848) and without (n = 6,279) diabetes were analyzed to determine differences in reported provider advice. Overweight and obese smokers with diabetes reported receiving more advice for both weight (46.4% vs. 23.4%, P < 0.001) and smoking (84.5% vs. 72.8%, P < 0.001) compared to those without diabetes. Advice for smoking cessation was reported two to three times more often than advice for weight. Nearly a quarter of those with diabetes and almost half of those without reported no receipt of advice about weight. Results indicate that providers are not adequately addressing overweight and obesity in patients with and at risk for diabetes.

Primary care providers advising smokers to quit: comparing effectiveness between those with and without alcohol, drug, or mental disorders

INTRODUCTION

Individuals with alcohol, drug, or mental (ADM) disorders combined make up over 40% of all smokers in the U.S. Primary care providers (PCPs) play an important role in smoking cessation counseling, but their effectiveness with this population is unclear. This study evaluated the effectiveness of PCP smoking cessation counseling for smokers with ADM disorders.

METHODS

Probit regressions conducted in 2009-2010 examined the relationship between past year PCP smoking cessation counseling and successful quitting among 1,356 adults who reported smoking in the 1998-1999 Community Tracking Study survey and who reported seeing a PCP in the past year in the follow-up 2000-2001 Healthcare for Communities Survey. Past year PCP exercise counseling was used as an instrumental variable for past year PCP smoking cessation counseling to account for potential hidden bias between smoking status and receipt of smoking cessation counseling.

RESULTS

Smokers with and without ADM disorders were equally likely to receive smoking cessation counseling (72.9% vs. 69.9%). Using the instrumental variable approach, smoking cessation counseling by PCPs was significantly associated (p < .01) with quitting among both groups. Predicted probabilities of quitting without smoking cessation counseling were 6.0% for smokers with ADM disorders and 10.5% for smokers without ADM disorders. Predicted probabilities of quitting with smoking cessation counseling were 31.3% for smokers with ADM disorders and 34.9% for smokers without ADM disorders.

CONCLUSIONS

This study shows that PCPs can help smokers with ADM disorders successfully quit. These smokers should be targeted for smoking cessation counseling to reduce the health burden of tobacco.