The role of health care systems in increased tobacco cessation

Scoping review of guidance on cessation interventions for electronic cigarettes and dual electronic and combustible cigarettes use

BACKGROUND

Although evidence-based smoking cessation guidelines are available, the applicability of these guidelines for the cessation of electronic cigarette and dual e-cigarette and combustible cigarette use is not yet established. In this review, we aimed to identify current evidence or recommendations for cessation interventions for e-cigarette users and dual users tailored to adolescents, youth and adults, and to provide direction for future research.

METHODS

We systematically searched MEDLINE, Embase, PsycINFO and grey literature for publications that provided evidence or recommendations on vaping cessation for e-cigarette users and complete cessation of cigarette and e-cigarette use for dual users. We excluded publications focused on smoking cessation, harm reduction by e-cigarettes, cannabis vaping, and management of lung injury associated with e-cigarette or vaping use. Data were extracted on general characteristics and recommendations made in the publications, and different critical appraisal tools were used for quality assessment.

RESULTS

A total of 13 publications on vaping cessation interventions were included. Most articles were youth-focused, and behavioural counselling and nicotine replacement therapy were the most recommended interventions. Whereas 10 publications were appraised as "high quality" evidence, 5 articles adapted evidence from evaluation of smoking cessation. No study was found on complete cessation of cigarettes and e-cigarettes for dual users.

INTERPRETATION

There is little evidence in support of effective vaping cessation interventions and no evidence for dual use cessation interventions. For an evidence-based cessation guideline, clinical trials should be rigorously designed to evaluate the effectiveness of behavioural interventions and medications for e-cigarette and dual use cessation among different subpopulations.

Reducing Smoking Cessation Disparities: Capacity for a Primary Care- and Technology-Based Approach Among Medicaid Recipients

While cigarette use among U.S adults has recently decreased, vulnerable subgroups continue to smoke at high rates, including individuals receiving Medicaid insurance. These individuals have also experienced treatment access disparities, highlighting the need for approaches that leverage their strong desire to quit. We conducted interviews with 100 adult primary care patients receiving Medicaid who were current tobacco users about their use, openness to technology-based interventions, and readiness to change. Most (92%) reported current cigarette use and readiness to change averaged 6.98 out of 10 (SD = 2.82). Nearly all were open to completing an iPad-based tobacco screening (95%) and brief intervention (90%) at their next appointment, while 91% and 88% were willing to talk with their provider or a cessation counselor, respectively, about the subsequent results. Results persisted across age, sex, and race/ethnicity. Openness to technology-based interventions in this population provides support for future work that may ultimately reduce disparities.

A Proactive Outreach Strategy Using a Local Area Code to Refer Unassisted Smokers in a Safety Net Health System to a Quitline: A Pragmatic Randomized Trial

INTRODUCTION

Proactive outreach offering tobacco treatment is a promising strategy outside of clinical settings, but little is known about factors for engagement. The study objective is to examine the impact of caller area code in a proactive, phone-based outreach strategy on consenting low-income smokers to a quitline e-referral.

AIMS AND METHODS

This pragmatic randomized trial included unassisted adult smokers (n = 685), whose preferred language was English or Spanish, in a Los Angeles safety-net health system. Patients were randomized to receive a call from a local or generic toll-free area code. Log-binomial regression was used to examine the association between area code and consent to a quitline e-referral, adjusted for age, gender, language, and year.

RESULTS

Overall, 52.1% of the patients were contacted and, among those contacted, 30% consented to a referral. The contact rate was higher for the local versus generic area code, although not statistically significant (55.6% vs. 48.7%, p = .07). The consent rate was higher in the local versus generic area code group (adjusted prevalence ratio 1.29, 95% CI 1.01-1.65) and also higher for patients under 61 years old than over (adjusted prevalence ratio 1.47, 95% CI 1.07-2.01), and Spanish-speaking than English-speaking patients (adjusted prevalence ratio 1.40, 95% CI 1.05-1.86).

CONCLUSIONS

Proactive phone-based outreach to unassisted smokers in a safety net health system increased consent to a quitline referral when local (vs. generic) area codes were used to contact patients. While contact rate did not differ by area code, proactive phone-based outreach was effective for engaging younger and Spanish-speaking smokers.

IMPLICATIONS

Population-based proactive phone-based outreach from a caller with a local area code to unassisted smokers in a safety net health system increases consent to an e-referral for quitline services. Findings suggest that a proactive phone-based outreach, a population-based strategy, is an effective strategy to build on the visit-based model and offer services to tobacco users, regardless of the motivational levels to quit.

A Qualitative Study of Factors Influencing Implementation of Tobacco Control in Pediatric Practices

Introduction

Clinical effort against secondhand smoke exposure (CEASE) is an evidence-based intervention that prepares child healthcare clinicians and staff with the knowledge, skills, and resources needed to ask family members about tobacco use, provide brief counseling and medication assistance, and refer to free cessation services.

Aim

This study sought to identify factors that influenced the implementation of CEASE in five pediatric intervention practices in five states that participated in a cluster randomized clinical trial of the CEASE intervention.

Methods

Guided by questions from the consolidated framework for implementation research (CFIR) interview guide, semistructured qualitative interviews were conducted with 11 clinicians and practice staff from five intervention practices after the practices had implemented CEASE for two years. Interviews were conducted by a trained qualitative researcher, recorded with permission, and transcribed verbatim. An interview codebook was inductively developed; two researchers used the codebook to code data. After coding, data was analyzed to identify factors, as described by the CFIR domains that influenced the implementation of CEASE.

Results

The implementation of CEASE in practices was influenced by the adaptability and complexity of the intervention, the needs of patients and their families, the resources available to practices to support the implementation of CEASE, other competing priorities at the practices, the cultures of practices, and clinicians' and office staffs' knowledge and beliefs about family-centered tobacco control.

Conclusion

Identifying and influencing certain critical factors guided by information gathered through interviews may help improve implementation and sustainability of family-centered tobacco control interventions in the future. Trial Registration: ClinicalTrials.gov Identifier: NCT01882348.

Public Health and Health Care Partnerships for Improved Tobacco Cessation

CONTEXT

Tobacco use remains a leading cause of preventable death and disease. While most tobacco users are interested in quitting, few receive professional assistance.

PROGRAM

This state health department-led project leveraged partnerships to build capacity and support 9 health care organizations in implementing system-level initiatives to improve delivery of tobacco cessation.

IMPLEMENTATION

Participating organizations' initiatives targeted 3 focus areas: implementing best practices for tobacco cessation; quality improvement; and utilization of the electronic health record.

EVALUATION

A qualitative study was conducted to examine facilitators and barriers to tobacco cession systems change among participating health care organizations. Common barriers included time constraints, staffing issues, and organizational structure. These factors often differed by organization type (eg, large vs small). Facilitators included leadership buy-in, organizational priority, technical assistance, teams/teamwork, and IT support.

DISCUSSION

Initial findings suggest that this type of partnership model can be leveraged to gain organizational support, build capacity, address key barriers, and ensure that systems change strategies align with best practices for tobacco cessation across a diverse set of health care organizations. Findings presented in this report provide insights for other public health and health care organizations looking to implement similar initiatives.

Co-creating opportunities to incorporate cessation for electronic nicotine delivery systems in family medicine - a qualitative program evaluation

Background

The number of Americans who use tobacco has decreased in the twenty-first century, but electronic nicotine delivery systems (ENDS) have increased the complexity of treating tobacco dependence. The experiences of 18 family medicine practices were explored and opportunities to improve ENDS cessation were co-created in this study.

Methods

Eighteen family medicine practices were enrolled into an implementation project to incorporate ENDS cessation into their practice. The participants’ experiences were explored throughout the project using an iterative qualitative approach. The research team provided technical assistance. Semi-structured group interviews and focus groups were held with participants at the beginning, middle, and end of the project to explore participants’ experiences. The collective knowledge and experiences of participants, expert consultants and the research team were fused together to co-create opportunities to improve ENDS cessation.

Results

Nine opportunities to improve ENDS cessation were identified in three larger categories. The first category was leading change. This included: creating a vision for change to establish buy-in from key stakeholders and educate health care professionals to improve their confidence to address ENDS. The second category was creating processes. This included: establishing criteria for screening and quality improvement for ENDS cessation; being specific when asking about ENDS; creating electronic health record systems to support incorporating ENDS cessation; using chart audits if electronic health records cannot support incorporating ENDS into tobacco cessation; and assigning roles and responsibilities to members of the clinical care team. The third category was assisting patients who use ENDS. This included: educating patients and their parents/caregivers about ENDS and their potential harms, avoiding dual use, and developing a plan to quit.

Conclusions

This study highlights challenges and opportunities for incorporating ENDS cessation into family medicine. The opportunities outlined here provide a practical approach which is rooted in the experiences of family physicians and their clinical care teams working to improve how they address ENDS and based on peer reviewed literature and expert input. Improving how ENDS are addressed in family medicine will require more than clinical expertise. It will also require leadership skills and the ability to create process improvements.

Trial registration

Not applicable

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01520-x.

Evidence-based smoking cessation treatment: a comparison by healthcare system

BACKGROUND

A systems-level approach to smoking cessation treatment may optimize healthcare provider adherence to guidelines. Institutions such as the Veterans Health Administration (VHA) are unique in their systematic approach, but comparisons of provider behavior in different healthcare systems are limited.

METHODS

We surveyed general medicine providers and specialists in a large academic health center (AHC) and its affiliated VHA in the Mid-South in 2017 to determine the cross-sectional association of healthcare system in which the provider practiced (exposure: AHC versus VHA) with self-reported provision of evidence-based smoking cessation treatment (delivery of counseling plus smoking cessation medication or referral) at least once in the past 12 months (composite outcome). Multivariable logistic regression with adjustment for specialty was performed in 2017-2019.

RESULTS

Of 625 healthcare providers surveyed, 407 (65%) responded, and 366 (59%) were analyzed. Most respondents practiced at the AHC (273[75%] vs VHA 93[25%]) and were general internists (215[59%]); pulmonologists (39[11%]); hematologists/oncologists (69[19%]); and gynecologists (43[12%]). Most respondents (328[90%]) reported the primary outcome. The adjusted odds of evidence-based smoking cessation treatment were higher among VHA vs. AHC healthcare providers (aOR = 4.3; 95% CI 1.3-14.4; p = .02). Health systems differed by provision of individual treatment components, including smoking cessation medication use (98% VHA vs. 90% AHC, p = 0.02) and referral to smoking cessation services (91% VHA vs. 65% AHC p = 0.001).

CONCLUSIONS

VHA healthcare providers were significantly more likely to provide evidence-based smoking cessation treatment compared to AHC healthcare providers. Healthcare systems' prioritization of and investment in smoking cessation treatment is critical to improving providers' adherence to guidelines.

Strategies for Referring Cancer Patients in a Smoking Cessation Program

Most people who smoke and develop cancer are unable to quit smoking. To address this, many cancer centers have now opened smoking cessation programs specifically designed to help cancer patients to quit. An important question has now emerged—what is the most effective approach for engaging smokers within a cancer center in these smoking cessation programs? We report outcomes from a retrospective observational study comparing three referral methods—traditional referral, best practice advisory (BPA), and direct outreach—on utilization of the Duke Cancer Center Smoking Cessation Program. We found that program utilization rate was higher for direct outreach (5.4%) than traditional referral (0.8%), p < 0.001, and BPA (0.2%); p < 0.001. Program utilization was 6.4% for all methods combined. Inferring a causal relationship between referral method and program utilization was not possible because the study did not use a randomized design. Innovation is needed to generate higher utilization rates for cancer center smoking cessation programs.

Health benefits and economic advantages associated with increased utilization of a smoking cessation program

Rationale, aim & objective: The goal of this study was to examine the health and economic impacts related to increased utilization of the Duke Smoking Cessation Program resulting from the addition of two relatively new referral methods - Best Practice Advisory and Population Outreach. Materials & methods: In a companion paper 'Comparison of Referral Methods into a Smoking Cessation Program', we report results from a retrospective, observational, comparative effectiveness study comparing the impact of three referral methods - Traditional Referral, Best Practice Advisory and Population Outreach on utilization of the Duke Smoking Cessation Program. In this paper we take the next step in this comparative assessment by developing a Markov model to estimate the improvement in health and economic outcomes when two referral methods - Best Practice Advisory and Population Outreach - are added to Traditional Referral. Data used in this analysis were collected from Duke Primary Care and Disadvantaged Care clinics over a 1-year period (1 October 2017-30 September 2018). Results: The addition of two new referral methods - Best Practice Advisory and Population Outreach - to Traditional Referral increased the utilization of the Duke Smoking Cessation Program in Primary Care clinics from 129 to 329 smokers and in Disadvantaged Care clinics from 206 to 401 smokers. The addition of these referral methods was estimated to result in 967 life-years gained, 408 discounted quality-adjusted life-years saved and total discounted lifetime direct healthcare cost savings of US$46,376,285. Conclusion: Health systems may achieve increased patient health and decreased healthcare costs by adding Best Practice Advisory and Population Outreach strategies to refer patients to smoking cessation services.

Melatonin for Treatment-Seeking Alcohol Use Disorder patients with sleeping problems: A randomized clinical pilot trial

A high percentage of subjects diagnosed with alcohol use disorder (AUD) suffer from sleeping difficulties. Lack of sleep could lead AUD patients to relapse or, sometimes, to suicide. Most of the currently prescribed medications to treat this complex problem retain a high risk of side effects and/or dependence. Therefore, the aim of the current clinical trial is to investigate the possibility of the use of a safer treatment, such as the natural health product melatonin, to treat alcohol-related sleeping problems. Sixty treatment-seeking AUD subjects were assigned to melatonin (5 mg) or placebo for 4 weeks of treatment. Change in sleeping quality which is the primary outcome of the study was assessed using the Pittsburgh sleep quality index (PSQI) scale. Linear mixed models were used to statistically analyze the difference in scores before and after 4 weeks of treatment. There was a reduction in the global PSQI score in both groups with no significant drug effect between groups. In conclusion, the use of melatonin (5 mg)/day didn't differ from placebo in decreasing sleeping problems in a sample of AUD subjects after 4 weeks of treatment. However, higher doses are worth exploring in future research.

Predictors of Smoking Cessation in Patients With Rheumatoid Arthritis in Two Cohorts: Most Predictive Health Care Factors

OBJECTIVE

Recognizing smoking as a risk factor for rheumatoid arthritis (RA) severity, the present study was undertaken to evaluate patient- and health care-level predictors of smoking cessation in patients with RA to guide implementation of smoking cessation interventions.

METHODS

Electronic health record data from 2 health systems were abstracted for patients with at least 2 International Classification of Disease diagnosis codes for RA between 2005 and 2016. Patients missing smoking statuses or with <6 months of follow-up were excluded. Multivariable logistic regression was used to determine predictors of smoking cessation.

RESULTS

Among 3,577 patients with RA, 507 smoked at baseline, and 29% quit over a median of 4.75 years. Black male patients, ages 40-59 years and enrolled in Medicaid, were significantly more likely to be baseline smokers; however, none of these factors predicted cessation. Instead, patients new to rheumatology care were 60% more likely to quit (adjusted odds ratio [OR_adj ] 1.60 [95% confidence interval (95% CI) 1.02-2.50]), and patients in the rural community health system were 66% more likely to quit (OR_adj 1.66 [95% CI 1.03-2.69]). Seropositive patients were 43% less likely to quit smoking (OR_adj 0.57 [95% CI 0.35-0.91]).

CONCLUSION

Health care factors, including health system and being new to rheumatology care, were more predictive of smoking cessation in patients with RA than patient sociodemographic factors, suggesting an important role for health system cessation efforts for patients with RA. Seropositive patients were less likely to quit and may particularly benefit from cessation support. Emphasizing smoking cessation with new or seropositive RA patients and leveraging health system interventions could improve smoking cessation and outcomes in RA.

Electronic medical record documentation of tobacco cessation support at eight community safety-net clinics with a high prevalence of tobacco use

OBJECTIVES

The high prevalence of tobacco use at primary care safety-net clinics represents an opportunity to offer assistance with cessation. Documentation of smoking status, offering advice and medications, and referral to cessation services are important steps in supporting cessation attempts and are required elements by payors and accrediting agencies to demonstrate care quality. This study examines tobacco cessation support rates and patient characteristics using electronic medical record (EMR) data.

METHODS

This cross-sectional study engaged eight community health centers affiliated with a county hospital system in NE Ohio where adult tobacco use rates exceed 30%. EMR data from June 2014 through May 2016 were analysed to assess rates of tobacco cessation counselling, order of cessation medications, or both. The association of tobacco cessation support with patient characteristics and quit attempts was assessed using multivariable logistic regression models.

RESULTS

Among 21 702 current tobacco users, 74% had no intervention documented; 15.4% had counselling documented, 6.4% were prescribed tobacco cessation medication, and 4.2% had both documented. Males, those aged 18 to 34, and African Americans were more likely to have no documented intervention. Of current tobacco users with at least two visits, 5.6% had a quit attempt. Medication alone was associated with a greater likelihood of a quit attempt (AOR: 1.72 [95% CI: 1.36-2.17]) as well as counselling and medication combined (AOR: 1.95 [95% CI: 1.48-2.56]).

CONCLUSIONS

Tobacco cessation support was lacking for 74% of current smokers and was less likely in subgroups including males, younger adults, and African Americans. Ordering tobacco cessation medication combined with counselling nearly doubled the likelihood of a quit attempt.

Effects of motivation phase intervention components on quit attempts in smokers unwilling to quit: A factorial experiment

BACKGROUND

Smoking reduction treatment is a promising approach to increase abstinence amongst smokers initially unwilling to quit. However, little is known about which reduction treatment elements increase quit attempts and the uptake of cessation treatment amongst such smokers.

METHODS

This study is a secondary analysis of a 4-factor randomized factorial experiment conducted amongst primary care patients (N = 517) presenting for regular healthcare visits in Southern Wisconsin who were unwilling to quit smoking but willing to cut down. We evaluated the main and interactive effects of Motivation-phase intervention components on whether participants: 1) made a quit attempt (intentional abstinence ≥24 h) by 6- and 26-weeks post-study enrollment and, 2) used cessation treatment. We also evaluated the relations of quit attempts with abstinence. The four intervention components evaluated were: 1) Nicotine Patch vs. None; 2) Nicotine Gum vs. None; 3) Motivational Interviewing (MI) vs. None; and 4) Behavioral Reduction Counseling (BR) vs. None. Intervention components were administered over 6 weeks, with an option to repeat treatment; participants could request cessation treatment at any point.

RESULTS

Nicotine gum significantly increased the likelihood of making a quit attempt by 6 weeks (23% vs. 15% without gum; p < .05). Conversely, nicotine patch reduced quit attempts when used with BR. Patch also discouraged use of cessation treatment (15.8% vs. 23% without patch; p < .05). Aided vs. unaided quit attempts produced abstinence in 42% vs. 10% of participants, respectively.

CONCLUSION

Nicotine gum is a promising Motivation-phase intervention that may spur quit attempts amongst smokers initially unwilling to quit.

Direct-to-Member Household or Targeted Mailings: Incentivizing Medicaid Calls for Quitline Services

INTRODUCTION

Innovative methods are needed to promote tobacco cessation services. The Medi-Cal Incentives to Quit Smoking project (2012-2015) promoted modest financial and medication incentives to encourage Medi-Cal smokers to utilize the California Smokers' Helpline (Helpline). This article describes the implementation and impact of two different direct-to-member mailing approaches.

METHODS

Medi-Cal Incentives to Quit Smoking promotional materials were mailed directly to members using two approaches: (1) household mailings: households identified through centralized membership divisions and (2) individually targeted mailings: smokers identified by medical codes from Medi-Cal managed care plans. Mailings included messaging on incentives, such as gift cards or nicotine patches. Number of calls per month, calls per unit mailed, and associated printing costs per call were compared during and 1 month after mailings. Activated caller response was based on reporting a household mailing promotional code or based on requesting financial incentives for individually targeted mailings. Analyses were conducted in 2018.

RESULTS

Direct-to-member mailings, particularly with incentive messaging, demonstrated an increase in call volumes during and 1 month after mailing, and increased Medi-Cal calls to the Helpline per unit mailed. Mailings with only counseling messages had the lowest percentage of activated calls per unit mailed, whereas the incentive messaging mailings were consistently higher. Although household mailings demonstrated lower printing costs per call, individually targeted mailings had a higher percentage of activated calls per unit mailed.

CONCLUSIONS

Household and individually targeted mailings are feasible approaches to increase Medi-Cal calls to the Helpline, particularly with incentive messaging. Choosing an approach and messaging depends on available resources, timing, and purpose.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Testing the PPAR hypothesis of tobacco use disorder in humans: A randomized trial of the impact of gemfibrozil (a partial PPARα agonist) in smokers

Previous pre-clinical studies demonstrated a promising role of alpha-type peroxisome proliferator-activated receptors (PPARα) agonists in decreasing nicotine self-administration and nicotine-seeking behavior in animals. Our goal was to investigate the potential of gemfibrozil, a PPARα agonist, on reducing tobacco smoking in humans. Methods: This was a double-blind, placebo-controlled, crossover study evaluating the effects of gemfibrozil (1200 mg/day) on smoking in 27 treatment-seeking smokers. The study had two 2-week phases separated by a washout period of at least 1 week. In each phase and after 1 week on medication, participants underwent a lab session where cue reactivity and forced choice paradigms were conducted. Physiological responses and self-reported craving were monitored during the presentation of smoking and neutral cues. In addition, two types of cigarettes were used in the forced choice paradigms: the Nicotinized cigarettes (Nic) and the Denicotinized cigarettes (Denic). The goal of the forced choice was to calculate the percentage of choice of Nic cigarettes while taking gemfibrozil or placebo. The number of quit days was calculated during the two quit attempts weeks (one while taking gemfibrozil and one while taking placebo) of the study. Results: There were no significant differences between gemfibrozil and placebo groups in the percentage of choice of Nic cigarettes, the cue-reactivity (both physiological and subjective measures), or in the number of days of abstinence. Conclusions: Although preclinical studies with PPAR α agonists showed promising results, this preliminary study did not demonstrate positive effect of gemfibrozil on tobacco use and cessation indices.

A National Survey of Community Pharmacists on Smoking Cessation Services in Thailand

Providing smoking cessation services is one role of community pharmacists in Thailand. This cross-sectional study aimed to investigate activities and barriers related to smoking cessation services provided in community pharmacies in Thailand, as well as to compare these activities and barriers between those pharmacists providing and those not providing smoking cessation services. A postal questionnaire was conducted to collect information from community pharmacists across Thailand. In all, 413 valid responses were received from 5235 questionnaires, giving a 7.9% response rate. Of the 413 respondents, 152 (37%) pharmacists provided smoking cessation services in their pharmacy. The activities of smoking cessation services varied. Time for counseling each smoker varied, a mean of 15.1 ± 10.9 min (range 1–60) per person for the first time, and 8.9 ± 6.7 min (range 1–30) for each follow-up visit. Community pharmacists, providing smoking cessation services, were more likely to have pharmacist assistants, be a member of the Thai Pharmacy Network for Tobacco Control, and have more than 1 pharmacist on duty. The most dispensed pharmaceutical product for smoking cessation was nicotine gum. Their most perceived barriers were being unable to follow-up and inadequate staff. In conclusion, only a minority of community pharmacists in Thailand are engaged in smoking cessation activities, even though some perceived barriers existed.

An analysis of adaptations to multi-level intervention strategies to enhance implementation of clinical practice guidelines for treating tobacco use in dental care settings

Introduction

Our team conducted a cluster randomized controlled trial (DUET) that compared the effectiveness of three theory-driven, implementation strategies on dental provider adherence to tobacco dependence treatment guidelines (TDT). In this paper we describe the process of adapting the implementation strategies to the local context of participating dental public health clinics in New York City.

Methods

Eighteen dental clinics were randomized to one of three study arms testing several implementation strategies: Current Best Practices (CBP) (i.e. staff training, clinical reminder system and Quitline referral system); CBP + Performance Feedback (PF) (i.e. feedback reports on provider delivery of TDT); and CBP + PF + Pay-for-Performance (i.e. financial incentives for provision of TDT). Through an iterative process, we used Stirman's modification framework to classify, code and analyze modifications made to the implementation strategies.

Results

We identified examples of six of Stirman's twelve content modification categories and two of the four context modification categories. Content modifications were classified as: tailoring, tweaking or refining (49.8%), adding elements (14.1%), departing from the intervention (9.3%), loosening structure (4.4%), lengthening and extending (4.4%) and substituting elements (4.4%). Context modifications were classified as those related to personnel (7.9%) and to the format/channel (8.8%) of the intervention delivery. Common factors associated with adaptations that arose during the intervention included staff changes, time constraints, changes in leadership preferences and functional limitations of to the Electronic Dental Record.

Conclusions

This study offers guidance on how to capture intervention adaptation in the context of a multi-level intervention aimed at implementing sustainable changes to optimize TDT in varying public health dental settings.

A Cluster Randomised Controlled Trial of a Brief Child Health Nurse Intervention to Reduce Infant Secondhand Smoke Exposure

Background Exposure to secondhand smoke (SHS) is a significant contributor to ill health in children. A study was undertaken to determine the effectiveness of two brief multi-strategic child health nurse delivered interventions in: decreasing the prevalence of infants exposed to SHS; decreasing the prevalence of smoking amongst parent/carers of infants and increasing the prevalence of household smoking bans. Methods This study was a 3 arm, cluster randomised controlled trial. Clusters were 39 community based well child health clinics in one local area health service. Clinics were stratified according to annual number of client appointments and then randomly assigned in a 1:1:1 ratio, (Intervention 1: Intervention 2: Control), with 13 clinics in each cluster. Parents/carers of infants in the intervention groups received a brief multi-strategic intervention from child health nurses during clinic consultations. Treatment condition 1 included computer delivered risk assessment and feedback and nurse brief advice. Treatment condition 2 included all elements of Treatment condition 1 with the addition of biochemical feedback of infant SHS exposure. Results When compared to the Control group at 12 months, no significant differences in the prevalence of infant exposure to SHS were detected from baseline to follow-up for Treatment condition 1 (OR 1.16, 95 % CI 0.73-1.85, p = 0.53) or Treatment condition 2 (OR 1.30, 95 % CI 0.88-1.92, p = 0.19) Similarly, no significant differences were detected in the proportion of parent/carers who reported that they were smokers (T1:OR 0.95, 95 % CI 0.78-1.15, p = 0.58 and T2:OR 0.97, 95 % CI 0.80-1.18, p = 0.77), or in the proportion of households reported to have a complete smoking ban (T1:OR 1.21, 95 % CI 0.89-1.64, p = 0.23 and T2:OR 1.06, 95 % CI 0.79-1.43, p = 0.68). Conclusions Further research is required to identify effective interventions that can be consistently provided by child health nurses if the potential of such settings to contribute to reductions in child SHS exposure is to be realised.

Economic Conditions and Drug and Opioid Overdose Deaths

We examine the effects of state-level economic conditions including unemployment rates, median house price, median household income, insurance coverage, and annual and weekly work time on deaths on drug overdose deaths including from opioids and prescription opioids between 1999 and 2014. We employ difference-in-differences estimation controlling for state and year fixed effects, state-specific time trends, and demographic characteristics. Drug overdose deaths significantly declined with higher house prices, an effect driven by reduction in prescription-opioid mortality, by nearly 0.17 deaths per 100,000 (~4%) with a $10,000 increase in median house price. House price effects were more pronounced and only significant among males, non-Hispanic Whites, and individuals younger 45 years. Other economic indicators had insignificant effects. Our findings suggest that economic downturns that substantially reduce house prices such as the Great Recession can increase opioid-related deaths, suggesting that efforts to control access to such drugs should especially intensify during these periods.

Systematic review of interventions to increase the delivery of preventive care by primary care nurses and allied health clinicians

Background

Primary care nurses and allied health clinicians are potential providers of opportunistic preventive care. This systematic review aimed to summarise evidence for the effectiveness of practice change interventions in increasing nurse or allied health professional provision of any of five preventive care elements (ask, assess, advise, assist, and/or arrange) for any of four behavioural risks (smoking, inadequate nutrition, alcohol overconsumption, physical inactivity) within a primary care setting.

Methods

A search of Medline, Embase, PsycInfo, and CINAHL databases was undertaken to locate controlled intervention trials published between 1992 and May 2014 that provided practice change interventions to primary care nurses and/or allied health professionals to increase preventive care. The effect of interventions aimed at increasing the provision of any of the five care elements for any of the four behavioural risks was examined. A narrative synthesis was utilised.

Results

From 8109 articles, seven trials met the inclusion criteria. All trials bar one, assessed multi-strategic practice change interventions (three to five strategies) focused on care by nurses (six trials) or mixed nursing/allied health clinicians. One trial examined care provision for all four risks, five trials examined care for smoking only, and one trial examined care for alcohol consumption only. For the six trials reporting significance testing (excludes one smoking care trial), significant effects favouring the intervention group were reported in at least one trial for smoking risk assessment (2/4 trials reported an effect for at least one analysis of an assessment outcome), brief advice (2/3), assistance (2/2), and arranging referral (2/3); alcohol risk assessment (1/2) and brief advice (1/2); inadequate nutrition risk assessment (1/1); and physical inactivity risk assessment and brief advice (1/1). When the number of analyses undertaken within trials focusing on smoking care was considered, the results were less promising (e.g. of the 15 analyses conducted on brief advice variables across three trials, four showed a positive effect).

Conclusions

Evidence for the effect of practice change interventions on preventive care by primary care nurses or allied health providers is inconclusive given the small number of trials and inconsistency of results between and within trials.

Systematic review registration number

None

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0409-3) contains supplementary material, which is available to authorized users.

Assessment of compliance with U.S. Public Health Service clinical practice guideline for tobacco by primary care physicians

Background

The US Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update established an expanded standard of care, calling on physicians to consistently identify their patients who use tobacco and treat them using counseling and medication.

Findings

To assess compliance, we examined the extent to which physicians self-report following four of the five components of the 5A model: Ask about tobacco use, Advise patients who use tobacco to quit, Assist the patient in making a quit attempt, and Arrange for follow-up care. We used data from a Web-based panel survey administered to a convenience sample of 1,253 primary care providers (family/general practitioners, internists, and obstetrician/gynecologists). We found that 97.1% of the providers reported that they consistently Asked and documented tobacco use, while 98.6% reported that they consistently Advised their patients to quit using tobacco. Among the family/general practitioners and internists, 98.3% recommended “any” (medication, counseling, counseling and medication, telephone quitline) smoking cessation strategies (Assist). Among all providers, 48.0% reported that they consistently scheduled a follow-up visit (Arrange).

Conclusions

This study revealed that most primary care physicians reported that they Ask their patients about tobacco use, Advise them to quit, and Assist them in making a quit attempt, but only half reported that they Arrange a follow-up visit. Tobacco use screening and intervention are among the most effective clinical preventive services; thus, efforts to educate, encourage, and support primary care physicians to provide evidence-based treatments to their patients should be continued.

Facilitators of health systems change for tobacco dependence treatment: a qualitative study of stakeholders' perceptions

Background

Health systems play key roles in identifying tobacco users and providing evidence-based care to help them quit. Health systems change – changes to health care processes, policies and financing – has potential to build capacity within these systems to address tobacco use. In 2010, ClearWay Minnesota^SM piloted a health systems change funding initiative, providing resources and technical assistance to four health care systems. This paper presents findings from a process evaluation, describing key stakeholders’ views on whether changes to how health systems treat tobacco use resulted from this initiative and what may have facilitated those changes.

Methods

A process evaluation was conducted by an independent evaluation firm. A qualitative case study approach provided understanding of systems change efforts. Interviews were conducted with key informants representing the health systems, funder and technical assistance providers. Core documents were reviewed and compared to thematic analysis from the interviews. Results were triangulated with existing literature to check for convergence or divergence. A cross-case analysis of the findings was conducted in which themes were compared and contrasted.

Results

All systems created and implemented well-defined written tobacco use screening, documentation and treatment referral protocols for every patient at every visit. Three implemented systematic follow-up procedures for patients referred to treatment, and three also implemented changes to electronic health records systems to facilitate screening, referral and reporting. Fax referral to quitline services was implemented or enhanced by two systems. Elements that facilitated successful systems changes included capitalizing on environmental changes, ensuring participation and support at all organizational levels, using technology, establishing ongoing training and continuous quality improvement mechanisms and leveraging external funding and technical assistance.

Conclusions

This evaluation demonstrates that health systems can implement substantial changes to facilitate routine treatment of tobacco dependence in a relatively short timeframe. Implementing best practices like these, including increased emphasis on the implementation and use of electronic health record systems and healthcare quality measures, is increasingly important given the changing health care environment. Lessons learned from this project can be resources for states and health systems likely to implement similar systems changes.

Increasing preventive care by primary care nursing and allied health clinicians: a non-randomized controlled trial

BACKGROUND

Although primary care nurse and allied health clinician consultations represent key opportunities for the provision of preventive care, it is provided suboptimally.

PURPOSE

To assess the effectiveness of a practice change intervention in increasing primary care nursing and allied health clinician provision of preventive care for four health risks.

DESIGN

Two-group (intervention versus control), non-randomized controlled study assessing the effectiveness of the intervention in increasing clinician provision of preventive care.

SETTING/PARTICIPANTS

Randomly selected clients from 17 primary healthcare facilities participated in telephone surveys that assessed their receipt of preventive care prior to (September 2009-2010, n=876) and following intervention (October 2011-2012, n=1,113).

INTERVENTION

The intervention involved local leadership and consensus processes, electronic medical record system modification, educational meetings and outreach, provision of practice change resources and support, and performance monitoring and feedback.

MAIN OUTCOME MEASURES

The primary outcome was differential change in client-reported receipt of three elements of preventive care (assessment, brief advice, referral/follow-up) for each of four behavioral risks individually (smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, physical inactivity) and combined. Logistic regression assessed intervention effectiveness.

RESULTS

Analyses conducted in 2013 indicated significant improvements in preventive care delivery in the intervention compared to the control group from baseline to follow-up for assessment of fruit and vegetable consumption (+23.8% vs -1.5%); physical activity (+11.1% vs -0.3%); all four risks combined (+16.9% vs -1.0%) and for brief advice for inadequate fruit and vegetable consumption (+19.3% vs -2.0%); alcohol overconsumption (+14.5% vs -8.9%); and all four risks combined (+14.3% vs +2.2%). The intervention was ineffective in increasing the provision of the remaining forms of preventive care.

CONCLUSIONS

The intervention's impact on the provision of preventive care varied by both care element and risk type. Further intervention is required to increase the consistent provision of preventive care, particularly referral/follow-up.

Tobacco cessation counseling training in US entry-level physical therapist education curricula: prevalence, content, and associated factors

BACKGROUND

The US Public Health Service (USPHS) recommends tobacco cessation counseling (TCC) training for all health care professionals. Within physical therapist practice, smoking can have adverse effects on treatment outcomes in all body systems. In addition, people with physical disabilities have a higher smoking prevalence than the general population, creating a strong need for tobacco cessation among physical therapy clientele. Therefore, TCC training is an important component of entry-level physical therapist education.

OBJECTIVE

The aims of this study were: (1) to determine need for TCC training within entry-level physical therapist education and (2) to identify potential barriers to implementation of USPHS guidelines in the academic environment.

DESIGN

A descriptive cross-sectional survey was conducted.

METHODS

Directors or academic coordinators of clinical education from entry-level physical therapist programs (N=204) were surveyed using an online instrument designed specifically for this study. Data regarding program and faculty characteristics, tobacco-related training content, and faculty opinions toward TCC in both physical therapist practice and education were analyzed descriptively.

RESULTS

The response rate was 71%. A majority (60%) of programs indicated inclusion of tobacco-related training, most commonly 1 to 2 hours in duration, and of these programs, 40% trained students in the implementation of USPHS clinical guidelines for TCC.

LIMITATIONS

Data analyses were constrained by limited or missing data in some areas. A single faculty member completed the survey for each program.

CONCLUSIONS

There is a need for TCC training in entry-level physical therapist education. Inclusion may be facilitated by addressing perceived barriers toward TCC as a component of physical therapist practice and promoting the relevance of TCC as it relates to intended outcomes of physical therapy interventions.

Health care provider advice for adolescent tobacco use: results from the 2011 National Youth Tobacco Survey

BACKGROUND

Health care providers play an important role in promoting tobacco use abstinence among adolescents. This study aimed to provide nationally representative data on the prevalence of provider tobacco use screening and advice delivered to adolescents. Cessation behaviors and correlates of past year quit attempts among current smokers are also explored.

METHODS

Data came from the 2011 National Youth Tobacco Survey, a nationally representative school-based survey of adolescents in grades 6 through 12 (n = 18385). Provider screening and advice were assessed by smoking status and demographic characteristics. Logistic regression was used to assess the association between advice and past year quit attempt.

RESULTS

The overall prevalence of current tobacco use was 16.6%; 10.8% were current cigarette smokers (3.6% were established smokers, 7.2% were nonestablished smokers); 17.3% were former smokers; and 71.9% were never smokers (22.6% high susceptibility, 77.4% low susceptibility). Among all respondents, the prevalence of being asked about tobacco use by a health care provider was 32.2%; the prevalence of being advised to quit or avoid tobacco was 31.4%. Established smokers were more likely than other groups to report provider assessment of tobacco use and advice. Receipt of advice was associated with a higher adjusted odds of having made a past year quit attempt (odds ratio: 1.47, 95% confidence interval: 1.18-1.82).

CONCLUSIONS

Less than one-third of adolescents report being asked about tobacco use or being advised not to use tobacco. Increased tobacco use intervention by health care providers is needed to prevent initiation and increase cessation.

Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings

BACKGROUND

Although dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence.

METHODS/DESIGN

Guided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines-staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers' tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence.

DISCUSSION

We hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings will improve knowledge pertinent to the implementation, dissemination, and sustained utilization of evidence-based tobacco use treatment in dental practices.

TRIAL REGISTRATION

NCT01615237.

Clinician assessment, advice and referral for multiple health risk behaviors: prevalence and predictors of delivery by primary health care nurses and allied health professionals

OBJECTIVE

Primary care clinicians have considerable potential to provide preventive care. This study describes their preventive care delivery.

METHODS

A survey of 384 community health nurses and allied health clinicians from in New South Wales, Australia was undertaken (2010-11) to examine the assessment of client risk, provision of brief advice and referral/follow-up regarding smoking inadequate fruit and vegetable consumption, alcohol misuse, and physical inactivity; the existence of preventive care support strategies; and the association between supports and preventive care provision.

RESULTS

Preventive care to 80% or more clients was least often provided for referral/follow-up (24.7-45.6% of clinicians for individual risks, and 24.2% for all risks) and most often for assessment (34.4-69.3% of clinicians for individual risks, and 24.4% for all risks). Approximately 75% reported having 9 or fewer of 17 supports. Provision of care was associated with: availability of a paper screening tool; training; GP referral letter; and number of supports.

CONCLUSION

The delivery of preventive care was limited, and varied according to type of care and risk. Supports were variably associated with elements of preventive care.

PRACTICE IMPLICATIONS

Further research is required to increase routine preventive care delivery and the availability of supports.

Attitudinal factors protective against youth smoking: an integrative review

PURPOSE

This review examines recent literature with the purpose of uncovering associations between attitudinal factors and smoking among youth populations.

ORGANIZING CONSTRUCT AND METHODS

Researchers conducted an integrative review of the literature in late 2012 and early 2013. As inclusion criteria, potential articles were measured against the following statement: "There is valid evidence of (an) attitudinal factor(s) potentially associated with smoking among youth."

FINDINGS

Researchers employed the salutogenic model as a theoretical framework to analyze search results. The narrative synthesis indicates that primary attitudinal factors protective against smoking among youth include the following: (a) a perception that there is little benefit to smoking, (b) a belief that smoking is likely harmful and addictive in the short term, and (c) a denial that smoking provides stress abatement, makes one look cool or more grown-up, or is common and accepted. Moreover, research signals that youth who smoke often demonstrate essentially the opposite beliefs and attitudes.

CONCLUSIONS

Findings suggest attitudinal factors play a role in protection against youth smoking. Those youth who assign realistic values to smoking risks and benefits are more equipped to engage in the health-protective behavior of not smoking. Youth, adolescents, and young adults appear vulnerable to inappropriate designation of risk and benefit values of smoking. Theoretical interpretation suggests that bolstering attitudinal factors during youth might counteract immature risk assessment. These findings justify further research related to protective mechanisms against youth smoking and youth-based smoking prevention interventions.

CLINICAL RELEVANCE

The establishment of associations between attitudinal factors and protection against smoking can help determine interventions effective in reducing smoking among youth.

Implementing point of care "e-referrals" in 137 clinics to increase access to a quit smoking internet system: the Quit-Primo and National Dental PBRN HI-QUIT Studies

Integrating electronic referral systems into clinical practices may increase use of web-accessible tobacco interventions. We report on our feasibility evaluation of using theory-driven implementation science techniques to translate an e-referral system (ReferASmoker.org) into the workflow of 137 community-based medical and dental practices, including system use, patient registration, implementation costs, and lessons learned. After 6 months, 2,376 smokers were e-referred (medical, 1,625; dental, 751). Eighty-six percent of the medical practices [75/87, mean referral = 18.7 (SD = 17.9), range 0-105] and dental practices [43/50, mean referral = 15.0 (SD = 10.5), range 0-38] had e-referred. Of those smokers e-referred, 25.3 registered [mean smoker registration rate-medical 4.9 (SD = 7.6, range 0-59), dental 3.6 (SD = 3.0, range 0-10)]. Estimated mean implementation costs are medical practices, US$429.00 (SD = 85.3); and dental practices, US$238.75 (SD = 13.6). High performing practices reported specific strategies to integrate ReferASmoker.org; low performers reported lack of smokers and patient disinterest in the study. Thus, a majority of practices e-referred and 25.3 % of referred smokers registered demonstrating e-referral feasibility. However, further examination of the identified implementation barriers is important as of the estimated 90,000 to 140,000 smokers seen in the 87 medical practices in 6 months, only 1,625 were e-referred.

Patient-reported recall of smoking cessation interventions from a health professional

OBJECTIVE

To determine the prevalence and characteristics of current cigarette smokers who report receiving health care provider interventions ('5A's': ask, advise, assess, assist, arrange) for smoking cessation.

METHODS

Data came from the 2009-2010 National Adult Tobacco Survey, a telephone survey of United States adults aged ≥ 18 years. Among current cigarette smokers who reported visiting a health professional in the past year (n=16,542), estimates were calculated overall and by sex, age, race/ethnicity, education, income, health insurance coverage, and sexual orientation.

RESULTS

Among smokers who visited a health professional (75.2%), 87.9% were asked if they used tobacco, 65.8% were advised to quit, and 42.6% were asked if they wanted to quit. Among those wanting to quit, 78.2% were offered assistance and 17.5% had follow-up arranged. Receipt of the 'ask' component was lower among males and uninsured individuals. Receipt of the 'advise' and 'assess' components was lower among those aged 18-24 and uninsured individuals. Receipt of the 'assist' component was lower among non-Hispanic blacks. No differences were observed for the 'arrange' component.

CONCLUSIONS

Many current smokers report receiving health care provider interventions for smoking cessation. Continued efforts to educate, encourage, and support all health professionals to provide effective, comprehensive tobacco cessation interventions to their patients may be beneficial.

Comprehensive assessment of the impact of cigarette smoking on survival of clear cell kidney cancer

PURPOSE

The impact of modifiable environmental factors on kidney cancer specific outcomes is under studied. We evaluated the impact of smoking exposure on cancer specific survival in patients with clear cell renal cell carcinoma treated with surgery.

MATERIALS AND METHODS

From a prospectively maintained database at a single center we collected the characteristics of 1,625 patients with clear cell renal cell carcinoma treated with surgery between 1995 through 2012. We determined the associations of smoking status with advanced disease, defined as AJCC (American Joint Committee on Cancer) stage greater than 2, and with cancer specific survival.

RESULTS

The prevalence rate of current, former and never smoking at diagnosis was 16%, 30% and 54%, respectively. Of the patients 62% reported a smoking history of 20 pack-years or greater. Median followup in survivors was 4.5 years (IQR 2.2-7.9). On univariable analysis a smoking history of 20 pack-years or greater was associated with a significantly increased risk of advanced disease (OR 1.43, 95% CI 1.02-2.00). However, it did not achieve an independent association after adjusting for age and gender. Pathological stage and Fuhrman grade adversely affected cancer specific survival on multivariable competing risks analysis. Although the association between smoking and cancer specific survival did not achieve statistical significance on multivariable analysis, the direction of the central estimate (HR 1.5, 95% CI 0.89-2.52) suggested that smoking adversely impacts cancer specific survival. Current smokers faced a higher risk of death from another cause than never smokers (HR 1.93, 95% CI 1.29-2.88).

CONCLUSIONS

Smoking exposure substantially increases the risk of death from another cause and adversely impacts cancer specific survival in patients with clear cell renal cell carcinoma. Treatment plans to promote smoking cessation are recommended for these patients.

The delivery of preventive care to clients of community health services

Background

Smoking, poor nutrition, risky alcohol use, and physical inactivity are the primary behavioral risks for common causes of mortality and morbidity. Evidence and guidelines support routine clinician delivery of preventive care. Limited evidence describes the level delivered in community health settings. The objective was to determine the: prevalence of preventive care provided by community health clinicians; association between client and service characteristics and receipt of care; and acceptability of care. This will assist in informing interventions that facilitate adoption of opportunistic preventive care delivery to all clients.

Methods

In 2009 and 2010 a telephone survey was undertaken of 1284 clients across a network of 56 public community health facilities in one health district in New South Wales, Australia. The survey assessed receipt of preventive care (assessment, brief advice, and referral/follow-up) regarding smoking, inadequate fruit and vegetable consumption, alcohol overconsumption, and physical inactivity; and acceptability of care.

Results

Care was most frequently reported for smoking (assessment: 59.9%, brief advice: 61.7%, and offer of referral to a telephone service: 4.5%) and least frequently for inadequate fruit or vegetable consumption (27.0%, 20.0% and 0.9% respectively). Sixteen percent reported assessment for all risks, 16.2% received brief advice for all risks, and 0.6% were offered a specific referral for all risks. The following were associated with increased care: diabetes services, number of appointments, being male, Aboriginal, unemployed, and socio-economically disadvantaged. Acceptability of preventive care was high (76.0%-95.3%).

Conclusions

Despite strong client support, preventive care was not provided opportunistically to all, and was preferentially provided to select groups. This suggests a need for practice change strategies to enhance preventive care provision to achieve adherence to clinical guidelines.

Impact of smoking status at diagnosis on disease recurrence and death in upper tract urothelial carcinoma

Cigarette smoking is the leading cause of urothelial carcinoma; however, the impact of smoking on outcomes after surgery for upper tract urothelial carcinoma is unknown. One study suggests that patients with a smoking history have an increased risk of recurrence in the bladder compared with never smokers but these patients did not differ with respect to time to pelvic recurrence or distant metastasis. We subdivided smokers into current and former smokers and performed multivariate analyses that showed that smoking status was not an independent predictor of recurrence when traditional prognostic factors were taken into account. In addition, competing risks analyses showed that although current smoking did not increase the risk of recurrence, it imparted a significant risk of dying compared with former and never smoking.

OBJECTIVE

To evaluate the impact of smoking exposure on oncological outcomes in patients with upper tract urothelial carcinoma (UTUC) treated with radical nephroureterectomy (RNU).

MATERIALS AND METHODS

Patient and disease characteristics from 288 patients with UTUC treated with RNU between 1995 and 2008 were collected from a prospectively maintained database at the Memorial Sloan-Kettering Cancer Center. Disease recurrence was defined as distant metastases, or local failure in the operative site or regional nodes. Factors associated with recurrence and death were determined.

RESULTS

The prevalence of current, former and never smoking at diagnosis was 19.1%, 55.2%, and 25.7%, respectively. 71.0% of patients reported a ≥20 pack-year smoking history. With a median follow-up of 4.02 years, disease recurrence occurred in 27% (n = 79) of patients and 41% (n = 117) died during follow-up. While age at diagnosis, American Society of Anesthesiologists score, advanced stage, nodal involvement and high grade adversely affected recurrence-free survival, smoking status was not associated with risk of recurrence or death in multivariate analysis (P = 0.60). Multivariate competing risks regression showed that current smokers faced a significantly higher risk of death than never smokers (hazard ratio 3.64, 95% confidence interval 1.59-8.34).

CONCLUSIONS

While smoking status at diagnosis and cumulative smoking exposure were not associated with UTUC recurrence, our findings highlight the substantial risk of death in patients with UTUC who are active smokers. Treatment plans to promote smoking cessation are recommended for these patients.

Addressing tobacco use in homeless populations: recommendations of an expert panel

A diverse group of panelists met for one day on October 21, 2009, in Washington, DC, for the purpose of addressing the high tobacco use prevalence rates in homeless populations; identifying appropriate policy, cessation practices and models for implementation in this population; and providing targeted recommendations for researchers, homeless service providers, tobacco control advocates, and policy makers. The panel was convened by Break Free Alliance, one of six national networks funded by the Centers for Disease Control and Prevention, Office on Smoking and Health. The panelists worked through a process of problem identification, generation of responses, analysis and prioritization, development of recommendations, and arrival of final decisions reached by consensus. The resulting recommendations for addressing tobacco use in homeless populations focused on tobacco non-use policy implementation, cessation programming, and expansion of partnerships and collaborations between tobacco control advocates and social service providers. The panel also identified unanswered research questions that can serve to develop a framework for future initiatives to reduce tobacco use among homeless persons. The expert panel model serves as one approach for engaging nontraditional partners and building consensus among leaders from a variety of sectors to address tobacco use in special populations.

Economic evaluation of pharmaco- and behavioral therapies for smoking cessation: a critical and systematic review of empirical research

Economic evaluations are an important tool to improve our understanding of the costs and effects of health care services and to create sustainable health care systems. This article critically assesses empirical evidence from economic evaluations of pharmaco- and behavioral therapies for smoking cessation. A comprehensive literature review of PubMed and the British National Health Service Economic Evaluation Database was conducted. The search identified 15 articles on nicotine-based pharmacotherapies, 12 articles on nonnicotine based pharmacotherapies, no articles on selegiline, and 10 articles on brief counseling for smoking cessation treatment. Results show that both pharmaco- and behavioral therapies for smoking cessation are cost-effective or even cost-saving. The review highlights several shortcomings in methodology and a lack of standardization of current economic evaluations. Efforts to improve methodology will help make future studies more comparable and increase the evidence base so that such evaluations can be more useful to public health practitioners and policy makers.

The effectiveness of an intervention in increasing community health clinician provision of preventive care: a study protocol of a non-randomised, multiple-baseline trial

BACKGROUND

The primary behavioural risks for the most common causes of mortality and morbidity in developed countries are tobacco smoking, poor nutrition, risky alcohol use, and physical inactivity. Evidence, guidelines and policies support routine clinician delivery of care to prevent these risks within primary care settings. Despite the potential afforded by community health services for the delivery of such preventive care, the limited evidence available suggests it is provided at suboptimal levels. This study aims to assess the effectiveness of a multi-strategic practice change intervention in increasing clinician's routine provision of preventive care across a network of community health services.

METHODS/DESIGN

A multiple baseline study will be conducted involving all 56 community health facilities in a single health district in New South Wales, Australia. The facilities will be allocated to one of three administratively-defined groups. A 12 month practice change intervention will be implemented in all facilities in each group to facilitate clinician risk assessment of eligible clients, and clinician provision of brief advice and referral to those identified as being 'at risk'. The intervention will be implemented in a non-random sequence across the three facility groups. Repeated, cross-sectional measurement of clinician provision of preventive care for four individual risks (smoking, poor nutrition, risky alcohol use, and physical inactivity) will occur continuously for all three facility groups for 54 months via telephone interviews. The interviews will be conducted with randomly selected clients who have visited a community health facility in the last two weeks. Data collection will commence 12 months prior to the implementation of the intervention in the first group, and continue for six months following the completion of the intervention in the last group. As a secondary source of data, telephone interviews will be undertaken prior to and following the intervention with randomly selected samples of clinicians from each facility group to assess the reported provision of preventive care, and the acceptability of the practice change intervention and implementation.

DISCUSSION

The study will provide novel evidence regarding the ability to increase clinician's routine provision of preventive care across a network of community health facilities.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN12611001284954 UNIVERSAL TRIAL NUMBER (UTN): U1111-1126-3465.

Offering population-based tobacco treatment in a healthcare setting: a randomized controlled trial

BACKGROUND

The healthcare system is a key channel for delivering treatment to tobacco users. Brief clinic-based interventions are effective but not reliably offered. Population management strategies might improve tobacco treatment delivery in a healthcare system.

PURPOSE

To test the effectiveness of supplementing clinic-based care with a population-based direct-to-smoker (DTS) outreach offering easily accessible free tobacco treatment.

DESIGN

Randomized controlled trial, conducted in 2009-2010, comparing usual clinical care to usual care plus DTS outreach.

SETTING/PARTICIPANTS

A total of 590 smokers registered for primary care at a community health center in Revere MA.

INTERVENTIONS

Three monthly letters offering a free telephone consultation with a tobacco coordinator who provided free treatment including up to 8 weeks of nicotine patches (NRT) and proactive referral to the state quitline for multisession counseling.

MAIN OUTCOME MEASURES

Use of any tobacco treatment (primary outcome) and tobacco abstinence at the 3-month follow-up; cost per quit.

RESULTS

Of 413 eligible smokers, 43 (10.4%) in the DTS group accepted the treatment offer; 42 (98%) requested NRT and 30 (70%) requested counseling. In intention-to-treat analyses adjusted by logistic regression for age, gender, race, insurance, diabetes, and coronary heart disease, a higher proportion of the DTS group, compared to controls, had used NRT (11.6% vs 3.9%, OR=3.47; 95% CI=1.52, 7.92) or any tobacco treatment (14.5% vs 7.3%, OR=1.95, 95% CI=1.04, 3.65) and reported being tobacco abstinent for the past 7 days (5.3% vs 1.1%, OR=5.35, 95% CI=1.23, 22.32) and past 30 days (4.1% vs 0.6%, OR=8.25, 95% CI=1.08, 63.01). The intervention did not increase smokers' use of counseling (1.7% vs 1.1%) or non-NRT medication (3.6% vs 3.9%). Estimated incremental cost per quit was $464.

CONCLUSIONS

A population-based outreach offering free tobacco treatment to smokers in a health center was a feasible, cost-effective way to increase the reach of treatment (primarily NRT) and to increase short-term quit rates.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.govNCT01321944.

Personalized medicine and tobacco-related health disparities: is there a role for genetics?

Genetic testing has been proposed as a means to increase smoking cessation rates and thus reduce smoking prevalence. To understand how that might be practically possible, with appreciation of the current social context of tobacco use and dependence, we performed a contextual analysis of smoking-related genetics and smoking cessation. To provide added value, genetics would need to inform and improve existing interventions for smokers (including behavioral and pharmacological treatments). Pharmacogenetics offers the most promising potential, because it may improve the efficacy of medication-based smoking cessations strategies. All proven interventions for treating tobacco dependence, however, including simple cost-effective measures, such as quit lines and physician counseling, are underutilized. As tobacco use occurs disproportionately among disadvantaged populations, efforts to improve smokers' access to health care, and to the tools that are known to help them quit, represent the most promising approaches for reducing smoking prevalence within these groups. Similar considerations apply to other chronic diseases contributing to population-level health disparities. We conclude that although genetics offers increasing opportunities to tailor drug treatment, and may in some cases provide useful risk prediction, other methods of personalizing care are likely to yield greater benefit to populations experiencing health disparities related to tobacco use.

A thematic analysis of theoretical models for translational science in nursing: mapping the field

The quantity and diversity of conceptual models in translational science may complicate rather than advance the use of theory. This paper offers a comparative thematic analysis of the models available to inform knowledge development, transfer, and utilization. Literature searches identified 47 models for knowledge translation. Four thematic areas emerged: (1) evidence-based practice and knowledge transformation processes, (2) strategic change to promote adoption of new knowledge, (3) knowledge exchange and synthesis for application and inquiry, and (4) designing and interpreting dissemination research. This analysis distinguishes the contributions made by leaders and researchers at each phase in the process of discovery, development, and service delivery. It also informs the selection of models to guide activities in knowledge translation. A flexible theoretical stance is essential to simultaneously develop new knowledge and accelerate the translation of that knowledge into practice behaviors and programs of care that support optimal patient outcomes.