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Lin SC, Gathua N, Thompson C, Sripipatana A, Makaroff L. Disparities in smoking prevalence and associations with mental health and substance use disorders in underserved communities across the United States. Cancer 2022; 128:1826-1831. [PMID: 35253202 DOI: 10.1002/cncr.34132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Smoking contributes to the top 3 deadliest cancers, cancers of the lung, colon, and pancreas, which account for nearly 40% of all cancer-related deaths in the United States. Despite historicly low smoking rates, substantial disparities remain among people with mental health conditions and substance use disorders (SUDs). METHODS The study examined the prevalence of smoking among adults from underserved communities who are served at federally qualified health centers through an analysis of the 2014 Health Center Patient Survey. Furthermore, the study assessed associations of smoking with co-occurring mental health conditions and SUDs among adult smokers (n = 1735). RESULTS The prevalence of smoking among health center patients was 28.1%. Among current smokers, 59.1% had depression and 45.4% had generalized anxiety. Non-Hispanic Black smokers had more than 2 times the odds of reporting SUDs (adjusted odds ratio [aOR], 2.13; 95% confidence interval [CI], 1.06-4.30). Individuals at or below 100% of the federal poverty level had more than 2 times the odds of having mental health conditions (aOR, 2.55; 95% CI, 1.58-4.11), and those who were unemployed had more than 3 times the odds for SUDs (aOR, 3.21; 95% CI, 1.27-8.10). CONCLUSIONS The prevalence of smoking in underserved communities is nearly double the national prevalence. In addition, the study underscores important socioeconomic determinants of health in smoking cessation behavior and the marked disparities among individuals with mental health conditions and SUDs. Finally, the findings illuminate the unique need for tailored treatments supporting cancer prevention care to address challenges confronted by vulnerable populations.
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Affiliation(s)
- Sue C Lin
- Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Maryland
| | - Naomie Gathua
- Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Maryland
| | - Cheryl Thompson
- Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Maryland
| | - Alek Sripipatana
- Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Maryland
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Gill VS, Chaudhary N, Randhawa A, Verma M, Rai GK, Mishra S. A Prospective Study to Assess the Outcome of Motivational Interviewing Among Male Students of Haryana, India: A Strive Towards Smoking Cessation in the Youth. Cureus 2022; 14:e22642. [PMID: 35371670 PMCID: PMC8964476 DOI: 10.7759/cureus.22642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background The brown plague is a classic example of the modern-day epidemic.Motivational interviewing has been found to increase smokers' readiness to quit, attempts to quit, and reduce smoking levels.Thus, this study, attempts to find out the prevalence of smoking and assess the impact of motivational interviewing on male smoker students (18-30 years). Methodology The study was conducted among the male students of educational institutes in Maharishi Markandeshwar University in Haryana. A cross-sectional study to estimate the prevalence of smoking was carried out. With motivational interviewing of the smokers a prospective cohort study was conducted following the smokers for six months. The probability proportionate to size (PPS) sampling method was applied to recruit 830 participants in the study. A self-designed, semi-structured proforma was used to collect data on smoking behavior, level of dependence, and level of motivation to quit. A modified Fagerstrom questionnaire was used to assess the nicotine dependence level. The motivation to quit smoking was measured by the 10 point scale of Contemplation Ladder, Prochaska, and DiClemente transtheoretical model was used to categorize smokers into stages of readiness to change. Statistical analysis was done using SPSS version 16.0 (IBM Inc., Armonk, New York). Results The prevalence of smoking was 20.4%. Following motivational interview on the first contact, more than half of the current smokers (66.2%) had high motivation which further increased to 88.13% on the third visit at six months (p < 0.001). Likewise, at first contact, 47% had low nicotine dependence; this increased to 52.5 % at two weeks, and finally, at six months, 53.4% had low nicotine dependence. But this finding was statistically insignificant (p=0.23). It was noted that 21 (16.5%) smokers out of 127 quit smoking. A high degree of motivation, support from family and friends, and a low degree of nicotine dependence were identified as significant independent predictors for smoking cessation. Conclusion A satisfying proportion of smokers could attain a high level of motivation for quitting smoking, but less than one-fourth of the current smokers were able to abstain from smoking at the end of the study period. However, the impact of motivational interviewing was not very promising and calls for multi-pronged approach for discouraging smoking.
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Priya H, Bhadauria U, Barma M, Agarwal D, Purohit B. Barriers to the utilization of tobacco cessation services: A perspective from healthcare workers. CANCER RESEARCH, STATISTICS, AND TREATMENT 2022. [DOI: 10.4103/crst.crst_288_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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Parthasarathi A, Kumar R, Undela K, Biligere Siddaiah J, Mahesh PA. The extent of formal tobacco cessation training received by student health professionals and the prevalence of tobacco use among them: a cross-sectional study. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16980.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Advice from health care professionals (HCPs) is critical for tobacco prevention and cessation efforts. The academic curricula for health care professional students (HCS) lack comprehensive training in assisting patients in tobacco cessation. Tobacco use among HCP’s deters them from giving proper tobacco prevention and cessation guidance. The objective of this study was to determine the prevalence and determinants of tobacco consumption in third-year students of four health care disciplines (medical, dental, pharmacy, and nursing) and to assess their undergraduate education on tobacco control and cessation. Methods: A web-based survey (response rate 84.4%) employing the Global Health Professions Student Survey (GHPSS) questionnaire; n= 838; [20.89 (SD± 0.94) years] was conducted in Mysore, India. A descriptive, comparative and multivariate analysis was performed. Results: The number of students who received formal training in smoking cessation approaches was only 14.04%. In total, two-thirds of medical students, compared to 38.9% of dental, 29.7% of pharmacy, and 11.40 % of nursing students, learned “the reasons why people smoke” as a part of their formal training. However, only less than a quarter of the study population were aware of the role of antidepressants in nicotine cessation medications. The total prevalence of tobacco use was 28.9%. A total of 37.72% wanted to quit smoking, while a mere 1.2% had sought any professional help to do so. Conclusions: Tobacco use in HCS, apart from personal health risks to themselves, may potentially affect their future commitment to support patients in tobacco cessation. There is a need for further research into tobacco prevention and cessation programs tailored to the needs of student groups. There is a need for an updated curriculum for tobacco cessation strategies and more research into better cessation strategies.
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Parthasarathi A, Kumar R, Undela K, Biligere Siddaiah J, Mahesh PA. The extent of formal tobacco cessation training received by student health professionals and the prevalence of tobacco use among them: a cross-sectional study. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16980.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Advice from health care professionals (HCPs) is critical for tobacco prevention and cessation efforts. The academic curricula for health care professional students (HCS) lack comprehensive training in assisting patients in tobacco cessation. Tobacco use among HCP’s deters them from giving proper tobacco prevention and cessation guidance. The objective of this study was to determine the prevalence and determinants of tobacco consumption in third-year students of four health care disciplines (medical, dental, pharmacy, and nursing) and to assess their undergraduate education on tobacco control and cessation. Methods: A web-based survey (response rate 84.4%) employing the Global Health Professions Student Survey (GHPSS) questionnaire; n= 838; [20.89 (SD± 0.94) years] was conducted in Mysore, India. A descriptive, comparative and multivariate analysis was performed. Results: The number of students who received formal training in smoking cessation approaches was only 14.04%. In total, two-thirds of medical students, compared to 38.9% of dental, 29.7% of pharmacy, and 11.40 % of nursing students, learned “the reasons why people smoke” as a part of their formal training. However, only less than a quarter of the study population were aware of the role of antidepressants in nicotine cessation medications. The total prevalence of tobacco use was 28.9%. A total of 37.72% wanted to quit smoking, while a mere 1.2% had sought any professional help to do so. Conclusions: Tobacco use in HCS, apart from personal health risks to themselves, may potentially affect their future commitment to support patients in tobacco cessation. There is a need for further research into tobacco prevention and cessation programs tailored to the needs of student groups. There is a need for an updated curriculum for tobacco cessation strategies and more research into better cessation strategies.
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Thornberry A, Garcia TJ, Peck J, Sefcik E. Occupational Health Nurses' Self-Efficacy in Implementing Smoking Cessation Interventions for Workers: A Manufacturing Company Quality Improvement Project. Workplace Health Saf 2021; 70:63-72. [PMID: 34338092 DOI: 10.1177/21650799211022991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Effective smoking cessation interventions (SCIs) are urgently needed for the working population where smoking continues at high rates. Occupational health nurses (OHNs) could be effective in providing SCI, but self-efficacy was found to be a major barrier. The purpose of this study was to improve the delivery of SCI to those who smoke in the workplace and to explore nurse self-efficacy. METHODS Pretest and posttest were conducted on two groups, OHNs (n = 5) and smokers (n = 11) working at U.S. manufacturing facilities. OHNs were trained on motivational interviewing (MI) techniques who then recruited smokers to help them practice their newly acquired skills. The two groups were measured by Likert-type scale for OHN self-efficacy and smoker level of change toward quitting. FINDINGS Paired t-tests detected statistically significant differences in OHN's preintervention and postintervention self-efficacy scores, t(4) = -4.46, p < .001,; d = 2.92) and smokers' preintervention and postintervention stage of change toward quitting scores, t(10) = -9.07, p < .001,; d = 2.09), suggesting that the training and MI intervention were effective in increasing OHN self-efficacy and smokers' motivation to change. CONCLUSION/APPLICATION TO PRACTICE This quality improvement (QI) project indicated smokers can be successfully recruited and counseled using MI techniques, while simultaneously improving OHN self-efficacy toward helping patients. Theory-based applications brought OHNs and smokers together in a new paradigm resulting in positive changes for both. Secondary findings in the reverse nurse-patient role revealed success in an innovative recruitment method for smoking cessation.
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Welzel FD, Bär J, Stein J, Löbner M, Pabst A, Luppa M, Grochtdreis T, Kersting A, Blüher M, Luck-Sikorski C, König HH, Riedel-Heller SG. Using a brief web-based 5A intervention to improve weight management in primary care: results of a cluster-randomized controlled trial. BMC FAMILY PRACTICE 2021; 22:61. [PMID: 33794781 PMCID: PMC8017625 DOI: 10.1186/s12875-021-01404-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/25/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND The primary health care setting is considered a major starting point in successful obesity management. However, research indicates insufficient quality of weight counseling in primary care. Aim of the present study was to implement and evaluate a 5A online tutorial aimed at improving weight management and provider-patient-interaction in primary health care. The online tutorial is a stand-alone low-threshold minimal e-health intervention for general practitioners based on the 5As guidance for obesity management by the Canadian Obesity Network. METHODS In a cluster-randomized controlled trial, 50 primary care practices included 160 patients aged 18 to 60 years with obesity (BMI ≥ 30). The intervention practices had continuous access to the 5A online tutorial for the general practitioner. Patients of control practices were treated as usual. Primary outcome was the patients' perspective of the doctor-patient-interaction regarding obesity management, assessed with the Patient Assessment of Chronic Illness Care before and after (6/12 months) the training. Treatment effects over time (intention-to-treat) were evaluated using mixed-effects linear regression models. RESULTS More than half of the physicians (57%) wished for more training offers on obesity counseling. The 5A online tutorial was completed by 76% of the physicians in the intervention practices. Results of the mixed-effects regression analysis showed no treatment effect at 6 months and 12 months' follow-up for the PACIC 5A sum score. Patients with obesity in the intervention group scored lower on self-stigma and readiness for weight management compared to participants in the control group at 6 months' follow-up. However, there were no significant group differences for weight, quality of life, readiness to engage in weight management, self-stigma and depression at 12 months' follow-up. CONCLUSION To our knowledge, the present study provides the first long-term results for a 5A-based intervention in the context of the German primary care setting. The results suggest that a stand-alone low-threshold minimal e-health intervention for general practitioners does not improve weight management in the long term. To improve weight management in primary care, more comprehensive strategies are needed. However, due to recruitment difficulties the final sample was smaller than intended. This may have contributed to the null results. TRIAL REGISTRATION The study has been registered at the German Clinical Trials Register (Identifier: DRKS00009241 , Registered 3 February 2016).
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Affiliation(s)
- Franziska D Welzel
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany.
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, Leipzig University Medical Center, Leipzig, Germany.
| | - Jonathan Bär
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
| | - Janine Stein
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
| | - Margrit Löbner
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, Leipzig University Medical Center, Leipzig, Germany
| | - Alexander Pabst
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
| | - Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
| | - Thomas Grochtdreis
- Department of Health Economics and Health Services Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anette Kersting
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, Leipzig University Medical Center, Leipzig, Germany
- Clinic for Psychosomatic Medicine and Psychotherapy, University of Leipzig, Leipzig, Germany
| | - Matthias Blüher
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, Leipzig University Medical Center, Leipzig, Germany
- Department of Endocrinology, Nephrology, Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Claudia Luck-Sikorski
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, Leipzig University Medical Center, Leipzig, Germany
- SRH University of Applied Sciences Gera, Gera, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Steffi G Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health (ISAP), Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103, Leipzig, Germany
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Goel D, Chaudhary PK, Khan A, Patthi B, Singla A, Malhi R, Gambhir RS. Acquaintance and Approach in the Direction of Tobacco Cessation Among Dental Practitioners-A Systematic Review. Int J Prev Med 2020; 11:167. [PMID: 33312476 PMCID: PMC7716613 DOI: 10.4103/ijpvm.ijpvm_316_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 12/13/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Nowadays, tobacco consumption has become one of the major public health problems and is the leading cause of escapable illness and death. A significant role is played by dental professionals in the identification of smokers; they are, thus, in a better position to offer preventive care. The aim of the present study was to systemically review the knowledge and attitude of dental practitioners toward tobacco cessation. Methods: A literature search was performed in PubMed Central and Cochrane Library, Medline—PubMed, Embase, Google Scholar up to 2018 to identify appropriate studies. Full-text original research articles of the cross-sectional design were only included in the study. Our target was to systemically review the knowledge and attitude of dental practitioners toward tobacco cessation. Results: The present review included a total of nine articles (studies) that fulfilled the eligibility criteria. Two articles which were hand searched and one article which was obtained through contact with experts were included. The results of the review revealed that the dental practitioners in most of the included studies lack satisfactory knowledge and were unaware of existing referral pathways to specialist smoking cessation services. At the same time, most of the dentists have a positive attitude toward tobacco cessation. Conclusions: Dental professionals are aware of their obligations toward smoking cessation counseling for patients but certain barriers including lack of time, confidence, and training prevent them from practicing the same in their daily routine. The dental professionals should obtain appropriate training and attain knowledge along with quantifiable skills for the prevention and cessation of tobacco use.
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Affiliation(s)
- Divyangi Goel
- Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
| | - Pankaj Kumar Chaudhary
- Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
| | - Ambar Khan
- Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
| | - Basavaraj Patthi
- Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
| | - Ashish Singla
- Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
| | - Ravneet Malhi
- Department of Public Health Dentistry, DJ College of Dental Sciences and Research, Modinagar, Uttar Pradesh, India
| | - Ramandeep Singh Gambhir
- Department of Public Health Dentistry, BRS Dental College and Hospital, Panchkula, Haryana, India
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Kar SS, Sivanantham P, Rehman T, Chinnakali P, Thiagarajan S. Willingness to quit tobacco and its correlates among Indian tobacco users-Findings from the Global Adult Tobacco Survey India, 2016-17. J Postgrad Med 2020; 66:141-148. [PMID: 32675450 PMCID: PMC7542056 DOI: 10.4103/jpgm.jpgm_408_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Willingness to quit in a tobacco user forms the basis for future quit attempts and quitting successfully. Objective To determine the prevalence and correlates of willingness to quit among tobacco users in India using the Global Adult Tobacco Survey (GATS), India, 2016-2017. Methods GATS, 2016-17 was a multistage geographically clustered sample survey done among 74,037 individuals aged 15 years and above across all the states and two of the Union Territories of India. Data of all those reported using any form of tobacco were studied for past attempts to quit tobacco, advised to quit by a health care provider, and exposure to anti-tobacco messages delivered through various media and the correlation of these with the willingness to quit using multivariate analysis. Results Of the 21,085 current tobacco users in the survey, 11,679 (52.2%), were willing to quit all forms of tobacco. Multivariate analysis showed that those in younger age groups (OR: 1.39 [1.23-1.56]), higher education levels (OR 1.15 [1.05-1.18]), time of first tobacco use in the day being more than 60 min after waking up in the morning (OR 1.11 [1.03-1.2]), history of attempts to quit in the past 12 months (OR 1.78 [1.69-1.87]), those advised to quit by health care provider in the past 12 months (OR 1.11 [1.06-1.17]), those using single form of tobacco (OR 1.1 [1.05-1.17]), those exposed to anti-tobacco messages in newspapers/magazines (OR 1.1 [1.05-1.17]), and cinemas (1.14 [1.08-1.20]) were more willing to quit compared to their counterparts. Conclusion Enhanced publicizing of anti-tobacco messages through the currently employed media, and ensuring that doctors give a brief advice to quit during any contact with a tobacco user could improve the willingness to quit and the consequent quit rate, especially among those tobacco users who are in younger age groups and who have attempted to quit earlier.
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Affiliation(s)
- S S Kar
- Department of PSM, JIPMER, Puducherry, India
| | | | - T Rehman
- Department of PSM, JIPMER, Puducherry, India
| | | | - S Thiagarajan
- Independent Consultant, Former Professor and Dean, TISS, Mumbai, Maharashtra, India
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Minian N, Lingam M, Moineddin R, Thorpe KE, Veldhuizen S, Dragonetti R, Zawertailo L, Taylor VH, Hahn M, deRuiter WK, Melamed O, Selby P. Impact of a Web-Based Clinical Decision Support System to Assist Practitioners in Addressing Physical Activity and/or Healthy Eating for Smoking Cessation Treatment: Protocol for a Hybrid Type I Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e19157. [PMID: 32990250 PMCID: PMC7556369 DOI: 10.2196/19157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Modifiable risk factors such as tobacco use, physical inactivity, and poor diet account for a significant proportion of the preventable deaths in Canada. These factors are also known to cluster together, thereby compounding the risks of morbidity and mortality. Given this association, smoking cessation programs appear to be well-suited for integration of health promotion activities for other modifiable risk factors. The Smoking Treatment for Ontario Patients (STOP) program is a province-wide smoking cessation program that currently encourages practitioners to deliver Screening, Brief Intervention, and Referral to treatment for patients who are experiencing depressive symptoms or consume excessive amounts of alcohol via a web-enabled clinical decision support system. However, there is no available clinical decision support system for physical inactivity and poor diet, which are among the leading modifiable risk factors for chronic diseases. OBJECTIVE The aim of this study is to assess whether adding a computerized/web-enabled clinical decision support system for physical activity and diet to a smoking cessation program affects smoking cessation outcomes. METHODS This study is designed as a hybrid type 1 effectiveness/implementation randomized controlled trial to evaluate a web-enabled clinical decision support system for supporting practitioners in addressing patients' physical activity and diet as part of smoking cessation treatment in a primary care setting. This design was chosen as it allows for simultaneous testing of the intervention, its delivery in target settings, and the potential for implementation in real-world situations. Intervention effectiveness will be measured using a two-arm randomized controlled trial. Health care practitioners will be unblinded to their patients' treatment allocation; however, patients will be blinded to whether their practitioner receives the clinical decision support system for physical activity and/or fruit/vegetable consumption. The evaluation of implementation will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RESULTS Recruitment for the primary outcome of this study is ongoing and will be completed in November 2020. Results will be reported in March 2021. CONCLUSIONS The findings of the study will provide much needed insight into whether adding a computerized/web-enabled clinical decision support system for physical activity and diet to a smoking cessation program affects smoking cessation outcome. Furthermore, the implementation evaluation would provide insight into the feasibility of online-based interventions for physical activity and diet in a smoking cessation program. Addressing these risk factors simultaneously could have significant positive effects on chronic disease and cancer prevention. TRIAL REGISTRATION ClinicalTrials.gov NCT04223336; https://clinicaltrials.gov/ct2/show/NCT04223336. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/19157.
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Affiliation(s)
- Nadia Minian
- Nicotine Dependence Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Mathangee Lingam
- Nicotine Dependence Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Scott Veldhuizen
- Nicotine Dependence Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Rosa Dragonetti
- Nicotine Dependence Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Laurie Zawertailo
- Nicotine Dependence Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Valerie H Taylor
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Margaret Hahn
- Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Banting and Best Diabetes Centre, University of Toronto, Toronto, ON, Canada
| | - Wayne K deRuiter
- Nicotine Dependence Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Osnat Melamed
- Nicotine Dependence Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Selby
- Nicotine Dependence Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Thornberry A, Garcia TJ, Peck J, Sefcik E. Occupational Health Nurses' Self-Efficacy in Smoking Cessation Interventions: An Integrative Review of the Literature. Workplace Health Saf 2020; 68:533-543. [PMID: 32600221 DOI: 10.1177/2165079920925106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Effective smoking cessation interventions (SCIs) are indicated, particularly among the working population, where a higher than expected prevalence of smoking continues. Occupational health nurses' (OHN) self-efficacy can affect SCI but current scientific literature is limited. The purpose of this integrative literature review was to determine factors that affect OHN self-efficacy and motivation for providing SCI and to guide research needed to enhance SCI programs. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted an integrative literature review. The strategy was an electronic data search of PubMed conducted between 2013 and 2018 and included peer-reviewed manuscripts written in English that addressed self-efficacy and its relationship to SCI. Findings: In total, 15 research articles met the inclusion criteria and two referred specifically to OHNs. Common themes revealed factors which positively and negatively influenced nurses' self-efficacy, including training, academic preparation, as well as nurse attitudes and personal/social influence. Studies specific to OHNs identify self-efficacy as the most influential factor affecting nurse implementation of SCI. Organizational support and theory-based training are more effective in overcoming personal and social barriers affecting OHN self-efficacy. Conclusion/Application to Practice: The results of this review revealed attitude, innovation, perceived social influence, and self-efficacy were factors for nurses' intention to implement SCI. Changes in the organizational environment supporting cessation programs and educational development, particularly theory-based training, should be further studied. Our findings suggest that designing programs utilizing these research findings to improve OHN self-efficacy could guide changes in clinical practice for motivating smokers to quit.
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Igniting activation: Using unannounced standardized patients to measure patient activation in smoking cessation. Addict Behav Rep 2019; 9:100179. [PMID: 31193839 PMCID: PMC6544561 DOI: 10.1016/j.abrep.2019.100179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/26/2019] [Accepted: 03/26/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Despite a decline, smoking rates have remained high, especially in communities with lower income, education, and limited insurance options. Evidence shows that physician-initiated counseling on smoking cessation is effective and saves lives, and that specific skills are needed to appropriately lead this type of patient-physician communication. Residency is a critical moment for future physicians and may be the optimal time to learn, practice, and refine this skillset. Unannounced Standardized Patients (USPs) have been found to be effective, incognito evaluators of resident practices. Methods This study introduced rigorously trained actors (USPs) into two urban, safety-net clinics to assess resident ability to engage, activate, and counsel a pre-contemplative smoker. A complementary chart review assessed appropriate documentation in the patient's electronic health record (EHR) and its relationship to counseling style and prescribing practices. Results Resident scores (% well done) on patient education and engagement were low (33% and 23%, respectively). Residents who coupled cessation advice with an open discussion style activated their patients more than those who solely advised cessation across all comparable measures. On EHR documentation, residents who accurately documented smoking history were more likely to directly advise their patient to quit smoking when compared to residents who did not document (t(97) = 2.828, p = .006, Cohen's D = 0.56). Conclusions Results highlight the need to reinforce training in patient-centered approaches including motivational interviewing, counseling, and shared decision-making. Future research should focus on the effects of smokers in pre-contemplation on physician counseling style and examine the relationship between medical training and provider communication to guide interventions. Counseling, documentation, and prescribing all vary when residents meet an Unannounced Standardized Patient (USP) smoker. Patients are activated to quit smoking when a provider couples cessation advice with an open discussion of pros and cons. Training in motivational interviewing and shared decision-making can enhance patient-provider cessation communication.
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13
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Harutyunyan A, Abrahamyan A, Hayrumyan V, Petrosyan V. Perceived barriers of tobacco dependence treatment: a mixed-methods study among primary healthcare physicians in Armenia. Prim Health Care Res Dev 2019; 20:e17. [PMID: 30421696 PMCID: PMC6476393 DOI: 10.1017/s1463423618000828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 08/22/2018] [Accepted: 10/04/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite compelling evidence that physicians play a prominent role in smoking cessation, most smokers do not receive the recommended smoking cessation counseling.AimTo identify perceived barriers that hinder primary healthcare physicians (PHPs) from providing smoking cessation treatment to patients in Armenia. METHODS A sequential exploratory mixed-methods study was conducted among PHPs from two Armenian cities (Yerevan and Gyumri). We implemented qualitative phase through focus group discussions (FGDs) using a semi-structured guide. For the subsequent quantitative phase, the data were collected through cross-sectional survey. A directed deductive content analysis technique was used to analyze the FGDs and questionnaires were analyzed descriptively. Following the data collection (March 2015-May 2016) and descriptive analysis, the qualitative and quantitative data sets were merged by drawing quantitative data onto qualitative categories.FindingsOverall, 23 PHPs participated in five FGDs and 108 participants completed the survey. Three main categories of barriers were identified: physician-based, patient-based, and system-based barriers. The main physicians-based barriers were insufficient knowledge and inadequate training on tobacco-dependence treatment. Lack of patients' motivation to quit, poor compliance with the treatment, patients' withdrawal symptoms were identified as patient-based disincentives. System-based barriers included lack of reimbursement for providing smoking cessation counseling, high price and low availability of smoking cessation medications. Most of the qualitative descriptions were confirmed by quantitative findings. CONCLUSIONS Targeted interventions are needed to address barriers that limited PHPs' involvement in providing smoking cessation services in Armenia. There is an urgent need to enhance PHPs' knowledge and skills in delivering smoking cessation counseling, to increase patients' demand for smoking cessation services, and to ensure availability and affordability of smoking cessation services in Armenia.
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Affiliation(s)
- Arusyak Harutyunyan
- Gerald and Patricia Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Armine Abrahamyan
- Gerald and Patricia Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Varduhi Hayrumyan
- Gerald and Patricia Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Varduhi Petrosyan
- Gerald and Patricia Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
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Chung YH, Chang HH, Lu CW, Huang KC, Guo FR. Addition of one session with a specialist counselor did not increase efficacy of a family physician-led smoking cessation program. J Int Med Res 2018; 46:3809-3818. [PMID: 29896996 PMCID: PMC6136037 DOI: 10.1177/0300060518780151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/10/2018] [Indexed: 11/21/2022] Open
Abstract
Objective Higher-intensity counseling sessions increase the smoking abstinence rate. However, counselors are limited in Taiwan. This study was performed to determine whether the addition of one session with a specialist counselor increases the efficacy of a family physician-led smoking cessation program. Methods Participants opted to either visit a family physician for brief counseling and pharmacotherapy (Po) or visit a specialist counselor for an initial session followed by a family physician for brief counseling sessions with pharmacotherapy (P+). The 7-day point prevalence (PP) rate was evaluated at weeks 12 and 24. Results In total, 356 patients were enrolled. In the intention-to-treat analysis, the PP rate at week 12 was higher in the Po than P+ group, but there was no significant difference at week 24. In the per-protocol analysis, the PP rates at weeks 12 and 24 were not significantly different between the Po and P+ groups. The adjusted odds ratios also revealed no significant differences in either the intention-to-treat analysis or the per-protocol analysis between the two groups. Conclusion The addition of one session with a specialist counselor had no benefit over the provision of counseling through a family physician at either 12 or 24 weeks of follow-up.
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Affiliation(s)
- Yi-Hsuan Chung
- Department of Family Medicine, Fu-Jen Catholic University
Hospital, New Taipei City, Taiwan
| | - Hao-Hsiang Chang
- Department of Family Medicine,
National
Taiwan University Hospital and College
of Medicine, Taipei, Taiwan
| | - Chia-Wen Lu
- Department of Family Medicine,
National
Taiwan University Hospital and College
of Medicine, Taipei, Taiwan
| | - Kuo-Chin Huang
- Department of Family Medicine,
National
Taiwan University Hospital and College
of Medicine, Taipei, Taiwan
- Office of Superintendent,
National
Taiwan University Hospital Bei-Hu
Branch, Taipei, Taiwan
| | - Fei-Ran Guo
- Department of Family Medicine,
National
Taiwan University Hospital and College
of Medicine, Taipei, Taiwan
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15
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Welzel FD, Stein J, Pabst A, Luppa M, Kersting A, Blüher M, Luck-Sikorski C, König HH, Riedel-Heller SG. Five A's counseling in weight management of obese patients in primary care: a cluster-randomized controlled trial (INTERACT). BMC FAMILY PRACTICE 2018; 19:97. [PMID: 29935541 PMCID: PMC6015469 DOI: 10.1186/s12875-018-0785-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 05/31/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Obesity is one of the most prevalent health problems in western societies. However, it seems not effectively managed in the healthcare system at present. Originating from smoking cessation a tool called the 5As for obesity management has been drafted and adapted by the Canadian Obesity Network (CON) to improve weight counseling and provider-patient-interaction. This paper describes the rationale and design of the INTERACT study. The objective of the INTERACT study is to evaluate the effectiveness and intervention costs of a 5As eLearning program for obesity management aimed specifically at general practitioners (GPs). METHODS The INTERACT study is a cluster randomized controlled trial aimed at implementing and evaluating an online-tutorial for obesity management based on the 5As approach in cooperating primary health care practices. Effectiveness of the 5As intervention will be evaluated by assessing patients and doctors perspectives on obesity management in primary care before and after the training. GPs in the intervention group will get access to the 5As obesity management online-tutorial while GPs in the control group will be assigned to a waiting list. Outcome measures for patients and GPs will be compared between the intervention group (treatment as usual + training of the GP) and the control group (treatment as usual). Hierarchical regression models will be used to analyze effects over time pre- and post-intervention. DISCUSSION The 5As present physicians with a simple mnemonic for patient counseling in the primary care context. While the use of the 5As in weight counseling seems to be associated with improved doctor-patient interaction and motivation to lose weight, intervention studies assessing the effectiveness of a short 5A eLearning tutorial for physicians on secondary outcomes, such as weight development, are lacking. TRIAL REGISTRATION The study has been registered at the German Clinical Trials Register ( DRKS00009241 ; date of registration: 03.02.2016).
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Affiliation(s)
- Franziska D. Welzel
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103 Leipzig, Germany
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, University Hospital Leipzig, Leipzig, Germany
| | - Janine Stein
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103 Leipzig, Germany
| | - Alexander Pabst
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103 Leipzig, Germany
| | - Melanie Luppa
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103 Leipzig, Germany
| | - Anette Kersting
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, University Hospital Leipzig, Leipzig, Germany
- Clinic for Psychosomatic Medicine and Psychotherapy, University Hospital Leipzig, University of Leipzig, Leipzig, Germany
| | - Matthias Blüher
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, University Hospital Leipzig, Leipzig, Germany
| | - Claudia Luck-Sikorski
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103 Leipzig, Germany
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases, University Hospital Leipzig, Leipzig, Germany
- University of Applied Sciences SRH Gera, Gera, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Steffi G. Riedel-Heller
- Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Straße 55, 04103 Leipzig, Germany
- Institute of General Medicine, University of Leipzig, Leipzig, Germany
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16
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Mistry R, Jones AD, Pednekar MS, Dhumal G, Dasika A, Kulkarni U, Gomare M, Gupta PC. Antenatal tobacco use and iron deficiency anemia: integrating tobacco control into antenatal care in urban India. Reprod Health 2018; 15:72. [PMID: 29720206 PMCID: PMC5932801 DOI: 10.1186/s12978-018-0516-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/24/2018] [Indexed: 12/19/2022] Open
Abstract
Background In India, tobacco use during pregnancy is not routinely addressed during antenatal care. We measured the association between tobacco use and anemia in low-income pregnant women, and identified ways to integrate tobacco cessation into existing antenatal care at primary health centers. Methods We conducted an observational study using structured interviews with antenatal care clinic patients (n = 100) about tobacco use, anemia, and risk factors such as consumption of iron rich foods and food insecurity. We performed blood tests for serum cotinine, hemoglobin and ferritin. We conducted in-depth interviews with physicians (n = 5) and auxiliary nurse midwives (n = 5), and focus groups with community health workers (n = 65) to better understand tobacco and anemia control services offered during antenatal care. Results We found that 16% of patients used tobacco, 72% were anemic, 41% had iron deficiency anemia (IDA) and 29% were food insecure. Regression analysis showed that tobacco use (OR = 14.3; 95%CI = 2.6, 77.9) and consumption of green leafy vegetables (OR = 0.6; 95%CI = 0.4, 0.9) were independently associated with IDA, and tobacco use was not associated with consumption of iron-rich foods or household food insecurity. Clinics had a system for screening, treatment and follow-up care for anemic and iron-deficient antenatal patients, but not for tobacco use. Clinicians and community health workers were interested in integrating tobacco screening and cessation services with current maternal care services such as anemia control. Tobacco users wanted help to quit. Conclusion It would be worthwhile to assess the feasibility of integrating antenatal tobacco screening and cessation services with antenatal care services for anemia control, such as screening and guidance during clinic visits and cessation support during home visits.
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Affiliation(s)
- Ritesh Mistry
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, 1415 Washington Heights, SPH I, Room 3806, Ann Arbor, MI, 48109-2029, USA.
| | - Andrew D Jones
- Department of Nutritional Sciences, University of Michigan, Ann Arbor, USA
| | | | - Gauri Dhumal
- Healis Sekhsaria Institute for Public Health, Navi Mumbai, India
| | - Anjuli Dasika
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, 1415 Washington Heights, SPH I, Room 3806, Ann Arbor, MI, 48109-2029, USA
| | - Ujwala Kulkarni
- Department of Nutritional Sciences, University of Michigan, Ann Arbor, USA
| | | | - Prakash C Gupta
- Healis Sekhsaria Institute for Public Health, Navi Mumbai, India
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17
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Jenkins WD, Matthews AK, Bailey A, Zahnd WE, Watson KS, Mueller-Luckey G, Molina Y, Crumly D, Patera J. Rural areas are disproportionately impacted by smoking and lung cancer. Prev Med Rep 2018; 10:200-203. [PMID: 29868368 PMCID: PMC5984228 DOI: 10.1016/j.pmedr.2018.03.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/14/2018] [Accepted: 03/21/2018] [Indexed: 10/27/2022] Open
Abstract
Rural populations have higher rates of late stage lung cancer incidence and mortality compared to urban populations, making them important target populations for low dose computed tomography (LDCT) screening. LDCT screening has been shown to reduce lung cancer mortality and is recommended by the United States Preventive Services Task Force for individuals who meet certain risk criteria. However, rural populations may experience greater system, provider, and individual-level barriers to screening and related health-seeking behavior (e.g. smoking cessation). LDCT screening was first tested in urban, academic centers, so it is still unknown how readily it may be implemented in rural areas. Additionally, rural populations have limited access to both primary care physicians who may refer to LDCT screening and specialty physicians who may perform the screening. Further, rural populations may be less likely to seek screening due to lack of awareness and understanding or other unknown knowledge or psychosocial barriers. There are several strategies that may address these rural specific challenges. First, further research is needed to better understand the individual-level barriers that rural patients experience. Second, to reduce system-level barriers, additional efforts should be made to increase rural access to screening through improved referral processes. Third, creation of decision support materials to equip rural providers to engage their patients in a shared decision making process regarding screening may help reduce physician level barriers. Fourth, development of a holistic approach to smoking cessation may help reduce lung cancer risk in conjunction with LDCT screening.
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Affiliation(s)
- Wiley D Jenkins
- Office of Population Science and Policy, SIU School of Medicine, Springfield, IL 62794-9664, United States
| | - Alicia K Matthews
- College of Nursing, University of Illinois at Chicago, Chicago, IL, United States
| | - Angie Bailey
- Southern Illinois Healthcare, Carbondale, IL 62902, United States
| | - Whitney E Zahnd
- Office of Population Science and Policy, SIU School of Medicine, Springfield, IL 62794-9664, United States
| | - Karriem S Watson
- Community Engaged Research and Implementation Science, University of Illinois at Chicago, Chicago, IL, United States.,Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
| | - Georgia Mueller-Luckey
- Applied Health Department, Southern Illinois University, Edwardsville, IL, United States
| | - Yamile Molina
- Community Engaged Research and Implementation Science, University of Illinois at Chicago, Chicago, IL, United States.,Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
| | - David Crumly
- Office of Population Science and Policy, SIU School of Medicine, Springfield, IL 62794-9664, United States
| | - Julie Patera
- Southern Illinois Healthcare, Carbondale, IL 62902, United States
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18
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Reddy MM, Kanungo S, Naik BN, Kar SS. Willingness to quit tobacco smoking and its correlates among Indian smokers - Findings from Global Adult Tobacco Survey India, 2009-2010. J Family Med Prim Care 2018; 7:1353-1360. [PMID: 30613524 PMCID: PMC6293941 DOI: 10.4103/jfmpc.jfmpc_169_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: In the stages of change model for smoking cessation, “willingness to quit” forms the starting point. Objective: To determine the prevalence and correlates of willingness to quit among smokers in India from Global Adult Tobacco Survey (GATS), 2009–2010. Methods: Secondary data analysis of GATS, 2009–10, was done to find the correlates of willingness to quit among smokers. All the sociodemographic variables, smoking-related factors such as frequency, previous attempt to quit, and also effect of antitobacco messages delivered to various media were tested for association using multivariable analysis. Results: Of 9627 current smokers analyzed, 50.9% [95% confidence interval (CI): 49.9–51.9] were willing to quit smoking. Multivariable analysis showed that younger age groups [prevalence ratio (PR): 1.31, 95% CI: 1.05–1.65], individuals who have their first smoke after 60 min of wakeup (PR: 1.19, 95% CI: 1.05–1.36), those living in a house with smoking restriction (PR: 1.29, 95% CI: 1.17–1.42), those who received advice to quit from doctor, those who attempted to quit in the past 12 months (PR: 1.28, 95% CI: 1.03–1.60), having knowledge about illness caused due to smoking, and those who have noticed antismoking messages in billboards/hoardings were willing to quit smoking compared to their counterparts (PR: 1.13, 95% CI: 1.04–1.23). Conclusion: Enforcing social restrictions like smoking restriction at house and also brief advice by doctors to quit smoking during any contact with the tobacco user could improve quit rate especially in young tobacco users and those who have attempted to quit before.
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Affiliation(s)
- Mahendra M Reddy
- Department of Community Medicine, Sri Devaraj Urs Medical College, Tamaka, Kolar, India
| | - Srikanta Kanungo
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Bijaya Nanda Naik
- Department of Community Medicine, Sri Venkateshwaraa Medical College Hospital and Research Centre, Puducherry, India
| | - Sitanshu Sekhar Kar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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19
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Lei MK, Beach SR, Dogan MV, Philibert RA. A pilot investigation of the impact of smoking cessation on biological age. Am J Addict 2017; 26:129-135. [PMID: 28106943 PMCID: PMC5323361 DOI: 10.1111/ajad.12502] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/22/2016] [Accepted: 12/24/2016] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Smoking is known to increase biological age. However, whether this process is reversible through smoking cessation is not known. In this pilot study, we attempt to determine whether smoking cessation reduces biological age. METHODS We conducted regression analyses of methylation data from 22 subjects, as they entered and exited inpatient substance use treatment, to determine change in biological age, as indicated by the deviation of their methylomic age from chronological age across two time points. RESULTS We found that, as compared to those subjects who did not stop smoking, subjects who significantly decreased their smoking consumption over a 1 month time period exhibited a marked reduction in methylomic age. CONCLUSION The rapid and substantial reversal of accelerated aging associated with successful smoking cessation suggests that it can reverse well-known smoking effects on methylomic aging. This preliminary finding can be readily examined in other, larger data sets, and if replicated, this observation may provide smokers with yet another good reason to quit smoking. SCIENTIFIC SIGNIFICANCE Successful smoking cessation makes patients appear biologically younger than they were at baseline, and to do so quite rapidly. In today's youth driven society, our observations may serve as a powerful impetus for some to quit smoking. (Am J Addict 2017;26:129-135).
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Affiliation(s)
- Man-Kit Lei
- Center for Family Research, University of Georgia, Athens, GA, USA, 30602
- Department of Sociology, University of Georgia, Athens, GA, USA, 30602
| | - Steven R.H. Beach
- Center for Family Research, University of Georgia, Athens, GA, USA, 30602
- Department of Psychology, University of Georgia, Athens, GA, USA, 30602
| | | | - Robert A. Philibert
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA, 52242
- Behavioral Diagnostics, 316 East Court Street, Iowa City, IA, USA, 52240
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20
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Proportion of Time Spent Delivering Support Predicts Stop Smoking Advisor Quit Rate Independently of Training, Experience, and Education. J Smok Cessat 2017. [DOI: 10.1017/jsc.2016.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Despite a downwards trend in smoking prevalence, smoking remains the UK's biggest preventable cause of premature mortality. Specialist stop smoking support programmes provided by the NHS have helped to reduce smoking prevalence and whilst there has been a vast amount of research investigating the most effective behavioural and pharmacological support models, little is known about the impact of smoking cessation advisor's smoking status and clinical effectiveness on quit rates. This study aimed to identify factors that contribute to NHS stop smoking advisor performance using a quantitative cross-sectional design via an online survey that was completed by 159 participants in 24 London boroughs. Multiple regression analyses revealed that level of training, years practiced, level of advisor education, number of patients supported in a given year, and smoking status had no significant impact on NHS stop smoking advisor quit rate in this sample. However, the model revealed that proportion of time spent delivering smoking cessation support was significantly associated with quit rate. It is imperative that this finding is considered when recruiting, commissioning, and training new smoking cessation advisors or provider organisations.
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21
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Vaidya V, Gangal NS, Shah S, Gangan N, Bechtol R. Trends in Smoking Status and Utilization of Smoking Cessation Agents Among Females with Cardiovascular Diseases. J Womens Health (Larchmt) 2016; 25:270-5. [PMID: 26862887 DOI: 10.1089/jwh.2015.5226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the United States, cigarette smoking accounts for almost 20% of all deaths attributed to heart disease. More women than men die each year of cardiovascular diseases (CVDs). Women who smoke have shown to be at a higher risk of cardiac deaths. The current study aims to determine the trend in smoking prevalence among women with CVD and their utilization of smoking cessation agents from 2004 to 2011. MATERIALS AND METHODS This was a retrospective exploratory study using Medical Expenditure Panel Survey data from 2004 to 2011. All female respondents with any one cardiovascular condition were identified. Descriptive statistics were carried out to obtain the number of female patients with CVD, their smoking status, and their use of smoking cessation agents. Furthermore, disparities in smoking status and smoking cessation agent utilization with respect to race and ethnicity were studied. RESULTS Among total CVD patients, 53% were females, which corresponded to 25.3 million females in the United States. Around 12.3% among them were current smokers. Only 6.9% among these females used smoking cessation agents. Smoking trends in females were inconsistent throughout the 8 years. Overall, the trend showed a decrease in the percentage of female smokers, while use of smoking cessation agents remained low from 2004 to 2011. Whites and non-Hispanics had more current smokers and women using smoking cessation agents. CONCLUSION The eight-year trend shows that the use of smoking cessation agents among females is very low, particularly among non-whites and Hispanics. This is of great concern and future efforts could focus on increasing the utilization of smoking cessation agents and collectively decreasing the risk of smoking in CVD by healthcare professionals.
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Affiliation(s)
- Varun Vaidya
- Department of Pharmacy Practice, College of Pharmacy, University of Toledo , Toledo, Ohio.,Poster presentation at ISPOR 18th Annual International Meeting held at New Orleans, Louisiana from May 18 to 22, 2013
| | - Neha S Gangal
- Department of Pharmacy Practice, College of Pharmacy, University of Toledo , Toledo, Ohio.,Poster presentation at ISPOR 18th Annual International Meeting held at New Orleans, Louisiana from May 18 to 22, 2013
| | - Surbhi Shah
- Department of Pharmacy Practice, College of Pharmacy, University of Toledo , Toledo, Ohio.,Poster presentation at ISPOR 18th Annual International Meeting held at New Orleans, Louisiana from May 18 to 22, 2013
| | - Nilesh Gangan
- Department of Pharmacy Practice, College of Pharmacy, University of Toledo , Toledo, Ohio.,Poster presentation at ISPOR 18th Annual International Meeting held at New Orleans, Louisiana from May 18 to 22, 2013
| | - Robert Bechtol
- Department of Pharmacy Practice, College of Pharmacy, University of Toledo , Toledo, Ohio.,Poster presentation at ISPOR 18th Annual International Meeting held at New Orleans, Louisiana from May 18 to 22, 2013
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22
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Burke MV, Ebbert JO, Schroeder DR, McFadden DD, Hays JT. Treatment Outcomes From a Specialist Model for Treating Tobacco Use Disorder in a Medical Center. Medicine (Baltimore) 2015; 94:e1903. [PMID: 26554789 PMCID: PMC4915890 DOI: 10.1097/md.0000000000001903] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Cigarette smoking causes premature mortality and multiple morbidity; stop smoking improves health. Higher rates of smoking cessation can be achieved through more intensive treatment, consisting of medication and extended counseling of patients, but there are challenges to integrating these interventions into healthcare delivery systems. A care model using a master-level counselor trained as a tobacco treatment specialist (TTS) to deliver behavioral intervention, teamed with a supervising physician/prescriber, affords an opportunity to integrate more intensive tobacco dependence treatment into hospitals, clinics, and other medical systems. This article analyzes treatment outcomes and predictors of abstinence for cigarette smokers being treated using the TTS-physician team in a large outpatient clinic over a 7-year period.This is an observational study of a large cohort of cigarette smokers treated for tobacco dependence at a medical center. Patients referred by the primary healthcare team for a TTS consult received a standard assessment and personalized treatment planning guided by a workbook. Medication and behavioral plans were developed collaboratively with each patient. Six months after the initial assessment, a telephone call was made to ascertain a 7-day period of self-reported abstinence. The univariate association of each baseline patient characteristic with self-reported tobacco abstinence at 6 months was evaluated using the chi-squared test. In addition, a multiple logistic regression analysis was performed with self-reported tobacco abstinence as the dependent variable and all baseline characteristics included as explanatory variables.Over a period of 7 years (2005-2011), 6824 cigarette smokers who provided general research authorization were seen for treatment. The 6-month self-reported abstinence rate was 28.1% (95% confidence interval: 27.7-30.1). The patients most likely to report abstinence were less dependent, more motivated to quit, and did not have a past year diagnosis of depression or alcoholism.Predictable patient characteristics such as level of dependence did predict abstinence, but all patient groups achieved comparable abstinence outcomes. While this study has limitations inherent in a single-center retrospective cohort study, it does suggest that the TTS model is an effective way to integrate more intensive tobacco dependence treatment into outpatient settings.
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Affiliation(s)
- Michael V Burke
- From the Nicotine Dependence Center, Department of Internal Medicine (MVB, JOE, DDM, JTH) and Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN (DRS)
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van Leer E, Connor NP. Predicting and influencing voice therapy adherence using social-cognitive factors and mobile video. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2015; 24:164-76. [PMID: 25611762 PMCID: PMC4610279 DOI: 10.1044/2015_ajslp-12-0123] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 03/17/2013] [Accepted: 10/23/2014] [Indexed: 05/13/2023]
Abstract
PURPOSE Patient adherence to voice therapy is an established challenge. The purpose of this study was (a) to examine whether adherence to treatment could be predicted from three social-cognitive factors measured at treatment onset: self-efficacy, goal commitment, and the therapeutic alliance, and (b) to test whether the provision of clinician, self-, and peer model mobile treatment videos on MP4 players would influence the same triad of social cognitive factors and the adherence behavior of patients. METHOD Forty adults with adducted hyperfunction with and without benign lesions were prospectively randomized to either 4 sessions of voice therapy enhanced by MP4 support or without MP4 support. Adherence between sessions was assessed through self-report. Social cognitive factors and voice outcomes were assessed at the beginning and end of therapy. Utility of MP4 support was assessed via interviews. RESULTS Self-efficacy and the therapeutic alliance predicted a significant amount of adherence variance. MP4 support significantly increased generalization, self-efficacy for generalization, and the therapeutic alliance. An interaction effect demonstrated that MP4 support was particularly effective for patients who started therapy with poor self-efficacy for generalization. CONCLUSION Adherence may be predicted and influenced via social-cognitive means. Mobile technology can extend therapy to extraclinical settings.
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Buchbinder M, Wilbur R, Zuskov D, McLean S, Sleath B. Teachable moments and missed opportunities for smoking cessation counseling in a hospital emergency department: a mixed-methods study of patient-provider communication. BMC Health Serv Res 2014; 14:651. [PMID: 25526749 PMCID: PMC4300850 DOI: 10.1186/s12913-014-0651-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 12/11/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Mara Buchbinder
- Department of Social Medicine, University of North Carolina at Chapel Hill, 333 S. Columbia St., 341A MacNider Hall CB 7240, Chapel Hill, NC, 27599, USA.
| | - Rachel Wilbur
- Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Diana Zuskov
- Department of Health Behavior and Health Education, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Samuel McLean
- Departments of Anesthesiology and Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Betsy Sleath
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Emre N, Topal K, Bozkurt N, Topaktas E. Mental health screening and increased risk for anxiety and depression among treatment-seeking smokers. Tob Induc Dis 2014; 12:20. [PMID: 25745381 PMCID: PMC4350969 DOI: 10.1186/1617-9625-12-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/27/2014] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The aim of this study was to compare the risk for mental health disorders between smokers and non-smokers and to assess the risk for depression and anxiety according to addiction severity. METHODS This cross-sectional study assesses the mental health status and relationship with the severity of nicotine addiction in a sample of smokers admitted to Pamukkale University Hospital Smoking Cessation Clinic (n = 101) from 1 June 2012 to 31 August 2012 compared to a group of non-smokers from the general population (n = 101). We conducted semi-structured face-to-face interviews to collect sociodemographic data; we assessed the participants' mental health status with the General Health Questionnaire-12 (GHQ-12) and the Hospital Anxiety and Depression Scale (HADS), and we measured nicotine addiction severity with the Fagerström Test. RESULTS The risk for mental illness reported by smokers based on the GHQ-12 was significantly higher than that for non-smokers (p = 0.001). The anxiety and depression scores according to HADS were higher among smokers (16.8% and 22.8%, respectively) than non-smokers (4.0% and 5.0%, respectively) (p = 0.006 and p = 0.001, respectively). The nicotine addiction severity was higher in smokers with higher anxiety and depression scores (p = 0.008). CONCLUSIONS We found high scores for mental illness in treatment-seeking smokers compared with non-smokers. The risk for anxiety and depression was higher among smokers. Increased nicotine addiction severity was associated with increased risk for mental illness and increased scores of anxiety and depression.
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Affiliation(s)
- Nilufer Emre
- />Department of Family Medicine, Pamukkale University Faculty of Medicine, C103, 20070 Kinikli, Denizli, Turkey
| | - Kenan Topal
- />Department of Family Medicine, Pamukkale University Faculty of Medicine, C103, 20070 Kinikli, Denizli, Turkey
| | - Nurgul Bozkurt
- />Denizli State Hospital, Chest Diseases Clinic, No 1, 20010 Denizli, Turkey
| | - Eylem Topaktas
- />Department of Family Medicine, Pamukkale University Faculty of Medicine, C103, 20070 Kinikli, Denizli, Turkey
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Davis CE, Serio FG, Califano JV. Guidelines for Motivating and Assisting Patients With Smoking Cessation in Dental Settings. Clin Adv Periodontics 2014; 4:263-273. [PMID: 32781814 DOI: 10.1902/cap.2013.130008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/25/2013] [Indexed: 11/13/2022]
Abstract
Focused Clinical Question: Periodontal disease is related to use of tobacco, particularly cigarettes. Cigarette smoking is the leading cause of preventable death in the United States, with 20% of annual deaths attributable to smoking-related illness. How does motivating patients to quit smoking challenge periodontists and other providers to improve clinical management? Summary: Four patient cases from the author's (CED) clinical practice in behavioral medicine illustrate key points in management of two patients who were successful in quitting smoking and two who were unsuccessful quitting. Conclusion: These cases illustrate some of the characteristics of patients and factors that contribute to successful smoking cessation and provide examples and practical information for use in the dental office for helping patients with smoking cessation.
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Affiliation(s)
- C Ervin Davis
- Department of General Dentistry, School of Dental Medicine, East Carolina University, Greenville, NC
| | | | - Joseph V Califano
- Department of Periodontology, School of Dentistry, Oregon Health & Science University, Portland, OR
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Levy S, Weiss R, Sherritt L, Ziemnik R, Spalding A, Van Hook S, Shrier LA. An electronic screen for triaging adolescent substance use by risk levels. JAMA Pediatr 2014; 168:822-8. [PMID: 25070067 PMCID: PMC4270364 DOI: 10.1001/jamapediatrics.2014.774] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Screening adolescents for substance use and intervening immediately can reduce the burden of addiction and substance-related morbidity. Several screening tools have been developed to identify problem substance use for adolescents, but none have been calibrated to triage adolescents into clinically relevant risk categories to guide interventions. OBJECTIVE To describe the psychometric properties of an electronic screen and brief assessment tool that triages adolescents into 4 actionable categories regarding their experience with nontobacco substance use. DESIGN, SETTING, AND PARTICIPANTS Adolescent patients (age range, 12-17 years) arriving for routine medical care at 2 outpatient primary care centers and 1 outpatient center for substance use treatment at a pediatric hospital completed an electronic screening tool from June 1, 2012, through March 31, 2013, that consisted of a question on the frequency of using 8 types of drugs in the past year (Screening to Brief Intervention). Additional questions assessed severity of any past-year substance use. Patients completed a structured diagnostic interview (Composite International Diagnostic Interview-Substance Abuse Module), yielding Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) substance use diagnoses. MAIN OUTCOMES AND MEASURES For the entire screen and the Screening to Brief Intervention, sensitivity and specificity for identifying nontobacco substance use, substance use disorders, severe substance use disorders, and tobacco dependence were calculated using the Composite International Diagnostic Interview-Substance Abuse Module as the criterion standard. RESULTS Of 340 patients invited to participate, 216 (63.5%) enrolled in the study. Sensitivity and specificity were 100% and 84% (95% CI, 76%-89%) for identifying nontobacco substance use, 90% (95% CI, 77%-96%) and 94% (95% CI, 89%-96%) for substance use disorders, 100% and 94% (95% CI, 90%-96%) for severe substance use disorders, and 75% (95% CI, 52%-89%) and 98% (95% CI, 95%-100%) for nicotine dependence. No significant differences were found in sensitivity or specificity between the full tool and the Screening to Brief Intervention. CONCLUSIONS AND RELEVANCE A single screening question assessing past-year frequency use for 8 commonly misused categories of substances appears to be a valid method for discriminating among clinically relevant risk categories of adolescent substance use.
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Affiliation(s)
- Sharon Levy
- Adolescent Substance Abuse Program, Boston Children’s Hospital, Boston, Massachusetts2Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Roger Weiss
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts5Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts
| | - Lon Sherritt
- Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts6Center for Adolescent Substance Abuse Research, Boston Children’s Hospital, Boston, Massachusetts
| | - Rosemary Ziemnik
- Adolescent Substance Abuse Program, Boston Children’s Hospital, Boston, Massachusetts2Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Allegra Spalding
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Shari Van Hook
- Adolescent Substance Abuse Program, Boston Children’s Hospital, Boston, Massachusetts2Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts3Department of Pediatrics, Harvard Medical School, Boston, Massachusetts6Center for
| | - Lydia A. Shrier
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts7Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts
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Duarte RS, Martins IH, Mendes CP, Silva Costa MA, Mendes DDS, Romano VF, Gomes SC, Reis A, Neves RD. Proposta interdisciplinar de apoio à cessação do tabagismo em uma unidade de saúde da Estratégia Saúde da Família: relato de experiência. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2014. [DOI: 10.5712/rbmfc9(33)708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Este artigo descreve a proposta interdisciplinar utilizada atualmente no Centro Municipal de Saúde Manguinhos (CMSM), Rio de Janeiro, para condução longitudinal do tratamento antitabagismo em pacientes residentes em comunidades de baixa renda da região, sob a ótica de um estudante de medicina em seu período de internato rotatório. A abordagem antitabágica consiste em terapia longitudinal dividida em duas etapas: (i) assistência a grupo de pacientes com abordagem interdisciplinar ao longo de quatro sessões distribuídas semanalmente que inclui tratamento psicoterápico e recursos farmacológicos; seguida de (ii) duas sessões quinzenais de terapia de manutenção, caracterizadas por atenção individualizada e desmame farmacológico, complementadas por um seguimento mensal de até um ano. Os protocolos atuais, as atividades dos profissionais e a condução da proposta são descritos. Este relato sugere que o aprimoramento da formação em medicina pode ocorrer por meio da participação dos estudantes em ações de educação em saúde, tais como o grupo antitabagismo.
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Philibert RA, Beach S, Brody GH. The DNA methylation signature of smoking: an archetype for the identification of biomarkers for behavioral illness. NEBRASKA SYMPOSIUM ON MOTIVATION. NEBRASKA SYMPOSIUM ON MOTIVATION 2014; 61:109-27. [PMID: 25306781 PMCID: PMC4543297 DOI: 10.1007/978-1-4939-0653-6_6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Smoking is perhaps the foremost public health challenge in the United States and in the world. In a series of rapidly emerging studies, we and others have demonstrated that cigarette smoking is associated with changes in the DNA methylation signature of peripheral blood cells. The changes associated with this type of substance use are both dose and time dependent. These changes in DNA methylation are also accompanied by changes in gene transcription and protein expression whose patterns are furthermore indicative of increased vulnerability to other forms of complex illness. In the past, our efforts to translate this knowledge into actionable information has been stymied by a lack of methods through which to systematically to assess these changes. The rapid advance of DNA methylation assessment technologies changes that dynamic and presents the possibility that methylation-based clinical tools to aid the ascertainment of smoking status or effectiveness of treatment can be developed. In this chapter, we will review the latest advances in this field and discuss how these advances allow us insight as to methods through which to prevent smoking and shed insight into optimizing strategies through which to identify biomarkers for other behavioral illnesses which share similar contributions from environmental and gene- environmental interaction effects.
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Affiliation(s)
| | - S.R.H. Beach
- The Center for Family Research, University of Georgia, Athens, GA
| | - Gene H. Brody
- The Center for Family Research, University of Georgia, Athens, GA
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Palazzolo DL. Electronic cigarettes and vaping: a new challenge in clinical medicine and public health. A literature review. Front Public Health 2013; 1:56. [PMID: 24350225 PMCID: PMC3859972 DOI: 10.3389/fpubh.2013.00056] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 11/01/2013] [Indexed: 01/04/2023] Open
Abstract
Electronic cigarette (e-cigarette) use, or vaping, in the United States and worldwide is increasing. Their use is highly controversial from scientific, political, financial, psychological, and sociological ideologies. Given the controversial nature of e-cigarettes and vaping, how should medical care providers advise their patients? To effectively face this new challenge, health care professionals need to become more familiar with the existing literature concerning e-cigarettes and vaping, especially the scientific literature. Thus, the aim of this article is to present a review of the scientific evidence-based primary literature concerning electronic cigarettes and vaping. A search of the most current literature using the pubmed database dating back to 2008, and using electronic cigarette(s) or e-cigarette(s) as key words, yielded a total of 66 highly relevant articles. These articles primarily deal with (1) consumer-based surveys regarding personal views on vaping, (2) chemical analysis of e-cigarette cartridges, solutions, and mist, (3) nicotine content, delivery, and pharmacokinetics, and (4) clinical and physiological studies investigating the effects of acute vaping. When compared to the effects of smoking, the scant available literature suggests that vaping could be a “harm reduction” alternative to smoking and a possible means for smoking cessation, at least to the same degree as other Food and Drug Administration-approved nicotine replacement therapies. However, it is unclear if vaping e-cigarettes will reduce or increase nicotine addiction. It is obvious that more rigorous investigations of the acute and long-term health effects of vaping are required to establish the safety and efficacy of these devices; especially parallel experiments comparing the cardiopulmonary effects of vaping to smoking. Only then will the medical community be able to adequately meet the new challenge e-cigarettes and vaping present to clinical medicine and public health.
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Affiliation(s)
- Dominic L Palazzolo
- Department of Physiology and Pharmacology, DeBusk College of Osteopathic Medicine, Lincoln Memorial University , Harrogate, TN , USA
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Collins R, Hammond M, Carry CL, Kinnon D, Killulark J, Nevala J. Distance education for tobacco reduction with Inuit frontline health workers. Int J Circumpolar Health 2013; 72:21078. [PMID: 23984270 PMCID: PMC3752291 DOI: 10.3402/ijch.v72i0.21078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Tobacco reduction is a major priority in Canadian Inuit communities. However, many Inuit frontline health workers lacked the knowledge, confidence and support to address the tobacco epidemic. Given vast distances, high costs of face-to-face training and previous successful pilots using distance education, this method was chosen for a national tobacco reduction course. OBJECTIVE To provide distance education about tobacco reduction to at least 25 frontline health workers from all Inuit regions of Canada. DESIGN Promising practices globally were assessed in a literature survey. The National Inuit Tobacco Task Group guided the project. Participants were selected from across Inuit Nunangat. They chose a focus from a "menu" of 6 course options, completed a pre-test to assess individual learning needs and chose which community project(s) to complete. Course materials were mailed, and trainers provided intensive, individualized support through telephone, fax and e-mail. The course ended with an open-book post-test. Follow-up support continued for several months post-training. RESULTS Of the 30 participants, 27 (90%) completed the course. The mean pre-test score was 72% (range: 38-98%). As the post-test was done using open books, everyone scored 100%, with a mean improvement of 28% (range: 2-62%). CONCLUSIONS Although it was often challenging to contact participants through phone, a distance education approach was very practical in a northern context. Learning is more concrete when it happens in a real-life context. As long as adequate support is provided, we recommend individualized distance education to others working in circumpolar regions.
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Affiliation(s)
- Rob Collins
- Consultancy for Alternative Education, Montreal, Canada.
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Sattler AC, Cade NV. Prevalência da abstinência ao tabaco de pacientes tratados em unidades de saúde e fatores relacionados. CIENCIA & SAUDE COLETIVA 2013; 18:253-64. [DOI: 10.1590/s1413-81232013000100026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 02/13/2012] [Indexed: 11/22/2022] Open
Abstract
O objetivo é conhecer a prevalência e identificar as variáveis relacionadas com a abstinência do tabaco em pacientes tratados nos Grupos de Apoio Terapêutico ao Tabagista (GATT) em unidades de saúde do município de Vitória (ES), no ano de 2009. Estudo transversal com 160 participantes do GATT que participaram de 75% das sessões. Realizada entrevista por telefone, 9 a 20 meses após o tratamento, e usado dados secundários do roteiro de entrevista inicial. Na análise estatística, foram utilizados os testes qui-quadrado e Fisher. A significância estatística foi 5%. Eram abstinentes 28,7%, recaíram 51,9% e 19,4% não pararam de fumar. Houve diferença estatística entre os grupos nas variáveis estado civil (0,039), tentativas anteriores para parar de fumar (0,029), quantidade de cigarros fumados por dia (0,019), uso de fármacos (0,001) e transtorno do humor referidos (0,040). O grupo de abstinente teve mais casados, tentou mais vezes parar de fumar, fumou menos cigarro/dia, apresentou menos ansiedade/alteração do humor. A abstinência foi semelhante a outros estudos e o maior percentual de sujeitos recaiu.
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Williams JH, Jones TE. Smoking cessation post-discharge following nicotine replacement therapy use during an inpatient admission. Intern Med J 2012; 42:154-9. [PMID: 21299782 DOI: 10.1111/j.1445-5994.2011.02442.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cigarette smoking remains a health issue despite declining prevalence in Australia. The burden of tobacco-related morbidity affects hospitals, particularly those in lower socioeconomic areas where prevalence is highest. AIM We have shown that nicotine replacement therapy (NRT) use during hospitalization increases motivation to quit post-discharge. We postulated that subjects using the nicotine patch post-discharge, in comparison to the inhaler, would have higher rates of abstinence at 12 months after discharge. The aim was to compare the efficacy of the nicotine patch or inhaler formulation for cessation post-discharge, following use during admission. METHODS Post-discharge, subjects chose their preferred formulation (patch or inhaler) based on their experience with NRT during admission. Tailored, medium-intensity support was provided with subsidized NRT during outpatient visits. Subjects were followed for 12 months. Exhaled breath CO confirmed non-smoking. RESULTS Of 123 subjects enrolled, 37 elected to use the inhaler, 50 the patch and 36 no NRT. At 12 months continuous abstinence rates were 38%, 38% and 25% respectively. DISCUSSION This study built upon the 'teachable moment' provided by hospitalization and the inpatient use of NRT, encouraging cessation post-discharge. Both NRT formulations provided similar 12 month cessation rates, and were superior to those achieved by subjects electing not to use NRT. Although the patch was the most popular formulation, the inhaler provided an equally efficacious alternative which addressed other facets of cigarette addiction. Subjects electing not to use NRT were less successful. Continuous abstinence rates were equivalent to community-based studies using NRT. We recommend a similar programme to other hospitals.
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Affiliation(s)
- J H Williams
- Respiratory Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia.
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Talley B, Mary Gee R, Allen D, Marshall ES, Encinas K, Lim S. Assessment of smokeless tobacco use in the history and physical examination by primary healthcare providers. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2011; 23:443-447. [PMID: 21790838 DOI: 10.1111/j.1745-7599.2011.00631.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE Following a simple descriptive research design, we examined how and to what extent primary healthcare providers in rural southern regions of the United States ask patients about the use of smokeless tobacco as indicated in the document used for the patient history. DATA SOURCES Copies of blank history and physical forms used in offices of primary care providers in Alabama, Georgia, South Carolina, and Tennessee were examined to identify items related specifically to tobacco use. CONCLUSIONS Twenty-nine providers returned history and physical forms, which revealed 24% showed no item related to tobacco use. Others included questions related to smoking, but only 7% mentioned any sort of smokeless tobacco use. IMPLICATIONS FOR PRACTICE Although a few studies have suggested the use of smokeless tobacco to be less harmful than smoking, all forms of smokeless tobacco are recognized carcinogens and dangerous for health. It is not sufficient to simply ask patients about smoking behaviors. Primary care providers, especially nurse practitioners, have the unique opportunity to assess use of smokeless tobacco and to offer treatment and counsel to help patients to stop the behavior.
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Affiliation(s)
- Brenda Talley
- School of Nursing, University of Alabama, Huntsville, Alabama, USA
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Morris CD, Miller BF, Mahalik JL. An expanded opportunity to provide tobacco cessation services in primary care. Transl Behav Med 2011; 1:31-4. [PMID: 24073030 PMCID: PMC3717686 DOI: 10.1007/s13142-010-0010-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The Patient Protection and Affordable Care Act, and Centers for Medicare and Medicaid Services (CMS) decision on tobacco cessation counseling support the need for expanded cessation coverage. Primary care practices receiving CMS payments will soon be mandated to offer these services. This commentary discusses the salience of tobacco cessation policy in terms of opportunities for primary care, and anticipated issues in meeting healthcare reform requirements. Comments build upon recent federal policy and suggest areas to which primary care practices will need to attend when operationalizing tobacco cessation policies. Research supports efficacious tobacco cessation interventions delivered in a primary care context. To effectively implement tobacco cessation in primary care, practices will need to address coding and payment issues, define service offerings, identify reporting requirements, align with the medical home model, and increase provider buy-in.
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Affiliation(s)
- Chad D Morris
- />Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO USA
- />Department of Psychiatry, University of Colorado Anschutz Medical Campus, Campus Box F478, 1784 Racine Street, Building 401, Aurora, CO 80045 USA
| | - Benjamin F Miller
- />Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - John L Mahalik
- />Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO USA
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Thompson B, McLerran D, Livaudais JC, Coronado GD. A group-randomized tobacco trial among 30 Pacific Northwest colleges: results from the Campus Health Action on Tobacco study. Nicotine Tob Res 2010; 12:635-46. [PMID: 20447935 DOI: 10.1093/ntr/ntq064] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION We conducted a group-randomized trial to increase smoking cessation and decrease smoking onset and prevalence in 30 colleges and universities in the Pacific Northwest. METHODS Random samples of students, oversampling for freshmen, were drawn from the participating colleges; students completed a questionnaire that included seven major areas of tobacco policies and behavior. Following this baseline, the colleges were randomized to intervention or control. Three interventionists developed Campus Advisory Boards in the 15 intervention colleges and facilitated intervention activities. The freshmen cohort was resurveyed 1 and 2 years after the baseline. Two-years postrandomization, new cross-sectional samples were drawn, and students were surveyed. RESULTS At follow-up, we found no significant overall differences between intervention and control schools when examining smoking cessation, prevalence, or onset. There was a significant decrease in prevalence in private independent colleges, a significant increase in cessation among rural schools, and a decrease in smoking onset in urban schools. DISCUSSION Intervention in this college population had mixed results. More work is needed to determine how best to reach this population of smokers.
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Affiliation(s)
- Beti Thompson
- Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA.
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Quantification of nortriptyline in plasma by HPLC and fluorescence detection. J Chromatogr B Analyt Technol Biomed Life Sci 2010; 878:841-4. [DOI: 10.1016/j.jchromb.2010.01.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 01/18/2010] [Accepted: 01/21/2010] [Indexed: 11/20/2022]
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Ahmad N, Boutron I, Dechartres A, Durieux P, Ravaud P. Applicability and generalisability of the results of systematic reviews to public health practice and policy: a systematic review. Trials 2010; 11:20. [PMID: 20187938 PMCID: PMC2838881 DOI: 10.1186/1745-6215-11-20] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 02/26/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The purpose of the study was to evaluate systematic reviews of research into two public health priorities, tobacco consumption and HIV infection, in terms of the reporting of data related to the applicability of trial results (i.e., whether the results of a trial can be reasonably applied or generalized to a definable group of patients in a particular setting in routine practice, also called external validity or generalisability). METHODS All systematic reviews of interventions aimed at reducing or stopping tobacco use and treating or preventing HIV infection published in the Cochrane database of systematic reviews and in journals indexed in MEDLINE between January 1997 and December 2007 were selected. We used a standardized data abstraction form to extract data related to applicability in terms of the context of the trial, (country, centres, settings), participants (recruitment, inclusion and exclusion criteria, baseline characteristics of participants such as age, sex, ethnicity, coexisting diseases or co-morbidities, and socioeconomic status), treatment (duration, intensity/dose of treatment, timing and delivery format), and the outcomes assessment from selected reviews. RESULTS A total of 98 systematic reviews were selected (57 Cochrane reviews and 41 non-Cochrane reviews); 49 evaluated interventions aimed at reducing or stopping tobacco use and 49 treating or preventing HIV infection. The setting of the individual studies was reported in 45 (46%) of the systematic reviews, the number of centres in 21 (21%), and the country where the trial took place in 62 (63%). Inclusion and exclusion criteria of the included studies were reported in 16 (16%) and 13 (13%) of the reviews, respectively. Baseline characteristics of participants in the included studies were described in 59 (60%) of the reviews. These characteristics concerned age in about half of the reviews, sex in 46 (47%), and ethnicity in 9 (9%).Applicability of results was discussed in 13 (13%) of the systematic reviews. The reporting was better in systematic reviews by the Cochrane Collaboration than by non-Cochrane groups. CONCLUSIONS Our study highlighted the lack of consideration of applicability of results in systematic reviews of research into 2 public health priorities: tobacco consumption and HIV infection.
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Affiliation(s)
- Nizar Ahmad
- Centre d'épidémiologie Clinique, Hôpital Hôtel Dieu, AP-HP (Assistance Publique des Hôpitaux de Paris), 1 place du Parvis Notre-Dame, Paris 75181, France.
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Rickert WS, Wright WG, Trivedi AH, Momin RA, Lauterbach JH. A comparative study of the mutagenicity of various types of tobacco products. Regul Toxicol Pharmacol 2007; 48:320-30. [PMID: 17614170 DOI: 10.1016/j.yrtph.2007.05.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Indexed: 10/23/2022]
Abstract
Toxicological data are an important aspect of tobacco product characterization. In this study, TPM (Total Particulate Matter) (three replicates) was collected from cigarettes [five brands, ISO conditions: puff volume, 35 mL; duration, 2s; interval, 60s (35/2/60)], cigars (two brands, 45/2/30), cigarillos (two brands, 35/2/60), bidis (two brands, 45/2/30), and pipe tobacco (two brands, 50/2/12). TPM was extracted from the Cambridge filter pad using dimethyl sulfoxide (DMSO). Smokeless tobacco (ST) (six brands) was extracted with DMSO using an ultrasonic homogenizer. Both types of extracts were filtered and stored at -80 degrees C. All extracts were analyzed for humectants, water and nicotine. Mutagenic activity was assessed per OECD guideline 471 using Salmonella typhimurium TA98+S9 and TA100+S9. TA98+S9 response (specific activity expressed as revertants/mg nicotine) was greatest for the cigarette fabricated with dark, air-cured tobaccos. Average product responses with TA98+S9 based on nicotine and relative to cigarettes (excluding dark tobacco) were cigars, 242%; cigarillos, 238%; bidis, 91%; and pipe tobacco, 44%. ST response was not significant for TA98+S9. Corresponding values for TA100+S9 were cigars, 189%; cigarillos, 155%; pipe tobacco, 130%; bidis, 114% and ST, 34%. ST TA100+S9 response ranged from a low of 501 to a high of 8547 revertants/mg nicotine, depending on ST composition.
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Affiliation(s)
- W S Rickert
- Labstat International ULC, 262 Manitou Drive, Kitchener, Ont., Canada N2C 1L3.
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Fagan KA. Smoking-cessation counseling practices of college/university health-care providers--a theory-based approach. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2007; 55:351-9. [PMID: 17517547 DOI: 10.3200/jach.55.6.351-360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The author's purpose in this study was to examine the relation between smoking cessation counseling self-efficacy, knowledge of smoking cessation counseling, motivation to counsel smokers, and barriers to performing smoking cessation counseling, relative to the smoking cessation counseling stage of change. PARTICIPANTS AND METHODS Members of The American College Health Association, who are health-care providers (N=296), completed a survey measuring the predictor variables of knowledge, motivation, self-efficacy and perceived barriers, and the members' readiness for conducting smoking-cessation counseling with students. RESULTS The majority reported that they were knowledgeable about smoking-cessation counseling practices, they were motivated to conduct counseling, and they had the confidence (self-efficacy) to perform smoking-cessation counseling effectively. Significant barriers to performing smoking cessation counseling included the lack of reimbursement for counseling, lack of training in smoking-cessation counseling, and lack of resources for follow-up. The author found a moderate negative correlation between self-efficacy for smoking-cessation counseling and barriers to performing smoking-cessation counseling. CONCLUSION The results suggest that researchers should address the barriers that prevent health-care providers from performing smoking-cessation counseling. Interventions on increasing healthcare providers' counseling self-efficacy may be instrumental in moving them further along the stage continuum and increase their readiness to perform smoking cessation counseling.
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Affiliation(s)
- Kathleen A Fagan
- University of Medicine & Dentistry of New Jersey's School of Nursing, Newark, NJ 07101, USA.
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de Granda-Orive JI, Martínez-Albiach JM. Smoking Cessation in Patients With Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2005; 41:625-33. [PMID: 16324602 DOI: 10.1016/s1579-2129(06)60297-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- J I de Granda-Orive
- Servicio de Neumología, Hospital Militar Central de la Defensa Gómez Ulla, Madrid, Spain.
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