Smoking cessation advice from healthcare professionals helps those in the contemplation and preparation stage: An application with transtheoretical model underpinning in a community-based program

INTRODUCTION

The efficacy of smoking cessation intervention has been proven with randomized controlled trials. Our study aims to elucidate the effects of the delivery method of smoking cessation advice on the process of stage of changes with transtheorectical model underpinning in a community setting.

METHODS

A total of 436 subjects were recruited in a quasi-experimental untreated control design study, with 46 receiving advice from healthcare professionals (HCP group) and 390 in the control group, in 2003, Nantou, Taiwan. A discrete time Markov model was used to quantify the multi-state process of smoking cessation in light of the transtheorectical model. Multiple polytomous logistic regression models were simultaneously applied to different transitions.

RESULTS

The estimated forward transition probabilities were higher in the HCP group compared to their counterparts in the control group. On the other hand, the backward transition probabilities were smaller in the HCP group. After adjusting for confounding factors, HCP had a 4.3-fold (95% CI: 2.21–8.46) odds ratio of moving forward from the contemplation stage, and 2.4-fold odds ratio (95% CI: 1.03–4.42) from the preparation stage. Elderly people were more reluctant to change from precontemplation (AOR=0.50; 95% CI: 0.34–0.74) and contemplation (AOR=0.58; 95% CI: 0.44–0.84), but once in the preparation stage, they were more likely to take action (AOR=1.28; 95% CI: 1.01–1.83). For those in the preparation stage, longer smoking years had a negative effect on taking action (AOR=0.74; 95% CI: 0.52–0.99), but cessation advice from others enhanced the likelihood to take action (AOR=1.36; 95% CI: 1.01–1.99).

CONCLUSIONS

The direct advice on smoking cessation from healthcare professionals enforced the net forward transition towards smoking cessation, especially the transition from contemplation and preparation. The proposed Markov regression model assessed the net effect of different intervention approaches allowing for the simultaneous consideration of multiple transitions and the effects of other confounders.

Analysis of household data on influenza epidemic with Bayesian hierarchical model

Data used for modelling the household transmission of infectious diseases, such as influenza, have inherent multilevel structures and correlated property, which make the widely used conventional infectious disease transmission models (including the Greenwood model and the Reed-Frost model) not directly applicable within the context of a household (due to the crowded domestic condition or socioeconomic status of the household). Thus, at the household level, the effects resulting from individual-level factors, such as vaccination, may be confounded or modified in some way. We proposed the Bayesian hierarchical random-effects (random intercepts and random slopes) model under the context of generalised linear model to capture heterogeneity and variation on the individual, generation, and household levels. It was applied to empirical surveillance data on the influenza epidemic in Taiwan. The parameters of interest were estimated by using the Markov chain Monte Carlo method in conjunction with the Bayesian directed acyclic graphical models. Comparisons between models were made using the deviance information criterion. Based on the result of the random-slope Bayesian hierarchical method under the context of the Reed-Frost transmission model, the regression coefficient regarding the protective effect of vaccination varied statistically significantly from household to household. The result of such a heterogeneity was robust to the use of different prior distributions (including non-informative, sceptical, and enthusiastic ones). By integrating out the uncertainty of the parameters of the posterior distribution, the predictive distribution was computed to forecast the number of influenza cases allowing for random-household effect.

Abstract S1-10: Disparities in the estimates of benefits and harms from mammography: Are the numbers really different?

It is generally accepted that screening with mammography prevents deaths from breast cancer, although debate continues about the absolute size of the mortality benefit, and the concomitant risks associated with screening. A number of recent observational studies have claimed to find low rates of benefit in terms of reducing mortality rates or late stage disease, and high rates of overdiagnosis, defined as the diagnosis by screening of cancer which would not have been diagnosed in the patient's lifetime if screening had not taken place. These publications have achieved a high profile in the mass media and stimulated further debate. We review the apparent disparities between different reviews of the effects of mammography screening on mortality from breast cancer and on overdiagnosis. The four major reviews are the UK Independent Review, the Nordic Cochrane review, the US Preventive Services Task Force (USPSTF) review, and the EUROSCREEN review. The estimated number needed to screen/invite to prevent one death from breast cancer ranges from 111 to 2000, almost a 20-fold range. The estimated number required varies by age group, whether the intervention described is actual screening or invitation to screening, follow-up time and other factors. To assess whether these represent genuine disagreements or whether the differences are mainly due to such factors as follow-up time and target population, we converted all four to pertain to the same scenario as used in the UK Independent Review, that is to the effect of screening for 20 years from age 50 to 69 on breast cancer mortality in ages 55-79, in a UK population. When all four reviews are converted to the UK review scenario, the range of absolute benefits is now only 2.5-fold rather than 20-fold. Thus, the differences between the reviews with respect to the absolute breast cancer mortality reduction are almost entirely due to expressing the same basic result relative to different denominators, choice of population mortality rates, etc. Thus, the so-called controversy over the benefit of mammography screening as estimated from the trials is largely contrived. When expressed relative to the same denominator, with the same screening and follow-up periods, and using the same absolute mortality rates, absolute benefit estimates are all of the same order of magnitude, and all indicate a substantial reduction in breast cancer mortality with screening. While there are genuine disagreements about overdiagnosis, methods which adjust for lead time and underlying incidence trends yield estimates which are modest and are outweighed by the mortality benefit.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S1-10.

Absolute numbers of lives saved and overdiagnosis in breast cancer screening, from a randomized trial and from the Breast Screening Programme in England

OBJECTIVES

To estimate the absolute numbers of breast cancer deaths prevented and the absolute numbers of tumours overdiagnosed in mammographic screening for breast cancer at ages 50-69 years.

SETTING

The Swedish Two-County randomized trial of mammographic screening for breast cancer, and the UK Breast Screening Programme in England, ages 50-69 years.

METHODS

We estimated the absolute numbers of deaths avoided and additional cases diagnosed in the study group (active study population) of the Swedish Two-County Trial, by comparison with the control group (passive study population). We estimated the same quantities for the mortality and incidence rates in England (1974-2004 and 1974-2003, respectively). We used Poisson regression for statistical inference.

RESULTS

A substantial and significant reduction in breast cancer mortality was associated with screening in both the Two-County Trial (P < 0.001) and the screening programme in England (P < 0.001). The absolute benefits were estimated as 8.8 and 5.7 breast cancer deaths prevented per 1000 women screened for 20 years starting at age 50 from the Two-County Trial and screening programme in England, respectively. The corresponding estimated numbers of cases overdiagnosed per 1000 women screened for 20 years were, respectively, 4.3 and 2.3 per 1000.

CONCLUSIONS

The benefit of mammographic screening in terms of lives saved is greater in absolute terms than the harm in terms of overdiagnosis. Between 2 and 2.5 lives are saved for every overdiagnosed case.

Differences in Endpoints between the Swedish W-E (Two County) Trial of Mammographic Screening and the Swedish Overview: Methodological Consequences

Objectives

To characterize and quantify the differences in the number of cases and breast cancer deaths in the Swedish W-E Trial compared with the Swedish Overview Committee (OVC) summaries and to study methodological issues related to trials in secondary prevention.

Setting

The study population of the W-E Trial of mammography screening was included in the first (W and E county) and the second (E-county) OVC summary of all Swedish randomized mammography screening trials. The OVC and the W-E Trial used different criteria for case definition and causes of death determination.

Method

A Review Committee compared the original data files from Wand E county and the first and second OVC. The reason for a discrepancy was determined individually for all non-concordant cases or breast cancer deaths.

Results

Of the 2615 cases included by the W-E Trial or the OVC, there were 478 (18%) disagreements. Of the disagreements 82% were due to inclusion/exclusion criteria, and 18% to disagreement with respect to cause of death or vital status at ascertainment. For E-County, the OVC inclusion rules and register based determination of cause of death (second OVC) rather than individual case review (W-E Trial and 1st OVC) resulted in a reduction of the estimate of the effect of screening, but for W-County the difference between the original trial and the OVC was modest.

Conclusions

The conclusion that invitation to mammography screening reduces breast cancer mortality remains robust. Disagreements were mainly due to study design issues, while disagreements about cause of death were a minority. When secondary research does not adhere to the protocols of the primary research projects, the consequences of such design differences should be investigated and reported. Register linkage of trials can add follow-up information. The precision of trials with modest size is enhanced by individual monitoring of case status and outcome status such as determination of cause of death.

The influence of media reporting of a celebrity suicide on suicidal behavior in patients with a history of depressive disorder

BACKGROUND

Few studies have directly assessed the impact of a specific media report in vulnerable people. This study investigates possible influences of media reporting of a celebrity suicide on subsequent suicidal behaviors and associated risk factors among depressive patients.

METHODS

Depressive patients (N=461) were assessed through a structured interview soon after extensive media reporting of a celebrity suicide.

RESULTS

Among 438 depressive patients exposed to the media report, 38.8% reported an influence on subsequent suicidal behaviors, including 24 (5.5%) with a suicide attempt. The risk of such influence was highest among patients in a severe depressive state just prior to the media report (adjusted OR 7.81, 95% CI 3.28-18.59). Such influence on a subsequent suicide attempt was highest in patients with a most recent suicide attempt within one month prior to the media reports (adjusted hazard ratio 11.91, 95% CI 3.76-37.72).

LIMITATIONS

Our finding of the significant media influence may reflect adverse thoughts among more suicidal and depressed individuals. The possible influence of other factors on the findings cannot be ruled out.

CONCLUSIONS

This study has provided more convincing evidence suggesting negative influences of media reporting of a celebrity suicide on subsequent suicidal behaviors among depressive patients. Particular attention in terms of potential negative media influences should be paid to patients who are younger and currently depressed and have made a recent suicide attempt.

The influence of media coverage of a celebrity suicide on subsequent suicide attempts

OBJECTIVE

To investigate the impact of media reporting of a celebrity suicide on subsequent suicide attempts.

METHOD

A Poisson time series autoregression analysis was conducted to examine whether there was a significant increase in suicide attempts during the 3-week period after the start of extensive media reporting of a celebrity suicide. The reporting began on May 2, 2005, and lasted about 17 days. To investigate the influence of media reporting on suicide attempts, a structured interview was conducted with 124 suicide attempters identified from 2 counties in Mid Taiwan who had exposure to the media reporting.

RESULTS

After controlling for seasonal variation, calendar year, temperature, and humidity, there was a marked increase in the number of suicide attempts during the 3-week period after media reporting began (adjusted relative risk = 1.55, 95% CI = 1.26 to 1.91). Among 124 suicide attempters exposed to the media reports, 23.4% reported an influence from them. There was no relationship between the attempters' ages and the age of the celebrity or the method, but male attempters had a significantly higher risk for such influence. A considerably higher risk for such influence was found among subjects with a history of suicide attempt(s) in the previous year (odds ratio = 52.3, 95% CI = 5.96 to 459.1).

CONCLUSIONS

The extensive media reporting of the suicide of a celebrity was followed by an increase in suicide attempts. The effect was particularly marked in individuals with a recent history of a suicide attempt. The results provide further support for the need for more restrained reporting of suicides as part of suicide prevention strategies and for special vigilance for contagious effects of such reporting on people who have carried out recent suicidal acts.

Screening for Breast Cancer

Strong evidence supports the value of breast cancer screening with mammography, and high-quality mammography screening can be considered a major public health achievement. As noted earlier in the discussion about the evaluation of service screening, the group of women who did not participate in mammographic screening in the decades after screening had been introduced had essentially unchanged or only minor improvements in mortality compared with the pattern before the introduction of screening, despite widespread use of adjuvant chemotherapy or hormonal therapy. Breast cancer should be treated in its preclinical phase if we are to save the lives of women with this disease, and a considerable body of evidence outlines best practices that, with broader adherence, would result in greater breast cancer mortality reductions than have been observed to date.

The randomized trials of breast cancer screening: what have we learned?

Eight randomized controlled trials of mammography screening have been conducted to date. In addition to evaluating the efficacy of screening with an experimental design, the trials provided investigators with access to information about breast cancers much earlier in their development than had previously been available. The trials of mammographic screening provide conclusive evidence that the policy of offering screening is associated with a significant and substantial reduction in breast cancer mortality.