Electronic Nicotine-Delivery Systems for Smoking Cessation

BACKGROUND

Electronic nicotine-delivery systems - also called e-cigarettes - are used by some tobacco smokers to assist with quitting. Evidence regarding the efficacy and safety of these systems is needed.

METHODS

In this open-label, controlled trial, we randomly assigned adults who were smoking at least five tobacco cigarettes per day and who wanted to set a quit date to an intervention group, which received free e-cigarettes and e-liquids, standard-of-care smoking-cessation counseling, and optional (not free) nicotine-replacement therapy, or to a control group, which received standard counseling and a voucher, which they could use for any purpose, including nicotine-replacement therapy. The primary outcome was biochemically validated, continuous abstinence from smoking at 6 months. Secondary outcomes included participant-reported abstinence from tobacco and from any nicotine (including smoking, e-cigarettes, and nicotine-replacement therapy) at 6 months, respiratory symptoms, and serious adverse events.

RESULTS

A total of 1246 participants underwent randomization; 622 participants were assigned to the intervention group, and 624 to the control group. The percentage of participants with validated continuous abstinence from tobacco smoking was 28.9% in the intervention group and 16.3% in the control group (relative risk, 1.77; 95% confidence interval, 1.43 to 2.20). The percentage of participants who abstained from smoking in the 7 days before the 6-month visit was 59.6% in the intervention group and 38.5% in the control group, but the percentage who abstained from any nicotine use was 20.1% in the intervention group and 33.7% in the control group. Serious adverse events occurred in 25 participants (4.0%) in the intervention group and in 31 (5.0%) in the control group; adverse events occurred in 272 participants (43.7%) and 229 participants (36.7%), respectively.

CONCLUSIONS

The addition of e-cigarettes to standard smoking-cessation counseling resulted in greater abstinence from tobacco use among smokers than smoking-cessation counseling alone. (Funded by the Swiss National Science Foundation and others; ESTxENDS ClinicalTrials.gov number, NCT03589989.).

Associations between urinary biomarkers of oxidative stress and biomarkers of tobacco smoke exposure in smokers

Oxidative stress can contribute to the development of diseases, and may originate from exposures to toxicants commonly found in air pollution and cigarette smoke such as polycyclic aromatic hydrocarbons (PAHs) and volatile organic compounds (VOCs). Yet, associations between these exposures and oxidative stress biomarkers are poorly characterized. We report here novel associations between 14 exposure biomarkers of PAHs and VOCs, and two oxidative stress biomarkers; 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) and 8-isoprostaglandin F_2α (8-isoprostane) in urine obtained from smokers participating in an ongoing clinical study (ESTxENDS, NCT03589989). We also assessed associations between six biomarkers of tobacco smoke exposure (metabolites of nicotine and tobacco-specific nitrosamines (TSNAs)) and both oxidative stress biomarkers. We then quantified the relative importance of each family of the 20 exposure biomarkers on oxidative stress. Participating smokers (153 men and 117 women, median age 44 years) had on average smoked 25 [2-62] years and smoked about 17 [5-40] cigarettes per day at the time of the study. Multiple linear regression results showed an association between 8-oxodG concentrations and the following metabolites in decreasing relative importance: PAHs (beta coefficient β = 0.105, p-value <0.001, partial R² = 0.15) > VOCs (β = 0.028, p < 0.001, partial R² = 0.09) > nicotine (β = 0.226, p < 0.001, partial R² = 0.08); and between 8-isoprostane concentrations and metabolites of PAHs (β = 0.117, p < 0.001, partial R² = 0.14) > VOCs (β = 0.040, p < 0.001, partial R² = 0.14) > TSNAs (β = 0.202, p = 0.003, partial R² = 0.09) > nicotine (β = 0.266, p < 0.001, partial R² = 0.08). Behavioral factors known to contribute to oxidative stress, including sleep quality, physical activity, and alcohol consumption, did not play a significant role. Exposures to PAHs and VOCs among smokers were significantly associated with oxidative stress.

[Dyspepsia: a more complex approach]

Dyspepsia is defined as epigastric pain that lasts at least one month and may be associated with a range of other upper gastrointestinal symptoms. Approximately 2/3 of outpatients with dyspepsia have a functional dyspepsia. The clinical assessment of dyspepsia is based on age of patients as well and the search for severity criteria. The endoscopy in cases of new-onset dyspepsia is recommended from an age of 55-60 and the presence of at least 1 severity criteria. A non-invasive test for Helicobacter pylori (HP) should be performed in all patients and followed by HP eradication when HP test is positive. The first-choice treatment of functional dyspepsia is a proton pump inhibitor (PPI) at maximal dose for 8 weeks. A therapeutic trial with a prokinetic or a central neuromodulator are alternatives to consider in case of failure of PPI treatment.

[Tobacco cessation treatment for people with schizophrenia]

Among patients suffering from schizophrenia, tobacco smoking prevalence is extremely high and represents a major burden in terms of morbidity and mortality. Tobacco smoking is under-diagnosed and under-treated by mental health professionals, mostly due to an overestimated risk of jeopardizing the patient's mental condition, but also due to a lack of expertise on tobacco cessation treatment. Despite the extent of this problem, pharmacological approaches haven't been studied enough. However, treatments such as varenicline, bupropion and nicotine replacement are effective and well tolerated and their prescription should be recommended for tobacco withdrawal among these patients.

[New approaches to risk and the use of electronic tools in primary care medicine in 2021]

Our selection of articles published in 2021 sheds light on topics related to risk, and to the use of electronic tools in primary care medicine. They cover blood pressure targets, telemonitoring, and the omega-3 fatty acid diet in the elderly and/or in patients with high cardiovascular risk. They present the role of primary care physicians in the management of patients with NAFLD, and in screening for domestic violence in all couples. They assess the risk of recurrence of a depressive episode after stopping antidepressant treatment. Finally, they discuss the place of apps to communicate with foreign-speaking patients and of vaping in smoking cessation.

Association between self-reported motivation to quit smoking with effectiveness of smoking cessation intervention among patients hospitalized for acute coronary syndromes in Switzerland

•

Smokers with low motivation to quit usually are not offered intensive counselling.

•

When offered to all smokers, most with low motivation to quit accepted counselling.

•

Proactive counselling was associated with higher quit rates among less motivated smokers.

Guidelines recommend brief smoking cessation interventions for hospitalized smokers reporting low motivation-to-quit. However, an intensive smoking cessation intervention may improve smoking cessation for these smokers. We conducted a secondary analysis of a pre-post interventional study that tested the efficacy of a proactive approach systematically offering intensive smoking cessation intervention to all hospitalized smokers with acute coronary syndrome (ACS) compared to a reactive approach offering it only to smokers willing to quit.

We analyzed data from one study site in Switzerland, which recorded motivation-to-quit smoking at study inclusion between 08.2009 and 02.2012. The primary outcome was smoking cessation at 1- and 5-year. We tested for interaction by participant’s motivation-to-quit score (low vs. high motivation), and calculated multivariable adjusted risk ratios (RR), stratified by motivation score.

We obtained motivation scores for 230 smokers. Follow-up was 94% (217/230) at 1-year and 68% (156/230) at 5-year. Among participants with low motivation to quit, 19% of smokers in the reactive phase had quit at 1 year compared to 50% of smokers in the proactive phase (multivariable adjusted RR = 2.85, 95%CI:0.91–8.91). Among highly motivated smokers, rates did not differ between phases: 48% vs. 49% (multivariable adjusted RR = 1.02, 95%CI:0.75–1.39, p-value for interaction between motivation-to-quit categories = 0.10). At 5-year follow-up, the point estimates were similar.

While our study has limitations inherent to the study design and sample size, we found that a proactive approach to offer systematic smoking cessation counseling for smokers with ACS reporting low motivation to quit was associated with higher smoking cessation rates at 1 year.

International expert consensus on electronic nicotine delivery systems and heated tobacco products: a Delphi survey

OBJECTIVES

To provide a consensus from a panel of international experts about electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP).

DESIGN

Cross-sectional survey.

METHODS

A Delphi survey was conducted among international experts in tobacco control and smoking cessation. The first part addressed statements or recommendations about ENDS, the second about HTP, both divided into four categories: regulation, sale, use and general issues.

SETTING

Experts from 15 countries.

PARTICIPANTS

Individuals with clinical, public health or research expertise in tobacco control and/or smoking cessation.

RESULTS

268 experts were contacted, 92 (34%) completed the first, 55/92 (60%) the second round. Consensus for ENDS: components of e-liquids, an upper limit of nicotine concentration should be defined; a warning on the lack of evidence in long-term safety and addiction potential should be stated; ENDS should not be regulated as consumer products but either as a new category of nicotine delivery or tobacco products; ENDS should not be sold in general stores but in specialised shops, shops selling tobacco or in pharmacies with restriction on sale to minors; administration of illegal drugs is likely with ENDS. Consensus for HTP: HTP have the same addictive potential as cigarettes; they should be regulated as a tobacco product with similar warning messages as cigarettes; their advertisement should not be allowed. ENDS and HTP use should not be allowed in indoor public places; a specific tax should be implemented for ENDS, taxes on HTP should not be lower than those for cigarettes; use of cigarettes is more likely with both ENDS and HTP (dual use) than quitting smoking.

CONCLUSIONS

Experts in tobacco control and/or smoking cessation recommend differential regulation for ENDS and HTP. The results of this survey may be useful for health authorities, decision makers and researchers of the tobacco use and cessation field.

Spatial clusters of daily tobacco consumption before and after a smoke-free policy implementation

This study assessed the spatial dependence of daily tobacco consumption and how it is spatially impacted by individual and neighborhood socioeconomic determinants, and tobacco consumption facilities before and after a smoke-free implementation. Individual data was obtained from the Bus Santé, a cross-sectional survey in Geneva. Spatial clusters of high and low tobacco consumption were assessed using Getis-Ord Gi*. Daily tobacco consumption was not randomly clustered in Geneva and may be impacted by tobacco consumption facilities independently of socioeconomic factors and a smoking ban. Spatial analysis should be considered to highlight the impact of smoke-free policies and guide public health interventions.

[Gynécology-obstretric - Perinatal smoking cessation support : why and how ?]

In Switzerland, tobacco smoking is a major public health problem, especially among pregnant women. Health problems encountered by pregnant women and their fetuses require specific care to assist smoking cessation. A specific consultation to support smoking cessation during pregnancy was created in May 2019 at the maternity ward of the University Hospitals of Geneva, with the support of the Fondation Privée des Hôpitaux Universitaires de Genève and Carrefour addictionS/CIPRET-Genève. The creation of a network of health professionnals trained in smoking cessation is an important step to support women during their cessation process.

Tobacco craving and withdrawal symptoms in psychiatric patients during a motivational enhancement intervention based on a 26-hour smoking abstinence period

INTRODUCTION

In psychiatric patients, tobacco withdrawal symptoms are frequently seen as a barrier to smoking cessation; however, further studies are warranted in this specific population.

METHODS

Patients receiving in- or out-patient mental health care participated in a motivational enhancement program including a 26-hour tobacco abstinence experience with professional support and optional nicotine replacement therapy. The study included 174 subjects, of whom 159 were evaluated 1 week before and at the end of the 26-hour abstinence period. Repeated assessments included the Minnesota Nicotine Tobacco Withdrawal Scale Revised (MNWS-R), two items of the Mood and Physical Symptoms Scale (MPSS) regarding craving, the State-Trait Anxiety Inventory (STAI-S), the Beck Depression Inventory (BDI-21), and the World Health Organization Well-Being Index (WHO-5).

RESULTS

More than half the participants (52.3%) succeeded in 26-hour smoking abstinence. Craving was the most frequent MNWS-R withdrawal symptom (28.3% scored ≥3 on a 0–4 scale). Comparison of pre- and post-intervention data revealed significant improvements in 13 of 16 MNWS-R symptoms as well as craving (MPSS) and well-being, and significant decreases in anxiety and depression. Increasing MNWS-R craving scores and greater depression were both significantly associated with lower success in the 26-hour smoking abstinence period.

CONCLUSIONS

The negative effects of tobacco withdrawal symptoms in psychiatric patients may be substantially overestimated. Participation in a supportive structured motivational intervention with a 26-hour smoking cessation experience was well tolerated and contributed to temporary improvements in mental state. Craving is an interesting symptom to evaluate during smoking cessation attempts.

[Ambulatory shift in general internal medicine: a need for evidence beyond economical aspects]

General internal medicine is particularly concerned by the shift from stationary to ambulatory care, a shift that unfortunately is more often discussed from an economic perspective than from the angle of evidence. This article presents the results of studies and reviews published in 2019 that investigated the effectiveness of ambulatory instead of stationary care.

[Addictions]

This article describes a new form of administration of inhaled prescribed heroin currently under investigation. It underlines the particularity of opioid agonist prescription in jail and presents new perspectives in using psilocybin in addiction medicine treatment. A brief literature review about vaping confirms its interest in quitting cigarette, with a cost of addiction to vaping and recent worrisome reports of chemical pneumonia. Finally, the withdrawal of WHO guidelines on opiates use in pain management, in the context of a suspicion of conflict of interest, underlines the sensible balance between over- and under- prescription of opiates in analgesic treatment.

Public smoking ban and socioeconomic inequalities in smoking prevalence and cessation: a cross-sectional population-based study in Geneva, Switzerland (1995-2014)

INTRODUCTION

Smoking bans were suggested to reduce smoking prevalence and increase quit ratio but their equity impact remains unclear. We aimed to characterise the socioeconomic status (SES)-related inequalities in smoking prevalence and quit ratio before and after the implementation of a public smoking ban.

METHODS

We included data from 17 544 participants in the population-based cross-sectional Bus Santé study in Geneva, Switzerland, between 1995 and 2014. We considered educational attainment (primary, secondary and tertiary) as a SES indicator. Outcomes were smoking prevalence (proportion of current smokers) and quit ratio (ex-smokers to ever-smokers ratio). We used segmented linear regression to assess the overall impact of smoking ban on outcome trends. We calculated the relative (RII) and slope (SII, absolute difference) indexes of inequality, quantifying disparities between educational groups in outcomes overall (1995-2014), before and after ban implementation (November 2009).

RESULTS

Least educated participants displayed higher smoking prevalence (RII=2.04, P<0.001; SII=0.15, P<0.001) and lower quit ratio (RII=0.73, P<0.001; SII=-0.18, P<0.001). As in other studies, smoking ban implementation coincided with a temporary reduction of smoking prevalence (P=0.003) and increase in quit ratio (P=0.02), with a progressive return to preban levels. Inequalities increased (P<0.05) in relative terms for smoking prevalence (RII_before=1.84, P<0.001 and RII_after=3.01, P<0.001) and absolute terms for both outcomes (smoking prevalence: SII_before=0.14, P<0.001 and SII_after=0.19, P<0.001; quit ratio: SII_before=-0.15, P<0.001 and SII_after=-0.27, P<0.001).

CONCLUSIONS

Implementation of a public smoking ban coincided with a short-lived decrease in smoking prevalence and increase in quit ratio but also with a widening in SES inequalities in smoking-related outcomes.

Uptake and efficacy of a systematic intensive smoking cessation intervention using motivational interviewing for smokers hospitalised for an acute coronary syndrome: a multicentre before-after study with parallel group comparisons

OBJECTIVES

To compare the efficacy of a proactive approach with a reactive approach to offer intensive smoking cessation intervention using motivational interviewing (MI).

DESIGN

Before-after comparison in 2 academic hospitals with parallel comparisons in 2 control hospitals.

SETTING

Academic hospitals in Switzerland.

PARTICIPANTS

Smokers hospitalised for an acute coronary syndrome (ACS).

INTERVENTION

In the intervention hospitals during the intervention phase, a resident physician trained in MI systematically offered counselling to all smokers admitted for ACS, followed by 4 telephone counselling sessions over 2 months by a nurse trained in MI. In the observation phase, the in-hospital intervention was offered only to patients whose clinicians requested a smoking cessation intervention. In the control hospitals, no intensive smoking cessation intervention was offered.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was 1 week smoking abstinence (point prevalence) at 12 months. Secondary outcomes were the number of smokers who received the in-hospital smoking cessation intervention and the duration of the intervention.

RESULTS

In the intervention centres during the intervention phase, 87% of smokers (N=193/225) received a smoking cessation intervention compared to 22% in the observational phase (p<0.001). Median duration of counselling was 50 min. During the intervention phase, 78% received a phone follow-up for a median total duration of 42 min in 4 sessions. Prescription of nicotine replacement therapy at discharge increased from 18% to 58% in the intervention phase (risk ratio (RR): 3.3 (95% CI 2.4 to 4.3; p≤0.001). Smoking cessation at 12-month increased from 43% to 51% comparing the observation and intervention phases (RR=1.20, 95% CI 0.98 to 1.46; p=0.08; 97% with outcome assessment). In the control hospitals, the RR for quitting was 1.02 (95% CI 0.84 to 1.25; p=0.8, 92% with outcome assessment).

CONCLUSIONS

A proactive strategy offering intensive smoking cessation intervention based on MI to all smokers hospitalised for ACS significantly increases the uptake of smoking cessation counselling and might increase smoking abstinence at 12 months.

[Teaching practice recommendations: prevention and screening]

The aim of this article is to provide guidance to family doctors on how to tutor students about effective screening and primary prevention. Family doctors know their patients and adapt national and international guidelines to their specific context, risk profile, sex and age as well as to the prevalence of the disorders under consideration. Three cases are presented to illustrate guideline use according to the level of evidence (for a 19-year-old man, a 60-year-old woman, and an 80-year-old man). A particular strength of family medicine is that doctors see their patients over the years. Thus they can progressively go through the various prevention strategies, screening, counselling and immunisation, accompanying their patients with precious advice for their health throughout their lifetime.

Acute respiratory and cardiovascular admissions after a public smoking ban in Geneva, Switzerland

Background

Many countries have introduced legislations for public smoking bans to reduce the harmful effects of exposure to tobacco smoke. Smoking bans cause significant reductions in admissions for acute coronary syndromes but their impact on respiratory diseases is unclear. In Geneva, Switzerland, two popular votes led to a stepwise implementation of a state smoking ban in public places, with a temporary suspension. This study evaluated the effect of this smoking ban on hospitalisations for acute respiratory and cardiovascular diseases.

Methods

This before and after intervention study was conducted at the University Hospitals of Geneva, Switzerland, across 4 periods with different smoking legislations. It included 5,345 patients with a first hospitalisation for acute coronary syndrome, ischemic stroke, acute exacerbation of chronic obstructive pulmonary disease, pneumonia and acute asthma. The main outcomes were the incidence rate ratios (IRR) of admissions for each diagnosis after the final ban compared to the pre-ban period and adjusted for age, gender, season, influenza epidemic and secular trend.

Results

Hospitalisations for acute exacerbation of chronic obstructive pulmonary disease significantly decreased over the 4 periods and were lowest after the final ban (IRR = 0.54 [95%CI: 0.42–0.68]). We observed a trend in reduced admissions for acute coronary syndromes (IRR = 0.90 [95%CI: 0.80–1.00]). Admissions for ischemic stroke, asthma and pneumonia did not significantly change.

Conclusions

A legislative smoking ban was followed by a strong decrease in hospitalisations for acute exacerbation of chronic obstructive pulmonary disease and a trend for reduced admissions for acute coronary syndrome. Smoking bans are likely to be very beneficial for patients with chronic obstructive pulmonary disease.

Text-messaging to reduce missed appointment in a youth clinic: a randomised controlled trial

BACKGROUND

To assess the effectiveness of text-messages in reducing the proportion of non-attendance in a youth clinic of a University Hospital.

METHODS

Patients who registered for an appointment and provided a mobile phone number were randomly selected to receive or not a text-message reminder before the planned appointment. A 10% reduction in the proportion of missed appointments was considered clinically and economically useful and the study was powered accordingly.

RESULTS

The proportion of missed appointments was 16.4% (95% CI 13.1% to 19.8%) in the text-message group (N 462) and 20.0% (95% CI 16.6% to 23.4%) in the control group (N 529), showing no significant effect of the intervention (p=0.346).

CONCLUSIONS

In our primary care youth clinic, text-message reminders are not effective in reducing the proportion of missed appointments. This may in part be due to the fact that most patients are referred by a professional or by their parents and do not initiate appointments themselves.

Text-messaging versus telephone reminders to reduce missed appointments in an academic primary care clinic: a randomized controlled trial

Background

Telephone or text-message reminders have been shown to significantly reduce the rate of missed appointments in different medical settings. Since text-messaging is less resource-demanding, we tested the hypothesis that text-message reminders would be as effective as telephone reminders in an academic primary care clinic.

Methods

A randomized controlled non-inferiority trial was conducted in the academic primary care division of the Geneva University Hospitals between November 2010 and April 2011. Patients registered for an appointment at the clinic, and for whom a cell phone number was available, were randomly selected to receive a text-message or a telephone call reminder 24 hours before the planned appointment. Patients were included each time they had an appointment. The main outcome was the rate of unexplained missed appointments. Appointments were not missed if they were cancelled or re-scheduled before or independently from the intervention. We defined non-inferiority as a difference below 2% in the rate of missed appointments and powered the study accordingly. A satisfaction survey was conducted among a random sample of 900 patients (response rate 41%).

Results

6450 patients were included, 3285 in the text-message group and 3165 in the telephone group. The rate of missed appointments was similar in the text-message group (11.7%, 95% CI: 10.6-12.8) and in the telephone group (10.2%, 95% CI: 9.2-11.3 p = 0.07). However, only text message reminders were cost-effective. No patient reported any disturbance by any type of reminder in the satisfaction survey. Three quarters of surveyed patients recommended its regular implementation in the clinic.

Conclusions

Text-message reminders are equivalent to telephone reminders in reducing the proportion of missed appointments in an academic primary care clinic and are more cost-effective. Both types of reminders are well accepted by patients.

Implementation and impact of anti-smoking interventions in three prisons in the absence of appropriate legislation

OBJECTIVE

To assess the acceptability and impact of anti-smoking policies in three prisons in Switzerland.

METHODS

A before-after intervention study in A) an open prison for sentenced prisoners, B) a closed prison for sentenced prisoners, and C) a prison for pretrial detainees. Prisoners and staff were surveyed before (2009, n=417) and after (2010-2011, n=228) the interventions. Medical staff were trained to address tobacco dependence systematically in prisoners. In prison A, a partial smoking ban was extended. No additional protection against second-hand smoke was feasible in prisons B and C.

RESULTS

In prison A, more prisoners reported receiving medical help to quit smoking in 2011 (20%) than in 2009 (4%, p=0.012). In prison A, prisoners and staff reported less exposure to second-hand smoke in 2011 than in 2009: 31% of prisoners were exposed to smoke at workplaces in 2009 vs 8% in 2011 (p=0.001); in common rooms: 43% vs 8%, (p<0.001). No changes were observed in prisons B and C.

CONCLUSIONS

Reinforcement of non-smoking rules was possible in only one of the three prisons but had an impact on exposure to tobacco smoke and medical help to quit. Implementing anti-smoking policies in prisons is difficult in the absence of appropriate legislation.

How to fulfill residents' training needs and public service missions in outpatient general internal medicine? An observational pilot study

QUESTION UNDER STUDY/PRINCIPLES: Ambulatory care is a mandatory component of post-graduate training in general internal medicine. Academic outpatient clinics face challenges in training residents in terms of exposure to sufficient patient case-mix, diversity of clinical activities and continuity of care while fulfilling their mission to provide care to vulnerable populations. We report the development and evaluation of a new postgraduate curriculum in ambulatory care in Geneva, Switzerland, designed to overcome such challenges.

METHODS/DESCRIPTION

The content of learning activities was adapted to core competencies and learning objectives. In the new 2-year curriculum, residents had their working week divided into 2½ days of continuity clinic over two years, and 2½ days of 6 to 12 months rotations (e.g., walk-in clinics). Team work was consolidated through the creation of subunits including an attending physician, 1-2 senior residents during one year and 6- to 8 residents, who met in bi-monthly meetings with other health professionals.

RESULTS/EVALUATION

In both local and national surveys, residents and senior residents expressed an overall global satisfaction with the new curriculum. Nursing and administrative staff were less satisfied, because of reduced residents' time in each unit. Interprofessional meetings were highly appreciated for both patient care and team building. Management of residents' absences became more complex.

CONCLUSION

The new curriculum met its goals in gaining residents' satisfaction and in reinforcing interprofessional collaboration although management of human resources became more complex. It also gave insights into challenges to be addressed when disseminating a new curriculum, such as strong leadership, educational expertise and management skills and tools.

Design, implementation and evaluation of a community health training program in an integrated problem-based medical curriculum: a fifteen-year experience at the University of Geneva Faculty of Medicine

BACKGROUND

In the literature the need for relevance in medical education and training has been stressed. In the last 40 years medical schools have been challenged to train doctors competent to respond to community health needs. In the mid-90s the University of Geneva Faculty of Medicine introduced an integrated medical curriculum. In this initiative a particular emphasis was put in introducing a 6-year longitudinal and multidisciplinary Community Health Program (CHP).

OBJECTIVES

The aims of the present article are to describe the conception, elaboration and implementation of the CHP as well as its evolution over 15 years and the evaluation of its outcomes.

METHODS

The CHP was at its origin elaborated by a small group of highly motivated teachers and later on developed by a multi-disciplinary group of primary care physicians, epidemiologists, public health and bio-ethics specialists, occupational health professionals, lawyers and historians. Evaluation of the program outcomes included educational innovations, new developments of the curriculum and interactions between students and the community.

RESULTS

The CHP learning objectives and teaching modalities were defined by the multi-disciplinary group in consensus meetings which triggered a collaborative spirit among teachers and facilitated further developments. The evaluation procedures allowed the monitoring of students' satisfaction which remained high over the years, students' active participation which decreased over time and success at certifying exams which was globally as good as in basic life sciences. The evaluation also assessed outcomes such as educational innovations, new developments of the curriculum and interactions between students and the community.

CONCLUSION

As suggested in the literature, our experience shows that the students' direct exposure and practice in the community health environment is an effective training approach to broaden students' education by offering them a community perspective of health and disease.

Improvement of measles immunity among migrant populations: lessons learned from a prevalence study in a Swiss prison

BACKGROUND

Measles persists worldwide despite the implementation of general vaccination campaigns. The environmental and demographic characteristics in many prisons increase the risk of measles epidemics. A large proportion of inmates come from countries where immunisation coverage is low. We aimed to estimate the susceptibility to measles among prisoners in order to implement preventative measures.

METHODS

Serology screening for measles was carried out among 116 inmates in Switzerland's largest pre-trial prison. Socio-demographic characteristics were collected through a structured questionnaire. Risk factors for lack of measles immunity were examined.

RESULTS

A total of 7 out of 116 (6%) inmates were not immune to measles. All 37 inmates from sub-Saharan Africa were immune. Considering only people native from regions other than sub-Saharan Africa, 7 of 40 inmates born after 1981 were susceptible (18.5%), whereas none of the 39 inmates born in 1981 or before were susceptible (p = 0.006).

CONCLUSION

Susceptibility to measles was fairly low in this prison population composed mainly of migrants. Living in sub-Saharan Africa during childhood, and birth before 1982 were protective factors associated with the presence of immunity against measles. The heterogeneity of vaccination campaigns in the various regions of the world, particularly in terms of the timing of their introduction and scale of diffusion, explains epidemiological variability. Targeted vaccination in accordance to origin and age would offer excellent herd immunity and would substantially reduce risks of outbreaks as well as costs.

Chickenpox in a Swiss prison: susceptibility, post-exposure vaccination and control measures

After the occurrence of a case of chickenpox in Switzerland's largest pre-trial prison, protective measures including post-exposure vaccination were implemented, as chickenpox can cause severe complications in adults. Serology for chickenpox was carried out for all contacts of the index case and rapid post-exposure vaccination proposed to all prisoners with a negative history for chickenpox. Susceptibility was found in 14 out of 110 prisoners (12.7%; 95% confidence interval 6.5-18.9). The positive predictive value of a history of chickenpox was 90%. In this predominantly migrant population, susceptibility to chickenpox was approximately 6 times higher than in the general Swiss adult population. Since the attack rate among susceptible household contacts is usually high, preventive measures such as vaccination and quarantine probably allowed containment of the spread of infection.

[Smoking cessation in patients with mental disorders]

Smoking cessation in patients with mental disorders Smoking prevalence is higher in all mental disorders, particularly depression and schizophrenia, through complex and multifactorial associations. Among patients with mental disorders, smoking cessation increases risk of relapse and recurring depression and might decrease smoking abstinence. Though smoking cessation interventions are less effective, professional support, relapse prevention strategies, nicotine replacement and bupropion help some patients to quit smoking. New strategies should overcome barriers to smoking cessation in psychiatric settings and improve intervention with smokers. Research needs to further explore the link between smoking and mental health and develop effective interventions integrated in psychiatric care provided to smokers.

Promoting hospital-based smoking cessation services at major Swiss hospitals: a before and after study

QUESTIONS UNDER STUDY

Whether a 1-year nationwide, government supported programme is effective in significantly increasing the number of smoking cessation clinics at major Swiss hospitals as well as providing basic training for the staff running them.

METHODS

We conducted a baseline evaluation of hospital services for smoking cessation, hypertension, and obesity by web search and telephone contact followed by personal visits between October 2005 and January 2006 of 44 major public hospitals in the 26 cantons of Switzerland; we compared the number of active smoking cessation services and trained personnel between baseline to 1 year after starting the programme including a training workshop for doctors and nurses from all hospitals as well as two further follow-up visits.

RESULTS

At base line 9 (21%) hospitals had active smoking cessation services, whereas 43 (98%) and 42 (96%) offered medical services for hypertension and obesity respectively. Hospital directors and heads of Internal Medicine of 43 hospitals were interested in offering some form of help to smokers provided they received outside support, primarily funding to get started or to continue. At two identical workshops, 100 health professionals (27 in Lausanne, 73 in Zurich) were trained for one day. After the programme, 22 (50%) hospitals had an active smoking cessation service staffed with at least 1 trained doctor and 1 nurse.

CONCLUSION

A one-year, government-supported national intervention resulted in a substantial increase in the number of hospitals allocating trained staff and offering smoking cessation services to smokers. Compared to the offer for hypertension and obesity this offer is still insufficient.

Promoting hospital-based smoking cessation services at major Swiss hospitals: a before and after study

QUESTIONS UNDER STUDY

Whether a 1-year nationwide, government supported programme is effective in significantly increasing the number of smoking cessation clinics at major Swiss hospitals as well as providing basic training for the staff running them.

METHODS

We conducted a baseline evaluation of hospital services for smoking cessation, hypertension, and obesity by web search and telephone contact followed by personal visits between October 2005 and January 2006 of 44 major public hospitals in the 26 cantons of Switzerland; we compared the number of active smoking cessation services and trained personnel between baseline to 1 year after starting the programme including a training workshop for doctors and nurses from all hospitals as well as two further follow-up visits.

RESULTS

At base line 9 (21%) hospitals had active smoking cessation services, whereas 43 (98%) and 42 (96%) offered medical services for hypertension and obesity respectively. Hospital directors and heads of Internal Medicine of 43 hospitals were interested in offering some form of help to smokers provided they received outside support, primarily funding to get started or to continue. At two identical workshops, 100 health professionals (27 in Lausanne, 73 in Zurich) were trained for one day. After the programme, 22 (50%) hospitals had an active smoking cessation service staffed with at least 1 trained doctor and 1 nurse.

CONCLUSION

A one-year, government-supported national intervention resulted in a substantial increase in the number of hospitals allocating trained staff and offering smoking cessation services to smokers. Compared to the offer for hypertension and obesity this offer is still insufficient.

[Relevant publications in ambulatory general internal medicine in 2007]

Screening procedures for genital Chlamydia infection, cancer risks linked to oral contraceptives, indications and efficacy of HPV vaccination, and diagnostic tools for celiac disease in adults; these are just a few of the general practice themes that were reviewed and analysed in 2007 by residents and chief residents at the Community medicine and primary care Service of the Geneva University Hospitals. These commented summaries, intended for all our colleagues, constitute Geneva's contribution to the literature data base initiated in 2005 by chief residents in Lausanne.

Cost-effectiveness analysis of a European primary-care physician training in smoking cessation counseling

BACKGROUND

Physician training in smoking cessation counseling has been shown to be effective as a means to increase quit success. We assessed the cost-effectiveness ratio of a smoking cessation counseling training programme. Its effectiveness was previously demonstrated in a cluster randomized, control trial performed in two Swiss university outpatients clinics, in which residents were randomized to receive training in smoking interventions or a control educational intervention.

DESIGN AND METHODS

We used a Markov simulation model for effectiveness analysis. This model incorporates the intervention efficacy, the natural quit rate, and the lifetime probability of relapse after 1-year abstinence. We used previously published results in addition to hospital service and outpatient clinic cost data. The time horizon was 1 year, and we opted for a third-party payer perspective.

RESULTS

The incremental cost of the intervention amounted to US$2.58 per consultation by a smoker, translating into a cost per life-year saved of US$25.4 for men and 35.2 for women. One-way sensitivity analyses yielded a range of US$4.0-107.1 in men and US$9.7-148.6 in women. Variations in the quit rate of the control intervention, the length of training effectiveness, and the discount rate yielded moderately large effects on the outcome. Variations in the natural cessation rate, the lifetime probability of relapse, the cost of physician training, the counseling time, the cost per hour of physician time, and the cost of the booklets had little effect on the cost-effectiveness ratio.

CONCLUSIONS

Training residents in smoking cessation counseling is a very cost-effective intervention and may be more efficient than currently accepted tobacco control interventions.

[Diagnosis and management of pharyngitis]

Although most pharyngitis are caused by viruses, up to 75% of patients visiting for a sore throat receive an antibiotic. As the performance of clinical features is poor a throat swab may help to differentiate a pharyngitis caused by a Group A beta3-hemolytic Streptococcus (GABHS) from other causes. A recent study tested and validated a new strategy combining a rapid test detecting GABHS and a clinical score with 2 or more of the four criteria (fever more than 38 degrees, tender cervical nodes, no cough and tonsillar exsudate). This strategy is cost-effective and limits antibiotic prescription to patients with GABHS. If the score is below two, a symptomatic treatment without antibiotic is recommended.

Counselling overweight and obese patients in primary care: a prospective cohort study

BACKGROUND

Primary care physicians are well positioned to provide counselling for overweight and obese patients, but no prospective study has assessed the effectiveness of this counselling in primary care. We aimed to evaluate weight reduction counselling by primary care physicians, and its relationship with weight change and patients' behaviour to control weight.

DESIGN

A prospective cohort study.

METHODS

We enrolled 523 consecutive overweight and obese patients from two Swiss academic primary care clinics. Physicians and patients were blinded to the study aims. We assessed the use of 10 predefined counselling strategies for weight reduction, and weight change and behaviour to control weight after 1 year.

RESULTS

Sixty-five per cent of patients received some form of weight reduction counselling whereas 35% received no counselling. A total of 407 patients completed the 1-year follow-up. Those who received counselling lost on average (SD) 1.0 (5.0) kg after 1 year, whereas those who were not advised gained 0.3 (5.0) kg (P = 0.02). In multivariate analysis, each additional counselling strategy was associated with a mean weight loss of 0.2 kg (95% confidence interval 0.03-0.4, P = 0.02). Patients counselled by their physician had more favourable behaviour to control weight than those not counselled, such as setting a target weight (56 versus 36%) or visiting a dietician (23 versus 10%, both P < 0.001).

CONCLUSIONS

Weight reduction counselling by primary care physicians is associated with a modest weight loss and favourable behaviour to control weight. However, many obese and overweight patients receive no advice on weight loss during primary care visits.

[Practitioners confronted with the four main health behavioral risk factors]

Four behavioural risk factors are common in primary care and are often clustered in individuals. Smoking is present from I cigarette per day, excessive alcohol use is defined either by drinking regularly more than 2-3 standard glasses per day or by occasional heavy drinking of more than 4-5 glasses at a time. Patients who don't have regular moderate physical activity of at least 30 minutes during 5 days of a week or intensive physical activity of at least 20 minutes 3 times a week are sedentary. A Body Mass Index of over 30 defines obesity. We propose a "generic" counselling tool in 5 steps, the 5 As, that can be used for any of the four behavioural risk factors during routine consultations. With this counselling guide, practitioners can help patients change behaviour in a motivational style that allows shared decision-making.

Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings

BACKGROUND

How to use clinical score, the rapid streptococcal antigen test (RSAT), and culture results is uncertain for efficient management of acute pharyngitis in adults.

METHODS

This prospective cohort study included 372 adult patients with pharyngitis treated at a Swiss university-based primary care clinic. In eligible patients with 2 to 4 clinical symptoms and signs (temperature >or=38 degrees C, tonsillar exudate, tender cervical adenopathy, and no cough or rhinitis), we performed an RSAT and obtained a throat culture. We measured sensitivity and specificity of RSAT with culture as a gold standard and compared appropriate antibiotic use with cost per patient appropriately treated for the following 5 strategies: symptomatic treatment, systematic RSAT, selective RSAT, empirical antibiotic treatment, and systematic culture.

RESULTS

RSAT had high sensitivity (91%) and specificity (95%) for the diagnosis of streptococcal pharyngitis. Systematic throat culture resulted in the highest antibiotic use, in 38% of patients with streptococcal pharyngitis. Systematic RSAT led to nearly optimal treatment (94%) and antibiotic prescription (37%), with minimal antibiotic overuse (3%) and underuse (3%). Empirical antibiotic treatment in patients with 3 or 4 clinical symptoms or signs resulted in a lower rate of appropriate therapy (59%) but higher rates of antibiotic use (60%), overuse (32%), and underuse (9%). Systematic RSAT was more cost-effective than strategies based on empirical treatment or culture: 15.00 dollars, 26.00 dollars, and 32.00 dollars, respectively, per patient appropriately treated.

CONCLUSIONS

The RSAT we used is a valid test for diagnosis of pharyngitis in adults. A clinical approach combining this RSAT and clinical findings efficiently reduces inappropriate antibiotic prescription in adult patients with acute pharyngitis. Empirical therapy in patients with 3 or 4 clinical symptoms or signs results in antibiotic overuse.

Youth smoking cessation: an update for primary care physicians

Tobacco use is a major public health problem, and onset usually begins in youth. This article reviews current knowledge and evidence of specific aspects of smoking in youth, tobacco control strategies, and smoking cessation interventions that target young people. Finally, it provides recommendations for primary care physicians.

Use of hormone replacement therapy by menopausal women: a comparison between primary care patients and the general population

OBJECTIVES

To compare frequency and patterns of hormone replacement therapy (HRT) between primary care patients and the local community.

METHODS

Comparison of data from a questionnaire survey of 107 peri- and postmenopausal patients in an academic primary care clinic during 1998 to similar data from a sample (n = 241) of an ongoing annual epidemiological survey representative of the general population.

RESULTS

Mean age, menopause status, age of initiation of HRT, and prior use of contraceptive pill were similar in both groups. Current HRT use tended to be lower among patients in the clinic than in the community. HRT users in the clinic were more likely to have had a surgical menopause (34.4% vs. 16.1%, p = 0.04) and to have used hormones for shorter periods than in the general population. Differences remained significant after adjustment in multivariate analysis.

CONCLUSIONS

Compared to the general population, patterns of HRT use in the outpatient clinic were more restrictive than recommendations on HRT that were published at the time. This is an example of how comparison of health issues between patients in medical care and a local epidemiological survey can help to understand clinical practice.

A new curriculum using active learning methods and standardized patients to train residents in smoking cessation

Physicians can play a key role in smoking cessation but often fail to advise smokers effectively, mainly because they lack counseling skills. We need effective training programs starting during residency to improve physicians' smoking cessation interventions and smokers' quit rates. To achieve this goal, we developed a curriculum using active learning methods and the stages-of-change model. A randomized trial demonstrated that this program increased the quality of physician's counseling and smokers' quit rates at 1 year. This paper describes the educational content and methods of this program. Participants learn to assess smokers' stage of change, to use counseling strategies matching the smoker's stage, and to prescribe pharmacological therapy. This 2 half-day training program includes observation of video-clips, interactive workshops, role plays, practice with standardized patients, and written material for physicians and patients. Participants reached learning objectives and appreciated the content and active methods of the program.

Promoting influenza vaccination of elderly patients in primary care

BACKGROUND

Though influenza is a serious health problem for elderly people, their influenza vaccination rate remains low in Switzerland.

OBJECTIVE

Our aim was to assess the impact of an intervention combining multiple strategies to promote influenza vaccination of elderly patients in primary care.

METHODS

We conducted a pre-/post-intervention study in a university-based primary care clinic in Geneva, Switzerland, where an annual community-wide campaign promotes influenza vaccination of people at high risk. We included 318 and 346 patients aged over 64 years attending the clinic during the last trimesters of 1995 and 1996, respectively. The intervention included: patient information by leaflets and posters, a walk-in vaccination clinic, a training workshop for physicians, record reminders and peer comparison feedback on vaccination performance. Using the computerized database, medical records and the vaccination register, we measured influenza immunization rates and relative benefits (RBs) of the intervention.

RESULTS

Influenza vaccine uptake globally increased from 21.7% before the intervention to 51.7% thereafter. Among 144 patients attending in both phases, the immunization rate rose from 29.2 to 69.4% [matched RB estimate (<RB>) = 2.4; 95% confidence interval (CI) 1.9-3.0]; vaccine uptake increased particularly among all chronic patients (<RB> = 3.2; 95% CI 2.2-4.6), cardiac patients (<RB> = 3.4; 95% CI 2.1-5.4) and diabetics (<RB> = 3.3; 95% CI 1.9-5.9). For 376 patients attending in a single phase, the vaccination rate rose from 15.5 to 39.1% (adjusted RB = 2.8; 95% CI 1.8-4.4), particularly among the elderly aged 65-75 years (adjusted RB = 5.7; 95% CI 2.7-12.4).

CONCLUSION

An intervention combining strategies targeting patients, physicians and care delivery significantly increased influenza vaccine uptake of elderly patients in primary care, particularly those at high risk.

Efficacy of resident training in smoking cessation: a randomized, controlled trial of a program based on application of behavioral theory and practice with standardized patients

BACKGROUND

New educational programs must be developed to improve physicians' skills and effectiveness in counseling patients about smoking cessation.

OBJECTIVE

To assess the efficacy of an educational program based on behavioral theory, active learning methods, and practice with standardized patients in helping patients abstain from smoking and changing physicians' counseling practices.

DESIGN

Cluster randomized, controlled trial.

SETTING

Two general internal medicine clinics in Switzerland.

PARTICIPANTS

35 residents and 251 consecutive smoking patients.

INTERVENTION

A training program administered over two half-days, during which physicians learned to provide counseling that matched smokers' motivation to quit and practiced these skills with standardized patients acting as smokers at different stages of change. The control intervention was a didactic session on management of dyslipidemia.

MEASUREMENTS

Self-reported abstinence from smoking at 1 year of follow-up, which was validated by exhaled carbon monoxide testing at one clinic; score of overall quality of counseling based on use of 14 counseling strategies; patient willingness to quit; and daily cigarette consumption.

RESULTS

At 1 year of follow-up, abstinence from smoking was significantly higher in the intervention group than in the control group (13% vs. 5%; P = 0.005); this corresponded to a cluster-adjusted odds ratio of 2.8 (95% CI, 1.4 to 5.5). Residents who received the study training provided better counseling than did those who received the control training (mean score, 4.0 vs. 2.7; P = 0.002). Smokers' willingness to quit was also higher in the intervention group (94% vs. 80%; P = 0.007). A nonsignificant trend toward lower daily cigarette consumption in the intervention group was observed.

CONCLUSION

A training program in smoking cessation administered to physicians that was based on behavioral theory and practice with standardized patients significantly increased the quality of physicians' counseling, smokers' motivation to quit, and rates of abstinence from smoking at 1 year.

Development and validation of a scale measuring self-efficacy of current and former smokers

AIMS

To develop and test the validity of a questionnaire measuring the confidence of current and former smokers in their ability to abstain from smoking in high-risk situations.

DESIGN AND PARTICIPANTS

We collected qualitative data in a first mail survey in 115 smokers and ex-smokers, and used these data to develop survey items. We collected quantitative data in a second mail survey in 529 smokers and ex-smokers to finalize the instrument.

SETTING

General population in Geneva, Switzerland, 1995, 1997 and 1998.

FINDINGS

The study resulted in a two-dimensional 12-item scale: the "Smoking Self-Efficacy Questionnaire" (SEQ-12). The two six-item subscales measure confidence in ability to refrain from smoking when facing internal stimuli (e.g. feeling depressed) and external stimuli (e.g. being with smokers). Internal consistency coefficients were high ("internal stimuli": alpha = 0.95; "external stimuli": alpha = 0.94). Test-retest intraclass correlation coefficients were high (0.95 and 0.93 for the two scales, respectively). In smokers, baseline self-efficacy scores predicted smoking cessation at 16-month follow-up. Finally, the scale respected criteria of content- and construct validity.

CONCLUSION

SEQ-12 is a valid and reliable scale, which has applications in both research and clinical settings. It can also produce input data for computer systems that generate counselling reports tailored to the characteristics of each individual smoker.

Development and validation of the Attitudes Towards Smoking Scale (ATS-18)

AIM

To develop and test the validity of a scale measuring attitudes towards smoking in current and former cigarette smokers.

DESIGN AND PARTICIPANTS

In a first mail survey, we collected qualitative data from 616 smokers. In a second mail survey, we collected quantitative data from 529 smokers and ex-smokers. We conducted a 16-month follow-up survey among 93 participants in the second survey.

SETTING

Geneva, Switzerland, 1995-98.

FINDINGS

The study resulted in a three-dimensional, 18-item scale: the "Attitudes Towards Smoking Scale" (ATS-18). The scale was validated with reference to criteria of content-, construct- and predictive validity. The three subscales measure perceptions of adverse effects of smoking (10 items), psychoactive benefits (four items) and pleasure of smoking (four items). Internal consistency coefficients (0.85, 0.88 and 0.81) and test-retest correlations were high (0.90, 0.75, 0.89, respectively). Differences in attitude scores between smokers in the pre-contemplation and preparation stages of change were -0.83, 0.71 and 1.23 standard deviation units, respectively. A differential score (advantages minus disadvantages of smoking) predicted smoking cessation in baseline smokers and relapse in baseline ex-smokers.

CONCLUSION

ATS-18 is a valid and reliable instrument which can be used in both research and clinical settings.

Smoking-cessation strategies observed in videotaped general practice consultations

BACKGROUND

This study describes opportunistic smoking-cessation counseling and compares strategies used in general practice to experts' recommendations.

METHODS

In this observational study we analysed 157 videotaped consultations with self-reported smokers, visiting 70 Australian general practitioners (GPs) who were randomly enrolled in the Victorian General Practice Study. Smoking-cessation strategies were analysed using a rating form assessed for intrarater reliability and compared to recommendations of 20 experts surveyed to ascertain effective and feasible strategies.

RESULTS

GPs identified smokers in 32% of consultations and counselled them in 29%. Median counselling time was 44 seconds in encounters typically lasting 10 minutes. When smoking was raised, advice to quit, personalising risks, discussing health risks, and quantifying consumption were the most commonly used strategies (46%-54%). Assessment of motivation to quit, individualised education, practical hints to stop, written materials, and follow-up were observed in a third or less of interventions. Quit dates and nicotine replacement were never proposed.

CONCLUSIONS

GPs miss many opportunities to advise smokers to quit and rarely use effective smoking-cessation techniques as recommended. Medical education has failed to provide GPs with skills to counsel smokers routinely and effectively. We recommend better training of GPs in effective smoking-cessation strategies and incentives to facilitate their implementation in practice.