How can hospitals change practice to better implement smoking cessation interventions? A systematic review

Smoking cessation reduces the risk of death, improves recovery, and reduces the risk of hospital readmission. Evidence and policy support hospital admission as an ideal time to deliver smoking-cessation interventions. However, this is not well implemented in practice. In this systematic review, the authors summarize the literature on smoking-cessation implementation strategies and evaluate their success to guide the implementation of best-practice smoking interventions into hospital settings. The CINAHL Complete, Embase, MEDLINE Complete, and PsycInfo databases were searched using terms associated with the following topics: smoking cessation, hospitals, and implementation. In total, 14,287 original records were identified and screened, resulting in 63 eligible articles from 56 studies. Data were extracted on the study characteristics, implementation strategies, and implementation outcomes. Implementation outcomes were guided by Proctor and colleagues' framework and included acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. The findings demonstrate that studies predominantly focused on the training of staff to achieve implementation. Brief implementation approaches using a small number of implementation strategies were less successful and poorly sustained compared with well resourced and multicomponent approaches. Although brief implementation approaches may be viewed as advantageous because they are less resource-intensive, their capacity to change practice in a sustained way lacks evidence. Attempts to change clinician behavior or introduce new models of care are challenging in a short time frame, and implementation efforts should be designed for long-term success. There is a need to embrace strategic, well planned implementation approaches to embed smoking-cessation interventions into hospitals and to reap and sustain the benefits for people who smoke.

Campus Smoking Policies and Smoking-Related Twitter Posts Originating From California Public Universities: Retrospective Study

Background

The number of colleges and universities with smoke- or tobacco-free campus policies has been increasing. The effects of campus smoking policies on overall sentiment, particularly among young adult populations, are more difficult to assess owing to the changing tobacco and e-cigarette product landscape and differential attitudes toward policy implementation and enforcement.

Objective

The goal of the study was to retrospectively assess the campus climate toward tobacco use by comparing tweets from California universities with and those without smoke- or tobacco-free campus policies.

Methods

Geolocated Twitter posts from 2015 were collected using the Twitter public application programming interface in combination with cloud computing services on Amazon Web Services. Posts were filtered for tobacco products and behavior-related keywords. A total of 42,877,339 posts were collected from 2015, with 2837 originating from a University of California or California State University system campus, and 758 of these manually verified as being about smoking. Chi-square tests were conducted to determine if there were significant differences in tweet user sentiments between campuses that were smoke- or tobacco-free (all University of California campuses and California State University, Fullerton) compared to those that were not. A separate content analysis of tweets included in chi-square tests was conducted to identify major themes by campus smoking policy status.

Results

The percentage of positive sentiment tweets toward tobacco use was higher on campuses without a smoke- or tobacco-free campus policy than on campuses with a smoke- or tobacco-free campus policy (76.7% vs 66.4%, P=.03). Higher positive sentiment on campuses without a smoke- or tobacco-free campus policy may have been driven by general comments about one’s own smoking behavior and comments about smoking as a general behavior. Positive sentiment tweets originating from campuses without a smoke- or tobacco-free policy had greater variation in tweet type, which may have also contributed to differences in sentiment among universities.

Conclusions

Our study introduces preliminary data suggesting that campus smoke- and tobacco-free policies are associated with a reduction in positive sentiment toward smoking. However, continued expressions and intentions to smoke and reports of one’s own smoking among Twitter users suggest a need for more research to better understand the dynamics between implementation of smoke- and tobacco-free policies and resulting tobacco behavioral sentiment.

Air quality at venues of mixed smoking policies in Kazakhstan

INTRODUCTION

Enclosed designated smoking areas (DSAs) and smoking zones are allowed in food-serving venues in Kazakhstan. Air quality in smoke-free food-serving venues, in venues with smoking throughout, in those with DSAs and those with smoking zones, is not fully understood.

METHODS

A cross-sectional study with aim to evaluate PM_2.5 concentrations in the venues with mixed smoking was conducted from September to October 2017 in Almaty, the largest city of Kazakhstan. A total of 44 rooms within the selected 29 venues were evaluated: 100% smoke-free (5), non-smoking zones (7), smoking zones (7), non-smoking venues with DSAs (8), venues that allow smoking throughout (9), and DSAs (8). Real-time PM_2.5 measurement was conducted by TSI SidePak AM510 Personal Aerosol Monitor and used to rank health-risk assessment using the Air Quality Index developed by the U.S. Environmental Protection Agency.

RESULTS

Smoke-free food-serving venues had moderate levels of air quality with mean PM_2.5 of 26.2 μg/m³ while non-smoking zones inside venues that also permitted smoking had a mean of 56.5 μg/m³, corresponding to unhealthy air quality. Venues restricting smoking only to DSAs also had unhealthy air quality in non-smoking areas (mean PM_2.5 = 87.6 μg/m³) while DSAs had hazardous levels of air quality (mean PM_2.5 = 647.9 μg/m³). Smoking zones inside the venues and venues allowing smoking throughout had a mean PM_2.5 of 180.3 and 182.0 μg/m³, respectively, ranking as very unhealthy. On average 3.5 persons were observed in DSAs with mean volume of 38.9 m³. Cigarette and/or hookah were the major source of PM_2.5. The higher the smoker density the poorer the air quality in the venue.

CONCLUSIONS

Hazardous level of PM_2.5 due to tobacco products inside DSAs demonstrated the low efficiency of a smoking ban with exemptions. A complete smoking ban in food-serving venues should be in place to fully protect people from hazardous air quality conditions.

Prevalence of and factors associated with violations of a campus smoke-free policy: a cross-sectional survey of undergraduate students on a university campus in the USA

OBJECTIVE

The aim of this study is to estimate the prevalence of smoking behaviour on campus and to identify the key factors that influence adherence to a campus smoke-free policy.

DESIGN & PARTICIPANTS

This study employed a cross-sectional, self-administered survey of undergraduate students at the University of Mississippi. A random sample of all available undergraduate classes was recruited for data collection. Students were provided a survey that included questions on demographics, alcohol use, smoking status, policy awareness, policy attitudes, smoking attitudes, policy support, barriers to policy success and policy violations.

RESULTS

The prevalence of past 30-day smoking was 23%. More than 63% of current smokers report ever smoking on campus, but less than 10% ever received a warning or a ticket for their violation. Nearly all respondents (92.5%) reported witnessing someone smoking on campus, and 22% reported witnessing someone receiving a ticket. Barriers to policy success include lack of reminders about the policy, lack of support from students and University administrators, and insufficient fines. Smoking behaviour (OR: 7.96; 95% CI: 5.13 to 12.36), beliefs about policy adherence (OR: 0.52; 95% CI: 0.40 to 0.69), support for the policy (OR: 0.71; 95% CI: 0.55 to 0.91) and attitudes against smoking behaviour (OR: 0.35; 95% CI: 0.25 to 0.49) were all significantly associated with self-reported policy violations.

CONCLUSIONS

This study found that violations of the campus smoke-free policy were fairly frequent and the policy has been largely ineffective, indicating a need for other interventions. Approaches to improve adherence to the policy should address barriers such as reminders about the policy, better policy enforcement and support from the administration.

Workplace smoking restrictions and support for smoking cessation in the USA: state, region, and overall trends from 2010-11 to 2014-15

We discuss the most recent changes in smoking policies and support for smoking cessation offered to smokers at US workplaces. We used reports of employed adults (n = 112,008) regarding smoking restrictions and support for smoking cessation offered at their indoor workplaces from the 2010–11 and 2014–15 Tobacco Use Supplement-Current Population Survey. The percentage of adults who reported having workplace smoking restrictions was 94% in 2010–11 and 93% in 2014–15 (P = 0.001). There was a decrease in the Northeastern region (P < 0.001) and no significant changes in the other three US regions. The percentages decreased in Hawaii, New York, Oregon, Pennsylvania, and Tennessee and increased in Indiana, Nebraska, and Wyoming. The percentage of employees who reported having workplace support for smoking cessation increased from 24% to 29% (P < 0.001), which was uniform across all US regions but differed across the US states. The percentages decreased in Hawaii and increased in the majority of states. Analysis of smokers’ reports (versus all reports) resulted in lower percentages of workplaces with smoking restrictions and support for smoking cessation. It is essential to further enhance support for smoking cessation offered to smokers at US workplaces.

Estimating the public economic consequences of introducing varenicline smoking cessation therapy in South Korea using a fiscal analytic framework

BACKGROUND AND AIMS

Smoking gives rise to many cross-sectorial public costs and benefits for government. Costs arise from increased healthcare spending and work-related social benefits, while smoking itself provides significant revenue for government from tobacco taxes. To better understand the public economic impact of smoking and smoking cessation therapies, this study developed a government perspective framework for assessing smoking-attributable morbidity and mortality and associated public costs. This framework includes changes in lifetime tax revenue and health costs, as well as changes in tobacco tax revenue, from fewer smokers.

METHODS

A modified generational accounting framework was developed to assess relationships between smoking-attributable morbidity and mortality and public economic consequences of smoking, including lifetime tax revenue gains/losses, government social transfers, and health spending. Based on the current prevalence of smoking in South Korean males, a cohort model was developed for smokers, former-smokers, and never-smokers. The model simulated the lifetime discounted fiscal transfers for different age cohorts in 5 year age bands, and the return on investment (ROI) from smoking cessation therapy.

RESULTS

Former smokers are estimated to generate higher lifetime earnings and direct tax revenues and lower lifetime healthcare costs due to the reduction of smoking-attributable mortality and morbidity compared to smokers, even after accounting for reduced tobacco taxes paid. Based on the costs of public investments in varenicline, this study estimated a ROI from 1.4-1.7, depending on treatment age, with higher ROI in younger cohorts, with an average ROI of 1.6 for those aged less than 65.

CONCLUSIONS

This analysis suggests that reductions in smoking can generate positive public economic benefits for government, even after accounting for lost tobacco tax revenues. The results described here are likely applicable to countries having similar underlying smoking prevalence, comparable taxation rates, and social benefit protection provided to individuals with smoking-related conditions.

Fiscal Impact of Smoking Cessation in Thailand: A Government Perspective Cost-Benefit Analysis

We evaluate the broader public economic consequences of investments in smoking cessation that change lifetime productivity, which can influence future government tax revenue and social transfer costs and health care spending. The analysis applies a government perspective framework for assessing the intergenerational relationships between morbidity and mortality and lifetime tax revenue and social transfers received. Applying smoking prevalence in Thailand, a cohort model was developed for smoker and former smokers to estimate impact on lifetime direct taxes and tobacco taxes paid. Age-specific earnings for males and wage appropriate tax rates were applied to estimate net taxes for smokers and former smokers. Introducing smoking cessation leads to lifetime public economic benefits of THB13 998 to THB43 356 per person depending on the age of introducing smoking cessation. Factoring in the costs of smoking cessation therapy, an average return on investment of 1.35 was obtained indicating fiscal surplus generated for government from the combined effect of increased tax revenues and of averting smoking-attributable health care costs.

Secondhand Smoke Exposure and Smoke-free Policy in Philadelphia Public Housing

OBJECTIVES

Multi-unit housing environments remain significant sources of secondhand smoke (SHS) exposure, especially for vulnerable populations in subsidized housing. In Philadelphia, the largest US housing authority to implement smoke-free policies, we measured baseline resident smoking-related behaviors and attitudes, and longitudinal exposures to airborne nicotine, during policy development and implementation.

METHODS

In 4 communities, we collected data in 2013, 2014, and 2016, before and after introduction of comprehensive smoke-free policies, interviewing persons in 172 households, and monitoring air-borne nicotine in non-smoking homes and public areas. Average nicotine level differences across years were estimated with multi-level models.

RESULTS

Fifty-six percent of respondents smoked. Only 37% of households were smoke-free, with another 41% restricting smoking by area or time of day. The number of locations with detectable nicotine did not differ before and after policy implementation, with approximately 20% of non-smoking homes and 70%-80% of public areas having detectable nicotine. However, public area nicotine levels were lower in 2016, after policy implementation, than in 2013 and 2014 (-0.19 μg/m3, p = .03).

CONCLUSIONS

Findings suggest that initial policy implementation was associated with reduced SHS exposure in Philadelphia. As HUD strengthens smoke-free policies, SHS monitoring can be useful to educate stakeholders and build support for policy enforcement.

Smoking and attitudes toward smoking policy at a University in Egypt

To assess smoking behavior, knowledge of smoking harm, and attitudes toward campus smoking policy at an Egyptian university, an online survey of students, staff, and faculty was conducted (N = 992). The smoking prevalence of 38% among men was in line with Egypt's national average, but the smoking prevalence among women of 20% was much higher than the national average. Smoking status influenced beliefs about smoking harm and attitudes toward smoking policy, with nonsmokers having stronger beliefs about the harm of smoking and showing stronger support for smoking regulations than smokers. Smokers were more knowledgeable about smoking policy than were nonsmokers and differed slightly in their preferences for smoking policy enforcement strategies. These findings contribute to our understanding of how to tailor college smoking policy and programs to an Egyptian context.

Workplace secondhand smoke exposure in the U.S. trucking industry

BACKGROUND

Although the smoking rate in the United States is declining because of an increase of smoke-free laws, among blue-collar workers it remains higher than that among many other occupational groups.

OBJECTIVES

We evaluated the factors influencing workplace secondhand smoke (SHS) exposures in the U.S. unionized trucking industry.

METHODS

From 2003 through 2005, we measured workplace SHS exposure among 203 nonsmoking and 61 smoking workers in 25 trucking terminals. Workers in several job groups wore personal vapor-phase nicotine samplers on their lapels for two consecutive work shifts and completed a workplace SHS exposure questionnaire at the end of the personal sampling.

RESULTS

Median nicotine level was 0.87 microg/m3 for nonsmokers and 5.96 microg/m3 for smokers. As expected, smokers experienced higher SHS exposure duration and intensity than did nonsmokers. For nonsmokers, multiple regression analyses indicated that self-reported exposure duration combined with intensity, lack of a smoking policy as reported by workers, having a nondriver job, and lower educational level were independently associated with elevated personal nicotine levels (model R2 = 0.52). Nondriver job and amount of active smoking were associated with elevated personal nicotine level in smokers, but self-reported exposure, lack of a smoking policy, and lower educational level were not.

CONCLUSIONS

Despite movements toward smoke-free laws, this population of blue-collar workers was still exposed to workplace SHS as recently as 2005. The perceived (reported by the workers), rather than the official (reported by the terminal managers), smoking policy was associated with measured SHS exposure levels among the nonsmokers. Job duties and educational level might also be important predictors of workplace SHS exposure.