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1.  A Longitudinal Study of Medicaid Coverage for Tobacco Dependence Treatments in Massachusetts and Associated Decreases in Hospitalizations for Cardiovascular Disease 
PLoS Medicine  2010;7(12):e1000375.
Thomas Land and colleagues show that among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was followed by a substantial decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease.
Insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence in a population. However, uncertainty about the impact of this coverage on health care utilization and costs is a barrier to the broader adoption of this policy, especially by publicly funded state Medicaid insurance programs. Whether a publicly funded tobacco cessation benefit leads to decreased medical claims for tobacco-related diseases has not been studied. We examined the experience of Massachusetts, whose Medicaid program adopted comprehensive coverage of tobacco cessation medications in July 2006. Over 75,000 Medicaid subscribers used the benefit in the first 2.5 years. On the basis of earlier secondary survey work, it was estimated that smoking prevalence declined among subscribers by 10% during this period.
Methods and Findings
Using claims data, we compared the probability of hospitalization prior to use of the tobacco cessation pharmacotherapy benefit with the probability of hospitalization after benefit use among Massachusetts Medicaid beneficiaries, adjusting for demographics, comorbidities, seasonality, influenza cases, and the implementation of the statewide smoke-free air law using generalized estimating equations. Statistically significant annualized declines of 46% (95% confidence interval 2%–70%) and 49% (95% confidence interval 6%–72%) were observed in hospital admissions for acute myocardial infarction and other acute coronary heart disease diagnoses, respectively. There were no significant decreases in hospitalizations rates for respiratory diagnoses or seven other diagnostic groups evaluated.
Among Massachusetts Medicaid subscribers, use of a comprehensive tobacco cessation pharmacotherapy benefit was associated with a significant decrease in claims for hospitalizations for acute myocardial infarction and acute coronary heart disease, but no significant change in hospital claims for other diagnoses. For low-income smokers, removing the barriers to the use of smoking cessation pharmacotherapy has the potential to decrease short-term utilization of hospital services.
Please see later in the article for the Editors' Summary
Editors' Summary
Smoking is the leading preventable cause of death in the world. Globally, it is responsible for one in ten deaths among adults. In developed countries, the death toll is even higher—in the USA and the UK, for example, one in five deaths are caused by cigarette smoking. In the USA alone, where a fifth of adults smoke, smoking accounts for more than 400,000 deaths every year; globally, smoking causes 5 million deaths per year. On average, smokers die 14 years earlier than nonsmokers, and half of all long-term smokers will die prematurely because of a smoking-related disease. These diseases include lung cancer, other types of cancer, heart disease, stroke, and lung diseases such as chronic airway obstruction, bronchitis, and emphysema. And, for every smoker who dies from one of these smoking-related diseases, another 20 will develop at least one serious disease because of their addiction to tobacco.
Why Was This Study Done?
About half of US smokers try to quit each year but most of these attempts fail. Many experts believe that counseling and/or treatment with tobacco cessation medications such as nicotine replacement products help smokers to quit. In the USA, where health care is paid for through private or state health insurance, there is some evidence that insurance coverage of tobacco cessation medications increases their use and reduces smoking prevalence. However, smoking cessation treatment is poorly covered by US health insurance programs, largely because of uncertainty about the impact of such coverage on health care costs. It is unknown, for example, whether the introduction of publicly funded tobacco cessation benefits decreases claims for treatment for tobacco-related diseases. In this longitudinal study (a study that follows a group of individuals over a period of time), the researchers ask whether the adoption of comprehensive coverage of tobacco cessation medications by the Massachusetts Medicaid program (MassHealth) in July 2006 has affected claims for treatment for tobacco-related diseases. During its first two and half years, more than 75,000 MassHealth subscribers used the tobacco cessation medication benefit and smoking prevalence among subscribers declined by approximately 10% (38.3% to 28.8%).
What Did the Researchers Do and Find?
The researchers used MassHealth claims data and a statistical method called generalized estimating equations to compare the probability of hospitalization prior to the use of tobacco cessation medication benefit with the probability of hospitalization after benefit use among MassHealth subscribers. After adjusting for other factors that might have affected hospitalization such as influenza outbreaks and the implementation of the Massachusetts Smoke-Free Workplace Law in July 2004, there was a statistically significant annualized decline in hospital admissions for heart attack of 46% after use of the tobacco cessation medication benefit. That is, the calculated annual rate of admissions for heart attacks was 46% lower after use of the benefit than before among MassHealth beneficiaries. There was also a 49% annualized decline in admissions for coronary atherosclerosis, another smoking-related heart disease. There were no significant changes in hospitalization rates for lung diseases (including asthma, pneumonia, and chronic airway obstruction) or for seven other diagnostic groups.
What Do These Findings Mean?
These findings show that, among MassHealth subscribers, the use of a tobacco cessation medication benefit was followed by a significant decrease in claims for hospitalization for heart attack and for coronary atherosclerosis but not for other diseases. It does not, however, show that the reduced claims for hospitalization were associated with a reduction in smoking because smoking cessation was not recorded by MassHealth. Furthermore, it is possible that the people who used the tobacco cessation medication benefit shared other characteristics that reduced their chances of hospitalization for heart disease. For example, people using tobacco cessation medication might have been more likely to adhere to prescription schedules for medications such as statins that would also reduce their risk of heart disease. Finally, these findings might be unique to Massachusetts, so similar studies need to be undertaken in other states. Nevertheless, the results of this study suggest that, for low-income smokers, removing financial barriers to the use of smoking cessation medications has the potential to produce short-term decreases in the use of hospital services that will, hopefully, outweigh the costs of comprehensive tobacco cessation medication benefits.
Additional Information
Please access these Web sites via the online version of this summary at
The US Centers for Disease Control and Prevention Office on Smoking and Health has information on all aspects of smoking and health, including advice on how to quit
The UK National Health Service Choices Web site provides advice about quitting smoking; more advice on quitting is provided by Smokefree
The American Heart Association provides information on heart disease, including advice on how to quit smoking (in several languages)
Information about MassHealth is available, including information on smoking and tobacco use prevention
PMCID: PMC3000429  PMID: 21170313
2.  Population-Based Smoking Cessation Strategies 
Executive Summary
The objective of this report was to provide the Ministry of Health Promotion (MHP) with a summary of existing evidence-based reviews of the clinical and economic outcomes of population-based smoking cessation strategies.
Tobacco use is the leading cause of preventable disease and death in Ontario, linked to approximately 13,000 avoidable premature deaths annually – the vast majority of these are attributable to cancer, cardiovascular disease, and chronic obstructive lung disease. (1) In Ontario, tobacco related health care costs amount to $6.1 billion annually, or about $502 per person (including non-smokers) and account for 1.4% of the provincial domestic product. (2) In 2007, there were approximately 1.7 to 1.9 million smokers in Ontario with two-thirds of these intending to quit in the next six months and one-third wanting to quit within 30 days. (3) In 2007/2008, Ontario invested $15 million in cessation programs, services and training. (4) In June 2009, the Ministry of Health Promotion (MHP) requested that MAS provide a summary of the evidence base surrounding population-based smoking cessation strategies.
Project Scope
The MAS and the MHP agreed that the project would consist of a clinical and economic summary of the evidence surrounding nine population-based strategies for smoking cessation including:
Mass media interventions
Telephone counselling
Post-secondary smoking cessation programs (colleges/universities)
Community-wide stop-smoking contests (i.e. Quit and Win)
Community interventions
Physician advice to quit
Nursing interventions for smoking cessation
Hospital-based interventions for smoking cessation
Pharmacotherapies for smoking cessation, specifically:
Nicotine replacement therapies
Anxiolytic drugs
Opioid antagonists
Nicotine receptor partial agonists
Reviews examining interventions for Cut Down to Quit (CDTQ) or harm reduction were not included in this review. In addition, reviews examining individual-level smoking cessation strategies (i.e. self-help interventions, counselling, etc.), web-based smoking cessation interventions, and smoking cessation strategies for special population groups outside of those identified from reviews included in this analysis were excluded from the scope. Information on cessation programs or strategies in other provinces or an evaluation of current population-based programs in Ontario was also not included in the scope.
Status in Ontario
In 2005, the McGuinty government launched the Smoke-Free Ontario Strategy, focusing on initiatives aimed at young people to encourage them not to smoke, protection from exposure to second-hand smoke, and programs to help smokers quit. There are currently many smoking cessation programs funded across the province and in 2007/2008, Ontario invested $15 million in cessation programs, services and training. Ontario Health Insurance Plan (OHIP) fee codes for physician advice to quit also exist.
Evidence-Based Analysis
Research Question
What are the efficacy and cost-effectiveness of the selected population-based strategies for smoking cessation?
Literature Search
A preliminary scan of Medline was conducted to identify major systematic reviews, meta-analyses, and health technology assessments (HTAs) in the area of smoking cessation. Based on the availability of a number of Cochrane Reviews on the topic of smoking cessation, a more systematic search of the literature was not conducted. For the economic analysis, a literature search was conducted of relevant databases for recently published article reviews, HTAs, and Cochrane Reviews of the nine identified population-based smoking cessation strategies. This analysis is limited as it is a summary of existing reviews and not a systematic review.
Outcomes of Interest
The primary outcome of interest for the clinical summary was abstinence from smoking at 6 months follow up; additional outcomes were examined where available. The primary outcomes of interest for the economic analysis were cost-effectiveness ratios.
Summary of Findings
The evidence suggests that pharmacotherapy, physician advice to quit, nursing interventions, hospital-based interventions, and proactive telephone counselling are effective and cost-effective in the short-term.
There is poor quality data around other population-based smoking cessation strategies including mass media campaigns, community interventions, quit and win contests, access to ‘quitlines’, and interventions for university and college campuses, making evaluation of their effectiveness and cost-effectiveness difficult.
Based on pooled summary estimates of effect and safety data, the most effective strategies are varenicline, buproprion, and nicotine replacement therapies, followed by physician advice to quit and nursing interventions (in non-hospitalized smokers without cardiovascular disease).
PMCID: PMC3377580  PMID: 23074386
3.  Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at:
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website:
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website:
The objective of this evidence-based analysis was to determine the effectiveness and cost-effectiveness of smoking cessation interventions in the management of chronic obstructive pulmonary disease (COPD).
Clinical Need: Condition and Target Population
Tobacco smoking is the main risk factor for COPD. It is estimated that 50% of older smokers develop COPD and more than 80% of COPD-associated morbidity is attributed to tobacco smoking. According to the Canadian Community Health Survey, 38.5% of Ontarians who smoke have COPD. In patients with a significant history of smoking, COPD is usually present with symptoms of progressive dyspnea (shortness of breath), cough, and sputum production. Patients with COPD who smoke have a particularly high level of nicotine dependence, and about 30.4% to 43% of patients with moderate to severe COPD continue to smoke. Despite the severe symptoms that COPD patients suffer, the majority of patients with COPD are unable to quit smoking on their own; each year only about 1% of smokers succeed in quitting on their own initiative.
Smoking cessation is the process of discontinuing the practice of inhaling a smoked substance. Smoking cessation can help to slow or halt the progression of COPD. Smoking cessation programs mainly target tobacco smoking, but may also encompass other substances that can be difficult to stop smoking due to the development of strong physical addictions or psychological dependencies resulting from their habitual use.
Smoking cessation strategies include both pharmacological and nonpharmacological (behavioural or psychosocial) approaches. The basic components of smoking cessation interventions include simple advice, written self-help materials, individual and group behavioural support, telephone quit lines, nicotine replacement therapy (NRT), and antidepressants. As nicotine addiction is a chronic, relapsing condition that usually requires several attempts to overcome, cessation support is often tailored to individual needs, while recognizing that in general, the more intensive the support, the greater the chance of success. Success at quitting smoking decreases in relation to:
a lack of motivation to quit,
a history of smoking more than a pack of cigarettes a day for more than 10 years,
a lack of social support, such as from family and friends, and
the presence of mental health disorders (such as depression).
Research Question
What are the effectiveness and cost-effectiveness of smoking cessation interventions compared with usual care for patients with COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on June 24, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations (1950 to June Week 3 2010), EMBASE (1980 to 2010 Week 24), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, and the Centre for Reviews and Dissemination for studies published between 1950 and June 2010. A single reviewer reviewed the abstracts and obtained full-text articles for those studies meeting the eligibility criteria. Reference lists were also examined for any additional relevant studies not identified through the search. Data were extracted using a standardized data abstraction form.
Inclusion Criteria
English-language, full reports from 1950 to week 3 of June, 2010;
either randomized controlled trials (RCTs), systematic reviews and meta-analyses, or non-RCTs with controls;
a proven diagnosis of COPD;
adult patients (≥ 18 years);
a smoking cessation intervention that comprised at least one of the treatment arms;
≥ 6 months’ abstinence as an outcome; and
patients followed for ≥ 6 months.
Exclusion Criteria
case reports
case series
Outcomes of Interest
≥ 6 months’ abstinence
Quality of Evidence
The quality of each included study was assessed taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Nine RCTs were identified from the literature search. The sample sizes ranged from 74 to 5,887 participants. A total of 8,291 participants were included in the nine studies. The mean age of the patients in the studies ranged from 54 to 64 years. The majority of studies used the Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD staging criteria to stage the disease in study subjects. Studies included patients with mild COPD (2 studies), mild-moderate COPD (3 studies), moderate–severe COPD (1 study) and severe–very severe COPD (1 study). One study included persons at risk of COPD in addition to those with mild, moderate, or severe COPD, and 1 study did not define the stages of COPD. The individual quality of the studies was high. Smoking cessation interventions varied across studies and included counselling or pharmacotherapy or a combination of both. Two studies were delivered in a hospital setting, whereas the remaining 7 studies were delivered in an outpatient setting. All studies reported a usual care group or a placebo-controlled group (for the drug-only trials). The follow-up periods ranged from 6 months to 5 years. Due to excessive clinical heterogeneity in the interventions, studies were first grouped into categories of similar interventions; statistical pooling was subsequently performed, where appropriate. When possible, pooled estimates using relative risks for abstinence rates with 95% confidence intervals were calculated. The remaining studies were reported separately.
Abstinence Rates
Table ES1 provides a summary of the pooled estimates for abstinence, at longest follow-up, from the trials included in this review. It also shows the respective GRADE qualities of evidence.
Summary of Results*
Abbreviations: CI, confidence interval; NRT, nicotine replacement therapy.
Statistically significant (P < 0.05).
One trial used in this comparison had 2 treatment arms each examining a different antidepressant.
Based on a moderate quality of evidence, compared with usual care, abstinence rates are significantly higher in COPD patients receiving intensive counselling or a combination of intensive counselling and NRT.
Based on limited and moderate quality of evidence, abstinence rates are significantly higher in COPD patients receiving NRT compared with placebo.
Based on a moderate quality of evidence, abstinence rates are significantly higher in COPD patients receiving the antidepressant bupropion compared to placebo.
PMCID: PMC3384371  PMID: 23074432
4.  Chinese Physicians and Their Smoking Knowledge, Attitudes, and Practices 
China has the most smokers in the world. Physicians play a key role in smoking cessation but little is known about Chinese physicians and smoking.
This 2004 clustered randomized survey of 3552 hospital-based physicians from six Chinese cities measured smoking attitudes, knowledge, personal behavior, and cessation practices for patients. Descriptive statistics and multivariate analysis of factors associated with asking about or advising against smoking were conducted in 2005 and 2006.
Smoking prevalence was 23% among all Chinese physicians, 41% for men and 1% for women. Only 30% report good implementation of smoke-free workplace policies and 37% of current smokers have smoked in front of their patients. Although 64% usually advise smokers to quit, only 48% usually ask about smoking status and 29% believe most smokers will follow their cessation advice. Less than 7% set quit dates or use pharmacotherapy when helping smokers quit. Although 95% and 89% respectively know active or passive smoking causes lung cancer, only 66% and 53% respectively know active or passive smoking causes heart disease. Physicians were significantly more likely to ask about or advise against smoking if they believed that counseling about health harms help smokers quit and that most smokers would follow smoking cessation advice.
Physician smoking cessation, smoke-free workplaces, and education on smoking cessation techniques need to be increased among Chinese physicians. Strengthening counseling skills may result in more Chinese physicians helping smoking patients to quit. These improvements can help reduce the Chinese and worldwide health burden from smoking.
PMCID: PMC2800817  PMID: 17572306
5.  Using the Internet to Understand Smokers’ Treatment Preferences: Informing Strategies to Increase Demand 
Most smokers attempt to quit on their own even though cessation aids can substantially increase their chances of success. Millions of smokers seek cessation advice on the Internet, so using it to promote cessation products and services is one strategy for increasing demand for treatments. Little is known, however, about what cessation aids these smokers would find most appealing or what predicts their preferences (eg, age, level of dependence, or timing of quit date).
The objective of our study was to gain insight into how Internet seekers of cessation information make judgments about their preferences for treatments, and to identify sociodemographic and other predictors of preferences.
An online survey assessing interest in 9 evidence-based cessation products and services was voluntarily completed by 1196 smokers who visited the American Cancer Society’s Great American Smokeout (GASO) webpage. Cluster analysis was conducted on ratings of interest.
In total, 48% (572/1196) of respondents were “quite a bit” or “very much” interested in nicotine replacement therapy (NRT), 45% (534/1196) in a website that provides customized quitting advice, and 37% (447/1196) in prescription medications. Only 11.5% (138/1196) indicated similar interest in quitlines, and 17% (208/1196) in receiving customized text messages. Hierarchical agglomerative cluster analysis revealed that interest in treatments formed 3 clusters: interpersonal – supportive methods (eg, telephone counseling, Web-based peer support, and in-person group programs), nonsocial – informational methods (eg, Internet programs, tailored emails, and informational booklets), and pharmacotherapy (NRT, bupropion, and varenicline). Only 5% (60/1196) of smokers were “quite a bit” or “very much” interested in interpersonal–supportive methods compared with 25% (298/1196) for nonsocial–informational methods and 33% (399/1196) for pharmacotherapy. Multivariate analyses and follow-up comparisons indicated that level of interest in pharmacotherapy (“quite a bit or “very much” vs. “not at all”) varied as a function of education (n = 575, χ2 3 =16.6, P = .001), age (n = 528, χ2 3 = 8.2, P = .04), smoking level (n = 514, χ2 3 = 9.5, P = .02), and when smokers were planning to quit (n = 607, χ2 4 = 34.0, P < .001). Surprisingly, greater age was associated with stronger interest in nonsocial–informational methods (n = 367, χ2 3 = 10.8, P = .01). Interest in interpersonal–supportive methods was greater if smokers had used a quitline before (n = 259, χ2 1 = 18.3, P < .001), or were planning to quit earlier rather than later (n = 148, χ2 1 = 4.9, P = .03).
Smokers accessing the Internet for information on quitting appear to differentiate cessation treatments by how much interpersonal interaction or support the treatment entails. Quitting date, smoking level, and sociodemographic variables can identify smokers with varying levels of interest in the 3 classes of cessation methods identified. These results can potentially be used to more effectively target and increase demand for these treatments among smokers searching the Internet for cessation information.
PMCID: PMC3222178  PMID: 21873150
Consumer demand; pharmacotherapy; quitline counseling; smoking cessation; social support
6.  Smoking Cessation Counseling Beliefs and Behaviors of Outpatient Oncology Providers 
The Oncologist  2012;17(3):455-462.
Many cancer patients continue to smoke after diagnosis, increasing their risk for treatment complications, reduced treatment efficacy, secondary cancers, and reduced survival. Outpatient oncology providers may not be using the “teachable moment” of cancer diagnosis to provide smoking cessation assistance. Additional training and clinic-based interventions may improve adherence to tobacco cessation practice guidelines in the outpatient oncology setting.
Learning Objectives
After completing this course, the reader will be able to: Describe current smoking cessation assessment and counseling behaviors of outpatient oncology providers.Identify key barriers to providing smoking cessation services identified by oncology providers.Describe available resources for enhancing training in smoking cessation counseling.
This article is available for continuing medical education credit at
Many cancer patients continue to smoke after diagnosis, increasing their risk for treatment complications, reduced treatment efficacy, secondary cancers, and reduced survival. Outpatient oncology providers may not be using the “teachable moment” of cancer diagnosis to provide smoking cessation assistance.
Providers and Methods.
Physicians and midlevel providers (n = 74) who provide outpatient oncology services completed an online survey regarding smoking cessation counseling behaviors, beliefs, and perceived barriers. Outpatient medical records for 120 breast, lung, head and neck, colon, prostate, and acute leukemia cancer patients were reviewed to assess current smoking cessation assessment and intervention documentation practices.
Providers reported commonly assessing smoking in new patients (82.4% frequently or always), but rates declined at subsequent visits for both current smokers and recent quitters. Rates of advising patients to quit smoking were also high (86.5% frequently or always), but <30% of providers reported frequently or always providing intervention to smoking patients (e.g., nicotine replacement therapy or other medications, self-help materials, and/or referrals). Only 30% of providers reported that they frequently or always followed up with patients to assess progress with quitting. Few providers (18.1%) reported high levels of confidence in their ability to counsel smoking patients. Patients' lack of motivation was identified as the most important barrier to smoking cessation.
Although beliefs about providing cessation services to smoking patients were generally positive, few providers reported commonly providing interventions beyond advice to quit. Additional training and clinic-based interventions may improve adherence to tobacco cessation practice guidelines in the outpatient oncology setting.
PMCID: PMC3316932  PMID: 22334454
Smoking cessation; Clinical oncology; Health care providers; Cancer
7.  "I did not intend to stop. I just could not stand cigarettes any more." A qualitative interview study of smoking cessation among the elderly 
BMC Family Practice  2011;12:42.
Every year, more than 650,000 Europeans die because they smoke. Smoking is considered to be the single most preventable factor influencing health. General practitioners (GP) are encouraged to advise on smoking cessation at all suitable consultations. Unsolicited advice from GPs results in one of 40-60 smokers stopping smoking. Smoking cessation advice has traditionally been given on an individual basis. Our aim was to gain insights that may help general practitioners understand why people smoke, and why smokers stop and then remain quitting and, from this, to find fruitful approaches to the dialogue about stopping smoking.
Interviews with 18 elderly smokers and ex-smokers about their smoking and decisions to smoke or quit were analysed with qualitative content analysis across narratives. A narrative perspective was applied.
Six stages in the smoking story emerged, from the start of smoking, where friends had a huge influence, until maintenance of the possible cessation. The informants were influenced by "all the others" at all stages. Spouses had vital influence in stopping, relapses and continued smoking. The majority of quitters had stopped by themselves without medication, and had kept the tobacco handy for 3-6 months. Often smoking cessation seemed to happen unplanned, though sometimes it was planned. With an increasingly negative social attitude towards smoking, the informants became more aware of the risks of smoking.
"All the others" is a clue in the smoking story. For smoking cessation, it is essential to be aware of the influence of friends and family members, especially a spouse. People may stop smoking unplanned, even when motivation is not obvious. Information from the community and from doctors on the negative aspects of smoking should continue. Eliciting life-long smoking narratives may open up for a fruitful dialogue, as well as prompting reflection about smoking and adding to the motivation to stop.
PMCID: PMC3132720  PMID: 21627833
Decisions; general medical practice; qualitative; smoking cessation; spouse
8.  Health professional's perceptions of and potential barriers to smoking cessation care: a survey study at a dental school hospital in Japan 
BMC Research Notes  2010;3:329.
Smoking is currently accepted as a well-established risk factor for many oral diseases such as oral cancer and periodontal disease. Provision of smoking cessation care to patients with oral problems is a responsibility of health care professionals, particularly dentists and dental hygienists. This study examined the smoking-related perceptions and practices of dental school hospital-based health professionals in Japan.
A cross-sectional study design was used. The sample was formed from dentists, dental hygienists, physicians and nurses of a dental school hospital in Tokyo, Japan (n = 93, 72%). Participants were asked to complete an 11-item questionnaire assessing demographic variables and smoking history, provision of smoking cessation advice or care, attitudes about smoking cessation, and perceived barrier(s) to smoking cessation care. Eighteen percent of participants reported being current smokers and 15% reported being ex-smokers, with higher smoking rates reported by dentists compared with other health professionals (p = 0.0199). While recognizing the importance of asking patients about their smoking status, actual provision of smoking cessation advice or care by participants was relatively insufficient. Interventions such as 'assess willingness to make a quit attempt' and 'assist in quit attempt' were implemented for less than one-quarter of their patients who smoke. Non-smokers were more likely to acknowledge the need for increased provision in smoking cessation care by oral health professionals. 'Lack of knowledge and training' was identified as a central barrier to smoking cessation care, followed by 'few patients willing to quit'.
A need for further promotion of smoking cessation activities by the health professionals was identified. The findings also suggest that dentists and dental hygienists, while perceiving a role in smoking care, do require training in the provision of smoking cessation care to hospital patients. In order to overcome the potential barriers, it is necessary to provide staff with appropriate training and create an atmosphere supportive of smoking cessation activities.
PMCID: PMC3016266  PMID: 21138553
9.  Physician Counseling of Pregnant Women About Active and Second-hand Smoking in Argentina 
Describe physicians' practices of smoking cessation and secondhand smoke (SHS) exposure counseling during prenatal visits.
Cross-sectional survey
13 public and private hospitals from three cities in Argentina
300 obstetrician/gynecologists
Self-administered survey included knowledge and attitudes about tobacco use during pregnancy, frequency, type and duration of smoking cessation counseling, barriers to counseling, communication skills, level of understanding, and personal smoking history.
Main Outcome Measures
Composite outcomes of 4 items, each representative of counseling on smoking cessation and SHS exposure.
235 (78.3%) questionnaires were completed; 54.5% men, mean age 45, 35% current smokers. Only 22% had received training in smoking cessation counseling and 48.5% reported insufficient knowledge to provide smoking cessation advice. Although 88.9% always or almost always advised women to stop smoking, 75% believed it was acceptable for pregnant women to smoke up to 6 cigarettes per day. The risk of SHS exposure was “always or almost always discussed” by only 34.5% of physicians. Multivariate logistic regression showed that lack of training was associated with less counseling about smoking cessation (OR 0.18; 95%CI 0.04-0.82) and SHS exposure (OR 0.27; 95%CI 0.12-0.59). Current compared to never smokers had lower odds of smoking cessation counseling (OR 0.39; 95%CI 0.05-0.82). Current smokers were less likely than former smokers to counsel about SHS (OR 0.25, 95%CI 0.11-0.62).
Smoking cessation counseling during pregnancy in Argentina occurs infrequently, interventions are needed to assist physicians motivate and counsel women to quit smoking and avoid SHS exposure. Physicians taking care of pregnant women also need to quit smoking.
PMCID: PMC3158573  PMID: 20367427
Tobacco use; adolescents; Latin America; ethnicity; pregnancy; smoking; second hand smoke; counselling
10.  Smoking behaviour, knowledge and attitudes among Family Medicine physicians and nurses in Bosnia and Herzegovina 
BMC Family Practice  2004;5:12.
Smoking rates among the general population in Bosnia and Herzegovina are extremely high, and national campaigns to lower smoking rates have not yet begun. As part of future activities of the Queen's University Family Medicine Development Program in the Balkans Region, technical assistance may be provided to Bosnia and Herzegovina to develop of national tobacco control strategies. This assistance may focus on training doctors and nurses on smoking cessation strategies with a view to helping their patients to stop smoking. Given this important role that health professionals have, data is needed on smoking rates as well as on smoking behaviour among doctors and nurses in Bosnia and Herzegovina. This study therefore seeks to determine the smoking rates and behaviour of family medicine physicians and nurses in Bosnia and Herzegovina and to determine how well prepared they feel with respect to counselling their patients on smoking cessation strategies.
The WHO Global Health Professional Survey, a self-administered questionnaire, was distributed to physicians and nurses in 19 Family Medicine Teaching Centres in Bosnia and Herzegovina in June 2002. Smoking rates and behaviour, as well as information on knowledge and attitudes regarding smoking were determined for both physicians and nurses.
Of the 273 physicians and nurses currently working in Family Medicine Teaching Centres, 209 (77%) completed the questionnaire. Approximately 45% of those surveyed currently smoke, where 51% of nurses smoked, compared to 40% of physicians. With respect to knowledge and attitudes, all respondents agreed that smoking is harmful to one's health. However, "ever" smokers, compared to "never" smokers, were less likely to agree that health professionals who smoke were less likely to advise patients to quit smoking than non-smoking health professionals. Less than half of physicians and nurses had received formal training in smoking cessations strategies, but about two thirds of health professionals felt very or somewhat prepared to counsel their patients on how to quit smoking.
Our study indicates that almost half of Family Medicine health professionals in Bosnia and Herzegovina are smokers. This indicates a severe public health problem throughout the country. Steps need to be taken at a national level to address the fight against tobacco.
PMCID: PMC449709  PMID: 15193160
11.  Characterizing Internet Searchers of Smoking Cessation Information 
The Internet is a viable channel to deliver evidence-based smoking cessation treatment that has the potential to make a large population impact on reducing smoking prevalence. There is high demand for smoking cessation information and support on the Internet. Approximately 7% (10.2 million) of adult American Internet users have searched for information on quitting smoking. Little is known about these individuals, their smoking status, what type of cessation services they are seeking on the Internet, or how frequently these searches for cessation information are conducted.
The primary goal of this study was to characterize individuals who search for smoking cessation information on the Internet to determine appropriate triage and treatment strategies. The secondary goal was to estimate the incidence of searches for cessation information using publicly available search engine data.
We recruited individuals who clicked on a link to a leading smoking cessation website (QuitNet) from within the results of a search engine query. Individuals were “intercepted” before seeing the QuitNet home page and were invited to participate in the study. Those accepting the invitation were routed to an online survey about demographics, smoking characteristics, preferences for specific cessation services, and Internet search patterns. To determine the generalizability of our sample, national datasets on search engine usage patterns, market share, and keyword rankings were examined. These datasets were then used to estimate the number of queries for smoking cessation information each year.
During the 10-day study period, 2265 individuals were recruited and 29% (N = 655) responded. Of these, 59% were female and overall tended to be younger than the previously characterized general Internet population. Most (76%) respondents were current smokers; 17% had quit within the last 7 days, and 7% had quit more than 7 days ago. Slightly more than half of active smokers (53%) indicated that they were planning to quit in the next 30 days. Smokers were more likely to seek information on how to quit and on medications; former smokers were more interested in how to cope with withdrawal. All participants rated withdrawal information and individually tailored information as being more useful, while displaying little interest in telephone counseling, expert support, or peer support. Publicly available data from large search engines suggest that 4 million Americans search for resources on smoking cessation each year.
This study adds to the limited data available on individuals who search for smoking cessation information on the Internet, supports the prior estimates of the size of the population, and indicates that these individuals are in appropriate stages for both active cessation interventions and aggressive relapse prevention efforts. Continued development and evaluation of online interventions is warranted, and organizations seeking to promote cessation should carefully evaluate the Internet as a possible modality for treatment and as a gateway to other traditional programs.
PMCID: PMC2018828  PMID: 17032633
Smoking; cessation; Internet; search engine; query
12.  Ethnic differences in smoking rate, nicotine dependence, and cessation-related variables among adult smokers in Hawaii 
Journal of community health  2012;37(6):1226-1233.
This study tests hypotheses concerning ethnic disparities in daily cigarette smoking rates, nicotine dependence, cessation motivation, and knowledge and past use of cessation methods (e.g., counseling) and products (e.g., nicotine patch) in a multiethnic sample of smokers in Hawaii. Previous research has revealed significant differences in smoking prevalence among Native Hawaiians, Filipinos, Japanese, and Caucasians in Hawaii. However, no study has examined differences in dependence and cessation-related knowledge and practices among smokers representing these ethnic groups. Participants were recruited through newspaper advertisement as part of a larger smoking cessation intervention study. Participants (N=919; M age=45.6, SD=12.7; 48% Women) eligible to participate provided self-report data through mail and telephone. Participants included 271 self-identified Native Hawaiians, 63 Filipinos, 316 Caucasians, 145 “East Asians” (e.g., Japanese, Chinese), and 124 “Other” (e.g., Hispanic, African-American). Pair-wise comparisons of means, controlling for age, gender, income, education, and marital status, indicated that Native Hawaiian smokers reported significantly higher daily smoking rates and higher levels of nicotine dependence compared to East Asians. Native Hawaiian smokers reported significantly lower motivation to quit smoking than Caucasians. Further, Filipino and Native Hawaiian smokers reported lesser knowledge of cessation methods and products, and less frequent use of these methods and products than Caucasians. The results suggest that Native Hawaiian and Filipino smokers could be underserved with regard to receiving cessation-related advice, and may lack adequate access to smoking cessation products and services. In addition, cessation interventions tailored for Native Hawaiian smokers could benefit from a motivational enhancement component.
PMCID: PMC3425666  PMID: 22438074
13.  Socioeconomic variations in access to smoking cessation interventions in UK primary care: insights using the Mosaic classification in a large dataset of primary care records 
BMC Public Health  2013;13:546.
Smoking prevalence is particularly high amongst more deprived social groups. This cross-sectional study uses the Mosaic classification to explore socioeconomic variations in the delivery and/or uptake of cessation interventions in UK primary care.
Data from 460,938 smokers registered in The Health Improvement Network between 2008 and 2010 were analysed. Logistic regression was used to calculate odds ratios for smokers having a record of receiving cessation advice or a prescription for a cessation medication during the study period by Townsend quintile and for each of the 11 Mosaic groups and 61 Mosaic types. Both of these measures are area-level indicators of deprivation. Profiles of Mosaic categories were used to suggest ways to target specific groups to increase the provision of cessation support.
Odds ratios for smokers having a record of advice or a prescription increased with increasing Townsend deprivation quintile. Similarly, smokers in more deprived Mosaic groups and types were more likely to have a documented cessation intervention. The odds of smokers receiving cessation advice if they have uncertain employment and live in social housing in deprived areas were 35% higher than the odds for successful professionals living in desirable areas (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.20-1.52; absolute risks 57.2% and 50.1% respectively), and those in low-income families living in estate-based social housing were 50% more likely to receive a prescription than these successful professionals (OR 1.50, 95% CI 1.31-1.73; absolute risks 19.5% and 13% respectively). Smokers who did not receive interventions were generally well educated, financially successful, married with no children, read broadsheet newspapers and had broadband internet access.
Wide socioeconomic variations exist in the delivery and/or uptake of smoking cessation interventions in UK primary care, though encouragingly the direction of this variation may help to reduce smoking prevalence-related socioeconomic inequalities in health. Groups with particularly low intervention rates may be best targeted through broadsheet media, the internet and perhaps workplace-based interventions in order to increase the delivery and uptake of effective quit support.
PMCID: PMC3710237  PMID: 23738743
14.  Preliminary Evidence That Adherence to Counseling Mediates the Effects of Pretreatment Self-efficacy and Motivation on Outcome of a Cessation Attempt in Smokers with ADHD 
Nicotine & Tobacco Research  2012;15(2):393-400.
Few studies have evaluated predictors of smoking cessation outcomes in smokers with attention-deficit/hyperactivity disorder (ADHD), which could help to improve suboptimal treatment outcomes in this population. The purpose of this study was to examine pretreatment thoughts about smoking abstinence (i.e., desire to quit, perceived difficulty quitting, and expected success in quitting) as predictors of smoking cessation outcomes in smokers with ADHD and to determine the extent to which treatment adherence mediates these relationships.
Participants were adult smokers with ADHD (n = 255), who were enrolled in a multisite smoking cessation study and received either osmotic-release oral system methylphenidate (OROS-MPH) or placebo in combination with transdermal nicotine replacement and brief cessation counseling. Bootstrapped logistic regression models were generated to test main effects of thoughts about abstinence on smoking cessation outcomes and to examine treatment adherence as a mediator of these relationships.
Desire to quit and expected success in quitting, but not perceived difficulty quitting, predicted smoking cessation outcomes, as did all of the treatment adherence variables (i.e., percent sessions attended, counselor ratings of counseling adherence, and percent patch adherence). Counseling adherence partially mediated the relationship between smoking cessation outcomes and both pretreatment desire to quit and expected success.
Smokers with ADHD who have higher self-efficacy (i.e., expected success) and motivation (i.e., desire) to quit are more adherent to smoking cessation counseling and have better smoking cessation outcomes. Additional research is needed to determine whether treatment-seeking smokers with ADHD would benefit from an intervention designed to increase self-efficacy and motivation to quit.
PMCID: PMC3612001  PMID: 22949577
15.  Characteristics of smokers who have never tried to quit: evidence from the British Opinions and Lifestyle Survey 
BMC Public Health  2014;14:346.
An understanding of the characteristics of smokers who have never tried to quit may be useful to help identify and target these individuals and encourage them to attempt to give up smoking. Using national survey data we investigated variables associated with smokers reporting never having tried to quit.
Using data from the 2007 and 2009 UK Office for National Statistics Opinions and Lifestyle Survey we identified all self-reported current smokers aged 16+. The primary outcome was response to the question ‘have you ever tried to quit smoking?’ Univariable and multivariable logistic regression quantified the association between this outcome and several potential explanatory variables, including age, sex, socioeconomic status, health status, smoking behaviour, and knowledge of the dangers of smoking.
Desire to quit was the most significant independent predictor of whether a smoker reported never having tried to quit. Smokers who reported that their health was good or very good were more likely to report never having tried to quit than those whose health was fair, bad or very bad (OR 1.59, 95% CI 1.05-2.41). Smokers who reported that no family members, friends or colleagues had been trying to get them to quit smoking in the last year were more likely to report never having tried to quit than those who reported that someone was trying to persuade them (OR 1.57, 95% CI 1.09-2.28). Smokers who hadn’t received any cessation advice from a health professional in the last five years which they considered to be helpful were also more likely to report never having tried to quit.
Smokers who do not want to quit, who are in good health, whose friends and family are not trying to get them to quit, and who do not report receiving helpful advice to quit from a health professional, are more likely to report never having tried to quit.
PMCID: PMC4008410  PMID: 24721488
16.  Effectiveness of a brief intervention based on the ‘5A’ model for smoking cessation at the primary care level in Santiago, Chile 
Health Promotion International  2008;23(3):240-250.
Chilean women have the highest smoking rates in Latin America. Prevalence in this population is about 40%. There are no national programs for smoking cessation at the primary care level. This study explores the feasibility and effectiveness of a brief counseling intervention targeted to women smokers of childbearing age who seek primary care in Santiago, Chile. A quasi-experimental design was used to compare the effect of an intervention based on the ‘5A’ model developed by the National Cancer Institute in the United States and the standard care provided in two control clinics. Women smokers seeking care at the three primary care clinics were contacted during a 2 months period and offer to participate in the study. Sampling was stratified according to the age groups to ensure comparability between cohorts. Quotas were calculated for each age group. Participants were asked about their willingness to quit, self-efficacy, smoking behavior, addiction level as well as support received for smoking cessation. After 18 months of intervention all women were re-evaluated. A total of 773 women were recruited for the study; 76% of them completed the trial. Women smokers are characterized by a large percentage of light smokers with a low self-efficacy for quitting and with very low information on where and how to get assistance to quit. At study end, 15.2% of women reported quitting smoking at least for 1 month in the intervention clinic versus 7.8% in one of the control clinics (p < 0.05) and 14.6% in the second control clinic (p = NS). Over 70% of women in the intervention clinic were asked, assessed and received advice for quitting in comparison with <15% in the control clinics (p < 0.01). To conclude, a primary care intervention based on the ‘5A’ model for smoking cessation is feasible and can have a significant effect in reducing smoking prevalence in this population.
PMCID: PMC2724879  PMID: 18397953
chile; tobacco use; primary care; brief intervention
17.  Systematic identification and treatment of smokers by hospital based cessation practitioners in a secondary care setting: cluster randomised controlled trial 
Objectives To investigate the effectiveness of the systematic default provision of smoking cessation support to all adult smokers admitted to hospital, relative to usual care.
Design Open, cluster randomised controlled trial.
Setting Acute medical wards in one large teaching hospital in the United Kingdom.
Participants 264 patients randomised to intervention and 229 to usual care; primary outcome data were available at four weeks for 260 and 224 patients, respectively. All adult smokers and recent ex-smokers able to give informed consent were eligible for entry into the study.
Interventions The intervention comprised systematic smoking ascertainment and default provision of behavioural support and cessation pharmacotherapy for the duration of the hospital stay for all smokers and recent ex-smokers, with follow-up and referral to community services after discharge. Usual care comprised cessation support delivered at the initiative and discretion of clinical staff. All staff and patients were aware of group assignment.
Main outcome measures Smoking cessation at four weeks, validated by measuring exhaled carbon monoxide. Secondary outcomes were uptake of inpatient behavioural support, use of cessation pharmacotherapy, referral to and uptake of community support after discharge, and validated smoking cessation at six months. Participants lost to follow-up were assumed to have reverted to smoking.
Results All patients in the intervention group received at least brief advice to quit smoking, compared to 106 (46%) patients in the usual care group. Cessation at four weeks was achieved by 38% (n=98) of intervention patients and 17% (n=37) of usual care patients (adjusted odds ratio 2.10 (95% confidence interval 0.96 to 4.61), P=0.06, number of patients needed to treat 8). Uptake of inpatient behavioural support, use of pharmacotherapy, and referral to and uptake of community support after discharge were all substantially and statistically significantly higher in the intervention group than in the usual care group. Cessation at six months was achieved by 19% (n=47) of intervention and 9% (n=19) of usual care patients, although this difference was not significant (adjusted odds ratio 1.53 (95% confidence interval 0.60 to 3.91); P=0.37).
Conclusions Substantial improvements in smoking cessation among smokers admitted to hospital can be achieved by systematic ascertainment and delivery of cessation support in secondary care.
Trial registration International Standard Randomised Controlled Trial Number ISRCTN25441641.
PMCID: PMC3704182  PMID: 23836616
18.  Cost effectiveness of computer tailored and non-tailored smoking cessation letters in general practice: randomised controlled trial 
BMJ : British Medical Journal  2001;322(7299):1396.
To develop and evaluate, in a primary care setting, a computerised system for generating tailored letters about smoking cessation.
Randomised controlled trial.
Six general practices in Aberdeen, Scotland.
2553 smokers aged 17 to 65.
All participants received a questionnaire asking about their smoking. Participants subsequently received either a computer tailored or a non-tailored, standard letter on smoking cessation, or no letter.
Main outcome measures
Prevalence of validated abstinence at six months; change in intention to stop smoking in the next six months.
The validated cessation rate at six months was 3.5% (30/857) (95% confidence interval 2.3% to 4.7%) for the tailored letter group, 4.4% (37/846) (3.0% to 5.8%) for the non-tailored letter group, and 2.6% (22/850) (1.5% to 3.7%) for the control (no letter) group. After adjustment for significant covariates, the cessation rate was 66% greater (−4% to 186%; P=0.07) in the non-tailored letter group than that in the no letter group. Among participants who smoked <20 cigarettes per day, the cessation rate in the non-tailored letter group was 87% greater (0% to 246%; P=0.05) than that in the no letter group. Among heavy smokers who did not quit, a 76% higher rate of positive shift in “stage of change” (intention to quit within a particular period of time) was seen compared with those who received no letter (11% to 180%; P=0.02). The increase in cost for each additional quitter in the non-tailored letter group compared with the no letter group was £89.
In a large general practice, a brief non-tailored letter effectively increased cessation rates among smokers. A tailored letter was not effective in increasing cessation rates but promoted shift in movement towards cessation (“stage of change”) in heavy smokers. As a pragmatic tool to encourage cessation of smoking, a mass mailing of non-tailored letters from general practices is more cost effective than computer tailored letters or no letters.
What is already known on this topicBrief opportunistic advice on stopping smoking that is given face to face by health professionals increases rates of cessation by 2-3%Intensive, expert-led interventions increase cessation rates by up to 20% or more but are expensive and reach only a small proportion of smokersWritten advice tailored to an individual's “stage of change” (intention to stop in a particular period of time) has been claimed to be as effective as intensive interventions, but previous studies of tailored written advice did not biochemically validate cessationWhat this paper addsA simple standard letter sent to patients of general practices that gave brief advice on stopping smoking increased the biochemically validated rate of cessation by 2%A letter tailored to the individual's “stage of change” was not more effective than the non-tailored standard letterAlthough the increase in cessation resulting from the non-tailored standard letter was small, this intervention was highly cost effective
PMCID: PMC32255  PMID: 11397745
19.  Smoking cessation guidelines for health professionals: an update 
Thorax  2000;55(12):987-999.
This paper updates the evidence base and key recommendations of the Health Education Authority (HEA) smoking cessation guidelines for health professionals published in Thorax in 1998. The strategy for updating the evidence base makes use of updated Cochrane reviews supplemented by individual studies where appropriate. This update contains additional detail concerning the effectiveness of interventions as well as comments on issues relating to implementation. The recommendations include clarification of some important issues addressed only in general terms in the original guidelines. The conclusion that smoking cessation interventions delivered through the National Health Service are an extremely cost effective way of preserving life and reducing ill health remains unchanged. The strategy recommended by the guidelines involves: (1) GPs opportunistically advising smokers to stop during routine consultations, giving advice on and/or prescribing effective medications to help them and referring them to specialist cessation services; (2) specialist smokers' services providing behavioural support (in groups or individually) for smokers who want help with stopping and using effective medications wherever possible; (3) specialist cessation counsellors providing behavioural support for hospital patients and pregnant smokers who want help with stopping; (4) all health professionals involved in smoking cessation encouraging and assisting smokers in use of nicotine replacement therapies (NRT) or bupropion where appropriate. The key points of clarification of the previous guidelines include: (1) primary health care teams and hospitals should create and maintain readily accessible records on the current smoking status of patients; (2) GPs should aim to advise smokers to stop, and record having done so, at least once a year; (3) inpatient, outpatient, and pregnant smokers should be advised to stop as early as possible and the advice recorded in the notes in a readily accessible form; (4) there is currently little scientific basis for matching individual smokers to particular forms of NRT; (5) NHS specialist smokers' clinics should be the first point of referral for smokers wanting help beyond what can be provided through brief advice from the GP; (6) help from trained health care professionals specialising in smoking cessation such as practice nurses should be available for smokers who do not have access to specialist clinics; (7) the provision of specialist NHS smokers' clinics should be commensurate with demand; this is currently one or two full time clinics or their equivalent per average sized health authority, but demand may rise as publicity surrounding the services increases.

PMCID: PMC1745657  PMID: 11083883
20.  Self help smoking cessation in pregnancy: cluster randomised controlled trial 
BMJ : British Medical Journal  2002;325(7377):1383.
To evaluate the effectiveness of a self help approach to smoking cessation in pregnancy.
Pragmatic cluster randomised controlled trial with community midwife as the unit of randomisation.
Three NHS hospital trusts in England.
1527 women who smoked at the start of pregnancy.
A series of five self help booklets comprising a step by step programme to increase motivation for quitting smoking and to teach strategies for cessation and relapse prevention. The first booklet was given to the women by a midwife at the earliest opportunity in antenatal care, together with a booklet for partners, family members, and friends. The remaining four booklets were mailed directly to the women.
Main outcome measures
The primary outcome was smoking cessation validated by cotinine measurement at the end of the second trimester of pregnancy. Other outcomes were self reported smoking status and cigarette consumption among daily smokers. Qualitative data exploring the acceptability of the intervention and the way that smoking cessation advice was delivered in both trial arms were also collected.
Smoking cessation rates were low: the cotinine validated rates were 18.8% (113/600) in the intervention group and 20.7% (144/695) in the normal care group (difference 1.9%, 95% confidence intervals −3.5% to 7.3%). Self reported quit rates were higher. In the intervention group, 156 (25.6%) women reported not smoking for at least seven days, compared with 207 (29.1%) in the normal care group. In both groups, median self reported daily cigarette consumption among daily smokers was 10 cigarettes per day. Pregnant women and midwives approved of the intervention, but the way in which it was delivered varied considerably. For the primary smoking outcome, the degree of clustering at the midwife level was non-trivial (intracluster correlation coefficient 0.031).
The self help intervention was acceptable but ineffective when implemented during routine antenatal care. More intensive and complex interventions, appropriately targeted and tailored, need to be developed and evaluated. Validated smoking cessation rates among pregnant women are substantially lower than the self reported rates on which current smoking policy is based.
What is already known on this topicThe most recent systematic review evidence suggests that self help interventions designed specifically for pregnant smokers can be effective in increasing cessation ratesThese reviews, however, are based mainly on efficacy trials involving staff who are specifically employed to provide the interventionIn other attempts to assess the effectiveness of such an approach within routine antenatal care, it has been difficult to implement scientifically rigorous evaluationsWhat this study addsA low cost, self help intervention was ineffective when implemented during routine antenatal care, even though it was acceptable to midwives and pregnant womenValidated smoking cessation rates among pregnant women are substantially lower than the self reported rates on which current smoking policy is based
PMCID: PMC138509  PMID: 12480850
21.  Smoking cessation among diabetes patients: results of a pilot randomized controlled trial in Kerala, India 
BMC Public Health  2013;13:47.
India has the second largest diabetic population (61 million) and tobacco users (275 million) in the world. Data on smoking cessation among diabetic patients are limited in low and middle income countries. The objective of the study was to document the effectiveness of diabetic specific smoking cessation counseling by a non-doctor health professional in addition to a cessation advice to quit, delivered by doctors.
In our parallel-group randomized controlled trial, we selected 224 adult diabetes patients aged 18 years or older who smoked in the last month, from two diabetes clinics in South India. Using a computer generated random sequence with block size four; the patients were randomized equally into intervention-1 and intervention-2 groups. Patients in both groups were asked and advised to quit smoking by a doctor and distributed diabetes specific education materials. The intervention-2 group received an additional diabetes specific 30 minutes counseling session using the 5As (Ask, Advise, Assess, Assist and Arrange), and 5 Rs (Relevance, Risks, Rewards, Roadblocks and Repetition) from a non-doctor health professional. Follow up data were available for 87.5% of patients at six months. The Quit Tobacco International Project is supported by a grant from the Fogarty International Centre of the US National Institutes of Health (RO1TW005969-01).
The primary outcomes were quit rate (seven day smoking abstinence) and harm reduction (reduction of the number of cigarettes / bidis smoked per day > 50% of baseline use) at six months.
In the intention to treat analysis, the odds for quitting was 8.4 [95% confidence interval (CI): 4.1-17.1] for intervention-2 group compared to intervention-1 group. Even among high level smokers the odds of quitting was similar. The odds of harm reduction was 1.9 (CI: 0.8-4.1) for intervention-2 group compared to intervention-1 group.
The value addition of culturally sensitive diabetic specific cessation counseling sessions delivered by non-doctor health professional was an impressive and efficacious way of preventing smoking related diabetic complications.
Trial Registration
Clinical Trial Registry of India (CTRI/2012/01/002327)
PMCID: PMC3560246  PMID: 23331722
Diabetes; Smoking cessation; Counseling; Kerala; India
22.  Quit smoking advice from health professionals in Taiwan: the role of funding policy and smoker socioeconomic status 
Tobacco Control  2009;19(1):44-49.
In 2002, Taiwan launched a program to encourage doctors to provide brief cessation counselling to their patients during routine outpatient visits. This study is to compare and analyse the annual prevalence rate of receiving advice to quit smoking from health professionals before (2004) and after (2005, 2006) the increase in funding and the withdrawal of additional funding (2007).
We analysed pooled data from 2004 to 2007 Taiwan Adult Tobacco Survey, an annual random digit dialling telephone survey, to estimate the prevalence of receiving quit advice among ever smokers across these years. Smoking characteristics and the socioeconomic factors of smokers associated with receipt of advice to quit smoking were also examined.
The prevalence rate of receiving quit advice increased from 21.1% in 2004 to 28.2% in 2006, and then decreased slightly to 27.6% in 2007 after the funds were cut. Multivariate analyses results indicated that increasing financing for smoking cessation services in 2005, being male, older, a daily cigarette user, having previously attempted to quit, perceiving oneself as having poor health and being aware of the benefits of smoking cessation services were significantly positively associated with receiving quit advice from health professionals. In contrast, smokers who were younger, female and occasional cigarette users were less likely to receive quit advice. Also, smokers with socioeconomic disadvantages were not less likely to receive quit advice.
During the period of increased funding for smoking cessation services, the rates of receiving quit advice increased among all smokers and across different socioeconomic groups.
PMCID: PMC2921261  PMID: 19965797
Cessation; health service; prevalence; public policy
23.  “Hike up yer Skirt, and Quit.” What Motivates and Supports Smoking Cessation in Builders and Renovators 
Construction-related occupations have very high smoking prevalence rates and are an identified priority population for efforts to promote cessation. This study sought to identify the smoking cessation supports and services which best suited this workforce group, and to identify gaps in reach of preventive health services. We performed qualitative text analysis on pre-existing conversations about smoking cessation among workers in this sector. The material appeared on a discussion forum about residential construction from 1998 and 2011. Roughly 250 unique user names appeared in these discussions. The qualitative analysis addressed knowledge, motivation, environmental influences, and positive and negative experiences with supports for cessation. Self-identified smokers tended to want to quit and described little social value in smoking. Actual quit attempts were attributed to aging and tangible changes in health and fitness. Peer-to-peer social support for cessation was evident. Advice given was to avoid cigarettes and smokers, to focus on personal skills, personal commitment, and the benefits of cessation (beyond the harms from smoking). Many discussants had received medical support for cessation, but behavioural counselling services appeared underutilized. Our findings support efforts toward more complete bans on workplace smoking and increased promotion of available behavioural support services among dispersed blue-collar workers.
PMCID: PMC3635167  PMID: 23380914
smoking cessation; workplace; qualitative research; blue-collar smokers
24.  Smoking cessation at the workplace. Results of a randomised controlled intervention study 
OBJECTIVES—To compare the effects of a worksite intervention by the occupational physician offering simple advice of smoking cessation with a more active strategy of advice including a "quit date" and extra support.
POPULATION—Employees of an electrical and gas company seen at the annual visit by their occupational physicians.
CRITERIA END POINTS—Smoking point prevalence defined as the percentage of smokers who were non-smokers at one year. Secondary criteria were the percentage of smokers who stopped smoking for more than six months and the difference in prevalence of smoking in both groups.
METHODS—Randomised controlled trial. The unit of randomisation was the work site physician and a random sample of the employees of whom he or she was in charge. The length of the follow up was one year. Each of 30 work site physicians included in the study 100 to 150 employees.
RESULTS—Among 504 subjects classified as smokers at baseline receiving simple advice (group A) and 591 the more active programme (group B), 68 (13.5%) in group A and 109 (18.4%) were non-smokers one year later (p=0.03; p=0.01 taking the occupational physician as the statistical unit and using a non-parametric test). Twenty three subjects (4.6%) in group A and 36 (6.1%) in group B (p=0.26) declared abstinence of six months or more. Among non-smokers at baseline, 3.4% in both groups were smokers after one year follow up. The prevalence of smokers did not differ significantly at baseline (32.9% and 32.4%, p=0.75). After the intervention the prevalence of smoking was 30.8% in group A and 28.7% in group B (p=0.19). An increase of the mean symptoms score for depression in those who quit was observed during this period.
CONCLUSIONS—A simple cessation intervention strategy during a mandatory annual examination, targeting a population of smokers independently of their motivation to stop smoking or their health status, showed a 36% relative increase of the proportion of smokers who quit smoking as compared with what can be achieved through simple advice.

Keywords: tobacco smoking; smoking cessation; randomised controlled trial; work site
PMCID: PMC1731676  PMID: 10814655
25.  Motivational Interviewing for encouraging quit attempts among unmotivated smokers: study protocol of a randomized, controlled, efficacy trial 
BMC Public Health  2012;12:456.
Although the current Clinical Practice Guideline recommend Motivational Interviewing for use with smokers not ready to quit, the strength of evidence for its use is rated as not optimal. The purpose of the present study is to address key methodological limitations of previous studies by ensuring fidelity in the delivery of the Motivational Interviewing intervention, using an attention-matched control condition, and focusing on unmotivated smokers whom meta-analyses have indicated may benefit most from Motivational Interviewing. It is hypothesized that MI will be more effective at inducing quit attempts and smoking cessation at 6-month follow-up than brief advice to quit and an intensity-matched health education condition.
A sample of adult community resident smokers (N = 255) who report low motivation and readiness to quit are being randomized using a 2:2:1 treatment allocation to Motivational Interviewing, Health Education, or Brief Advice. Over 6 months, participants in Motivational Interviewing and Health Education receive 4 individual counseling sessions and participants in Brief Advice receive one brief in-person individual session at baseline. Rigorous monitoring and independent verification of fidelity will assure the counseling approaches are distinct and delivered as planned. Participants complete surveys at baseline, week 12 and 6-month follow-up to assess demographics, smoking characteristics, and smoking outcomes. Participants who decide to quit are provided with a self-help guide to quitting, help with a quit plan, and free pharmacotherapy. The primary outcome is self-report of one or more quit attempts lasting at least 24 hours between randomization and 6-month follow-up. The secondary outcome is biochemically confirmed 7-day point prevalence cessation at 6-month follow-up. Hypothesized mediators of the presumed treatment effect on quit attempts are greater perceived autonomy support and autonomous motivation. Use of pharmacotherapy is a hypothesized mediator of Motivational Interviewing’s effect on cessation.
This trial will provide the most rigorous evaluation to date of Motivational Interviewing’s efficacy for encouraging unmotivated smokers to make a quit attempt. It will also provide effect-size estimates of MI’s impact on smoking cessation to inform future clinical trials and inform the Clinical Practice Guideline.
Trial registration NCT01188018
PMCID: PMC3487752  PMID: 22713093
Smoking; Motivational Interviewing; Health education; Brief advice

Results 1-25 (736332)