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1.  The Emergency Department Action in Smoking Cessation (EDASC) Trial: Impact on Delivery of Smoking Cessation Counseling 
Academic Emergency Medicine  2012;19(4):409-420.
Objectives
The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange), and 2) assess ED nurses’ and physicians’ perceptions of smoking cessation counseling.
Methods
The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians, and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses’ and physicians’ self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable linear regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates.
Results
Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted OR = 2.0, 95% CI = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5), and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians. ED nurses’ self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in “pros” and “cons” attitudes toward smoking cessation in either ED nurses or physicians.
Conclusions
Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.
doi:10.1111/j.1553-2712.2012.01331.x
PMCID: PMC3334343  PMID: 22506945
2.  Integrating a Behavioural Sleep Intervention into Smoking Cessation Treatment for Smokers with Insomnia: A Randomised Pilot Study 
Journal of smoking cessation  2013;9(1):31-38.
Introduction
Sleep disturbance is common among cigarette smokers and predicts smoking cessation failure.
Aims
The purpose of this study was to conduct a pilot test of whether provision of a sleep intervention might bolster smoking cessation outcomes among this vulnerable group.
Methods
Smokers with insomnia (N = 19) seeking smoking cessation treatment were randomly assigned to receive 8 sessions over 10 weeks of either: (1) cognitive-behavioural therapy for insomnia + smoking cessation counselling (CBT-I+SC; n = 9) or (2) smoking cessation counselling alone (SC; n = 10). Counselling commenced 4 weeks prior to a scheduled quit date, and nicotine patch therapy was also provided for 6 weeks starting on the quit date.
Results
There was no significant effect of counselling condition on smoking cessation outcomes. Most participants had difficulty initiating and maintaining smoking abstinence in that 7-day point prevalence abstinence rates at end of treatment (CBT-I+SC: 1/7, 14%; SC: 2/10, 20%) and follow-up (CBT-I+SC: 1/7, 14%; SC: 0/10, 0%) were low for both conditions. CBT-I+SC participants reported improvements in sleep efficiency, quality, duration and insomnia symptoms. Sleep changes were not associated with the likelihood of achieving smoking abstinence.
Conclusions
This randomised pilot study suggests that behavioural interventions may improve sleep among smokers with insomnia, but a larger sample is needed to replicate this finding and evaluate whether these changes facilitate smoking cessation.
doi:10.1017/jsc.2013.19
PMCID: PMC4076952  PMID: 24995044
3.  A before-after implementation trial of smoking cessation guidelines in hospitalized veterans 
Background
Although most hospitalized smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. US Department of Veterans Affairs (VA) hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Few studies have applied the Chronic Care Model (CCM) to improve inpatient smoking cessation.
Specific objectives
The primary objective of this protocol is to determine the effect of a nurse-initiated intervention, which couples low-intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients. Key secondary aims are to determine the impact of the intervention on staff nurses' attitudes toward providing smoking cessation counseling; to identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals; and to determine the short-term cost-effectiveness of implementing the intervention.
Design
Pre-post study design in four VA hospitals
Participants
Hospitalized patients, aged 18 or older, who smoke at least one cigarette per day.
Intervention
The intervention will include: nurse training in delivery of bedside cessation counseling, electronic medical record tools (to streamline nursing assessment and documentation, to facilitate prescription of pharmacotherapy), computerized referral of motivated inpatients for proactive telephone counseling, and use of internal nursing facilitators to provide coaching to staff nurses practicing in non-critical care inpatient units.
Outcomes
The primary endpoint is seven-day point prevalence abstinence at six months following hospital admission and prolonged abstinence after a one-month grace period. To compare abstinence rates during the intervention and baseline periods, we will use random effects logistic regression models, which take the clustered nature of the data within nurses and hospitals into account. We will assess attitudes of staff nurses toward cessation counseling by questionnaire and will identify barriers and facilitators to implementation by using clinician focus groups. To determine the short-term incremental cost per quitter from the perspective of the VA health care system, we will calculate cessation-related costs incurred during the initial hospitalization and six-month follow-up period.
Trial number
NCT00816036
doi:10.1186/1748-5908-4-58
PMCID: PMC2753631  PMID: 19744339
4.  Comparative effectiveness of post-discharge interventions for hospitalized smokers: study protocol for a randomized controlled trial 
Trials  2012;13:124.
Background
A hospital admission offers smokers an opportunity to quit. Smoking cessation counseling provided in the hospital is effective, but only if it continues for more than one month after discharge. Providing smoking cessation medication at discharge may add benefit to counseling. A major barrier to translating this research into clinical practice is sustaining treatment during the transition to outpatient care. An evidence-based, practical, cost-effective model that facilitates the continuation of tobacco treatment after discharge is needed. This paper describes the design of a comparative effectiveness trial testing a hospital-initiated intervention against standard care.
Methods/design
A two-arm randomized controlled trial compares the effectiveness of standard post-discharge care with a multi-component smoking cessation intervention provided for three months after discharge. Current smokers admitted to Massachusetts General Hospital who receive bedside smoking cessation counseling, intend to quit after discharge and are willing to consider smoking cessation medication are eligible. Study participants are recruited following the hospital counseling visit and randomly assigned to receive Standard Care or Extended Care after hospital discharge. Standard Care includes a recommendation for a smoking cessation medication and information about community resources. Extended Care includes up to three months of free FDA-approved smoking cessation medication and five proactive computerized telephone calls that use interactive voice response technology to provide tailored motivational messages, offer additional live telephone counseling calls from a smoking cessation counselor, and facilitate medication refills. Outcomes are assessed at one, three, and six months after hospital discharge. The primary outcomes are self-reported and validated seven-day point prevalence tobacco abstinence at six months. Other outcomes include short-term and sustained smoking cessation, post-discharge utilization of smoking cessation treatment, hospital readmissions and emergency room visits, and program cost per quit.
Discussion
This study tests a disseminable smoking intervention model for hospitalized smokers. If effective and widely adopted, it could help to reduce population smoking rates and thereby reduce tobacco-related mortality, morbidity, and health care costs.
Trial registration
United States Clinical Trials Registry NCT01177176.
doi:10.1186/1745-6215-13-124
PMCID: PMC3487923  PMID: 22852832
Smoking cessation; Hospitalization; Pharmacotherapy; Counseling; Randomized clinical trial; Interactive voice response
5.  A pilot study combining individual-based smoking cessation counseling, pharmacotherapy, and dental hygiene intervention 
BMC Public Health  2010;10:348.
Background
Dentists are in a unique position to advise smokers to quit by providing effective counseling on the various aspects of tobacco-induced diseases. The present study assessed the feasibility and acceptability of integrating dentists in a medical smoking cessation intervention.
Methods
Smokers willing to quit underwent an 8-week smoking cessation intervention combining individual-based counseling and nicotine replacement therapy and/or bupropion, provided by a general internist. In addition, a dentist performed a dental exam, followed by an oral hygiene treatment and gave information about chronic effects of smoking on oral health. Outcomes were acceptability, global satisfaction of the dentist's intervention, and smoking abstinence at 6-month.
Results
39 adult smokers were included, and 27 (69%) completed the study. Global acceptability of the dental intervention was very high (94% yes, 6% mostly yes). Annoyances at the dental exam were described as acceptable by participants (61% yes, 23% mostly yes, 6%, mostly no, 10% no). Participants provided very positive qualitative comments about the dentist counseling, the oral exam, and the resulting motivational effect, emphasizing the feeling of oral cleanliness and health that encouraged smoking abstinence. At the end of the intervention (week 8), 17 (44%) participants reported smoking abstinence. After 6 months, 6 (15%, 95% CI 3.5 to 27.2) reported a confirmed continuous smoking abstinence.
Discussion
We explored a new multi-disciplinary approach to smoking cessation, which included medical and dental interventions. Despite the small sample size and non-controlled study design, the observed rate was similar to that found in standard medical care. In terms of acceptability and feasibility, our results support further investigations in this field.
Trial Registration number
ISRCTN67470159
doi:10.1186/1471-2458-10-348
PMCID: PMC2894778  PMID: 20565724
6.  Effectiveness of a Smoking Cessation Intervention for Methadone-Maintained Women: A Comparison of Pregnant and Parenting Women 
Women in substance abuse programs have high rates of smoking. Pregnancy represents a unique opportunity for intervention, but few data exist to guide tailoring of effective interventions. In this study, 44 pregnant and 47 nonpregnant opioid-dependent women enrolled in comprehensive substance abuse treatment received a 6-week smoking cessation intervention based on the 5A's counseling model. The number of daily cigarettes decreased by 49% for pregnant patients and 32% for nonpregnant patients at the 3-month followup. Length of time in substance abuse treatment did not correlate with smoking cessation or reduction for either group. Factors predicting reduction of cigarette smoking differed for pregnant versus nonpregnant patients. For pregnant patients, lower levels of nicotine use prior to intervention and self-reported cigarette cravings predicted successful reduction in smoking. For nonpregnant patients, lower affiliative attachment to cigarettes, reliance on cigarettes for cognitive enhancement, and greater sense of control predicted more successful outcomes.
doi:10.1155/2011/567056
PMCID: PMC3147124  PMID: 21822438
7.  Quitline referral vs. self-help manual for tobacco use cessation in the Emergency Department: a feasibility study 
Background
Tobacco use counseling interventions delivered in the primary care setting are efficacious, but limited evidence exists regarding their feasibility or efficacy in the Emergency Department (ED). ED randomized controlled trials evaluating referral for outpatient tobacco use counseling have not had a single subject in the intervention groups attend scheduled clinic appointments. Telephone counseling potentially affords the opportunity to provide this population with individual counseling more conveniently than traditional clinic counseling. The purpose of this preliminary study was to evaluate the intervention completion rate among cigarette smokers enrolled through the ED in a tobacco quitline (QL) and to assess the feasibility of a randomized controlled trial assessing the efficacy of this intervention.
Methods
We conducted a prospective, randomized, controlled, un-blinded pilot study enrolling cigarette smokers presenting to a tertiary-care ED. Patients indicating a desire to quit smoking were randomized to receive either proactive telephone counseling through a QL (intervention) or a self-help manual (control).
Results
Of 212 smokers who indicated an interest in quitting, 20 subjects were randomized to the QL and 19 to control. Twenty-one did not meet inclusion criteria and 152 refused to participate. A total of 10 patients (50%) enrolled in the QL completed the full intervention. However, only a total of 20 patients (51%) were reached for follow-up at 3 or 6 months (10 in each arm). At 6-month follow-up a total of six subjects had either disconnected their phone, no longer lived at the provided phone number or had provided an incorrect number. Two declined to provide follow-up and the remainder could not be reached. Assuming all patients unavailable for follow-up were still smoking, the 7-day point prevalence smoking abstinence rate at 6 months was 20% (95% CI: 6 to 44%) for the QL group and 0% (95% CI: 0 to 15%) for the control group (p = 0.11).
Conclusion
Compliance with the QL intervention was encouraging and may hold promise for providing needed tobacco use counseling to ED patients. Future studies are required, and should focus on more effective mechanisms to obtain outcome measures and a larger sample size.
Trial Registration
NCT00394420
doi:10.1186/1471-227X-7-15
PMCID: PMC2008199  PMID: 17868444
8.  Smoking Cessation Counselling for Pregnant and Postpartum Women among Midwives, Gynaecologists and Paediatricians in Germany 
The incorporation of guidelines for the treatment of tobacco smoking into routine care requires positive attitudes, counselling skills and knowledge about additional help available for smokers. The study assesses performance of smoking cessation intervention, attitudes, training status and knowledge about additional help for smokers in the care for pregnant and parenting women by midwives, gynaecologists and paediatricians. A survey of all midwives, gynaecologists and paediatricians registered for primary medical care in the federal state Saarland, Germany, was conducted. Participation in the postal questionnaires was 85 %. Depending on profession, 90 % to 100 % see smoking cessation counselling as their assignment, 17 % to 80 % screen for, 48 % to 90 % document smoking status, and 55 % to 76 % offer brief or extensive counselling. 61 % to 87 % consider training to enhance their knowledge and/or counselling skills necessary. The compliance of providers with the necessity to give support in smoking cessation is very high. However, the current status of cessation counselling does not sufficiently correspond to the evidence based requirements. Reports in medical press and advanced training courses should support health care providers and establish smoking as an inherent topic of the anamnesis and treatment of current and former pregnant or parenting smokers.
doi:10.3390/ijerph6010096
PMCID: PMC2672345  PMID: 19440272
Smoking cessation counselling pregnancy
9.  Smoking Cessation Treatment for Adolescents 
Cigarette smoking in the adolescent population remains a public health concern. A significant portion of the adolescent population currently uses tobacco. Nicotine is particularly addicting in adolescents, and quitting is difficult. The goals for adolescent cigarette smoking efforts must include both primary prevention and smoking cessation. Bupropion and nicotine replacement therapies—including nicotine patches, gum, and nasal spray—have been studied to a limited extent in the adolescent population. Varenicline has not been evaluated as a treatment modality in adolescents. Long-term quit rates in the pharmacotherapy trials have not been optimal; however, decreases in cigarettes smoked per day have been observed. Several evidencebased guidelines include recommendations for smoking cessation in adolescents that include counseling and pharmacotherapy. Pharmacotherapy may be instituted for some adolescents in addition to counseling and behavioral interventions. Therapy should be individualized, based on smoking patterns, patient preferences, and concomitant disease states. Smoking cessation support for parents should be instituted as well. The pharmacist can play a large role in helping the adolescent quit smoking. Further studies evaluating pharmacotherapy options for smoking cessation in adolescents are necessary. If pharmacotherapy is used, it should be individualized and combined with psychosocial and behavioral interventions.
PMCID: PMC3042263  PMID: 22477813
adolescent; bupropion; nicotine replacement therapy; smoking cessation; varenicline
10.  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 CME.TheOncologist.com
Purpose.
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.
Results.
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.
Conclusions.
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.
doi:10.1634/theoncologist.2011-0350
PMCID: PMC3316932  PMID: 22334454
Smoking cessation; Clinical oncology; Health care providers; Cancer
11.  A Randomized Trial of a Multicomponent Cessation Strategy for Emergency Department Smokers 
Objectives
To determine the efficacy of an emergency department (ED)-based smoking cessation intervention.
Methods
A randomized trial conducted from January 2006 to September 2007 at an urban ED that treats 90,000 adults per year. Discharged adults who smoked at least 10 cigarettes per day were randomized to 1) Usual Care, receiving a smoking cessation brochure, or 2) Enhanced Care, receiving the brochure, a motivational interview, nicotine patches, and a phone call at three days. Interventions were performed by a peer educator trained in tobacco treatment. Blinded follow-up was performed at three months.
Results
Three hundred thirty-eight subjects were enrolled, mean age 40.2 years (SD ±12.0 years), 51.8% were female, and 56.5% were either self-pay or Medicaid. Demographic and clinical variables were comparable between groups. Enhanced and Usual Care arms showed similar cessation rates at three months (14.7% vs. 13.2%, respectively). The proportion of subjects making a quit attempt (69.2% vs. 66.5%), and decrease in daily cigarette use (5 vs. 1) (all p > 0.05) were also similar. In logistic modeling, factors associated with quitting included any tobacco-related ICD9 code for the ED visit (OR 3.42, 95% CI = 1.61 to 7.26), or subject belief that the ED visit was tobacco-related (OR 2.47, 95% CI = 1.17 to 5.21). Conversely, subjects who reported having a pre-existing tobacco-related illness were less likely to quit (OR 0.22, 95% CI = 0.10 to 0.50).
Conclusions
The primary endpoint was negative, reflecting a higher-than-expected quit rate in the control group. Subjects whose ED visit was tobacco-related, based either on physician diagnosis or subject perception, were more than twice as likely to quit. These data suggest that even low-intensity screening and referral may prompt substantial numbers of ED smokers to quit or attempt to quit.
doi:10.1111/j.1553-2712.2011.01097.x
PMCID: PMC3117220  PMID: 21676054
12.  Pharmacy residents and students as an adjunct to current smoking cessation education 
Pharmacy Practice  2012;10(2):92-96.
Objective
The purpose of this study was to evaluate the impact of individualized tobacco cessation counseling provided by pharmacy residents and students to patients in the inpatient setting at an academic medical center.
Methods
Documented tobacco users were evaluated for study inclusion. The intervention group received counseling specific to their readiness to quit. After discharge, patients in the intervention group received weekly phone calls for additional counseling and data collection. One month after discharge, the standard therapy group received one phone call for data collection.
Results
No significant differences were found between groups for demographic variables or number of years smoking. At baseline, the intervention group reported significantly fewer quit attempts and more packs per day than the control group. The odds ratio (OR) for the primary outcome, abstinence, was 1.68 [95%CI=0.29:9.748] favoring the intervention group. The OR for patients using outpatient pharmacotherapy was 3.20 [95%CI=0.484:21.167] for the intervention group compared to the control group. The percentage of patients using outpatient treatment programs was 5.26% in the control group vs. 0% in the intervention group.
Conclusions
Results showed a trend toward significance for abstinence and increased use of outpatient pharmacotherapy; however, our sample size and study period limit conclusions that may be drawn. Further study is warranted for definitive results.
PMCID: PMC3780479  PMID: 24155823
Smoking Cessation; Health Education; Students, Pharmacy; United States
13.  Intensive Intervention for Alcohol-Dependent Smokers in Early Recovery: A Randomized Trial 
Drug and Alcohol Dependence  2011;122(3):186-194.
Introduction
The purpose of this study was to investigate the efficacy of an intensive tobacco cessation intervention for alcohol-dependent smokers in early recovery.
Methods
A total of 162 alcohol-dependent smokers were randomized to either intensive intervention for smoking cessation or usual care. The intensive intervention consisted of 16 sessions of individual cognitive behavior therapy (CBT) and combination nicotine replacement therapy that lasted 26 weeks. Usual care involved referral to a free-standing smoking cessation program that provided smoking cessation counseling of varying duration and guideline-concordant medications. The primary cessation outcome was verified 7-day point prevalence abstinence (PPA) at 12, 26, 38, and 52 weeks.
Results
At 12 and 26 weeks, the verified 7-day point-prevalence quit rate was significantly higher for the intensive intervention group than for the usual care group (both p = .03). However, the quit rates for the two treatment groups were not significantly different at 38 or 52 weeks. Verified 30-day alcohol abstinence rates were not significantly different for the two treatment groups at any of the follow-up assessments.
Conclusions
The intensive smoking cessation intervention yielded a higher short-term smoking quit rate without jeopardizing sobriety. A chronic care model might facilitate maintenance of smoking cessation during the first year of alcohol treatment and perhaps for longer periods of time. It is hoped that studies such as this will inform the development of more effective interventions for concurrent alcohol and tobacco use disorders.
doi:10.1016/j.drugalcdep.2011.09.026
PMCID: PMC3288470  PMID: 22014532
Smoking cessation; tobacco use; alcohol dependence; concurrent intervention; early recover
14.  Smoking cessation initiated during hospital stay for patients with coronary artery disease: a randomized controlled trial 
Background
Programs for smoking cessation for cardiac patients are underused in Canada. We examined the efficacy of an intervention for smoking cessation for patients admitted to hospital for coronary artery bypass graft (CABG) or because of acute myocardial infarction (MI).
Methods
Nurses randomly assigned 276 sequential patients admitted because of acute MI or for CABG who met the inclusion criteria. Participants received an intensive or minimal smoking-cessation intervention. The minimal intervention included advice from physicians and nurses and 2 pamphlets. The intensive intervention included the minimal intervention plus 60 minutes of bedside counselling, take-home materials and 7 nurse-initiated counselling calls for 2 months after discharge. The outcomes were point prevalence of abstinence at 3, 6 and 12 months after discharge.
Results
The 12-month self-reported rate of abstinence was 62% among patients in the intensive group and 46% among those in the minimal group (odds ratio [OR] 2.0, 95% confidence interval [CI] 1.2–3.1). Abstinence was confirmed for 54% of patients in the intensive group and 35% in the minimal group (OR 2.0, 95% CI 1.3–3.6). Abstinence was significantly lower among those who used pharmacotherapy than among those who did not (p < 0.001). Continuous 12-month abstinence was 57% in the intensive group and 39% in the minimal group (p < 0.01). It was significantly higher among patients admitted for CABG than among those admitted because of acute MI (p < 0.05).
Interpretation
Providing intensive programs for smoking cessation for patients admitted for CABG or because of acute MI could have a major impact on health and health care costs.
doi:10.1503/cmaj.080862
PMCID: PMC2696525  PMID: 19546455
15.  Electronic cigarettes and thirdhand tobacco smoke: two emerging health care challenges for the primary care provider 
Primary care providers should be aware of two new developments in nicotine addiction and smoking cessation: 1) the emergence of a novel nicotine delivery system known as the electronic (e-) cigarette; and 2) new reports of residual environmental nicotine and other biopersistent toxicants found in cigarette smoke, recently described as “thirdhand smoke”. The purpose of this article is to provide a clinician-friendly introduction to these two emerging issues so that clinicians are well prepared to counsel smokers about newly recognized health concerns relevant to tobacco use. E-cigarettes are battery powered devices that convert nicotine into a vapor that can be inhaled. The World Health Organization has termed these devices electronic nicotine delivery systems (ENDS). The vapors from ENDS are complex mixtures of chemicals, not pure nicotine. It is unknown whether inhalation of the complex mixture of chemicals found in ENDS vapors is safe. There is no evidence that e-cigarettes are effective treatment for nicotine addiction. ENDS are not approved as smoking cessation devices. Primary care givers should anticipate being questioned by patients about the advisability of using e-cigarettes as a smoking cessation device. The term thirdhand smoke first appeared in the medical literature in 2009 when investigators introduced the term to describe residual tobacco smoke contamination that remains after the cigarette is extinguished. Thirdhand smoke is a hazardous exposure resulting from cigarette smoke residue that accumulates in cars, homes, and other indoor spaces. Tobacco-derived toxicants can react to form potent cancer causing compounds. Exposure to thirdhand smoke can occur through the skin, by breathing, and by ingestion long after smoke has cleared from a room. Counseling patients about the hazards of thirdhand smoke may provide additional motivation to quit smoking.
doi:10.2147/IJGM.S16908
PMCID: PMC3068875  PMID: 21475626
e-cigarette; nicotine; tobacco; thirdhand smoke; electronic nicotine delivery systems
16.  A randomized placebo-controlled clinical trial of five smoking cessation pharmacotherapies 
Archives of general psychiatry  2009;66(11):1253-1262.
Context
Little direct evidence exists on the relative efficacies of different smoking cessation pharmacotherapies, yet such evidence is needed to make informed decisions about their clinical use.
Objective
The primary objective of this research was to assess the relative efficacies of five smoking cessation pharmacotherapy interventions using placebo-controlled, head-to-head comparisons.
Design
This was a randomized double-blind, placebo-controlled clinical trial.
Setting
Smokers were recruited from the community at two urban research sites.
Patients
Participants were 1504 adult smokers who smoked at least 10 cigarettes per day during the past 6 months and reported being motivated to quit smoking. Participants were excluded if they reported: using any form of tobacco other than cigarettes; current use of bupropion; having a current psychosis or schizophrenia diagnosis; or having medical contraindications for any of the study medications.
Interventions
Participants were randomized to one of six treatment conditions: nicotine lozenge, nicotine patch, bupropion SR, nicotine patch + nicotine lozenge, bupropion + nicotine lozenge or placebo. In addition, all participants received six individual counseling sessions.
Main Outcome Measures
The main outcome measures were biochemically-confirmed 7-day point-prevalence abstinence assessed at 1 week post-quit, end of treatment (8 weeks post-quit) and 6 months post-quit. Other outcomes were initial cessation, number of days to lapse, number of days to relapse, and latency to relapse after the first lapse.
Results
All pharmacotherapies differed from placebo when examined without protection for multiple comparisons (OR’s = 1.63–2.34). With such protection, only the nicotine patch + nicotine lozenge (OR = 2.34, p < .001) produced significantly higher abstinence rates at 6-months post-quit than did placebo.
Conclusions
While the nicotine lozenge, bupropion, and bupropion + lozenge produced effects that were comparable to those reported in previous research, the nicotine patch + lozenge produced the greatest benefit relative to placebo for smoking cessation.
doi:10.1001/archgenpsychiatry.2009.142
PMCID: PMC2933113  PMID: 19884613
17.  Best practices for smoking cessation interventions in primary care 
BACKGROUND:
In Canada, smoking is the leading preventable cause of premature death. Family physicians and nurse practitioners are uniquely positioned to initiate smoking cessation. Because smoking is a chronic addiction, repeated, opportunity-based interventions are most effective in addressing physical dependence and modifying deeply ingrained patterns of beliefs and behaviour. However, only a small minority of family physicians provide thorough smoking cessation counselling and less than one-half offer adjunct support to patients.
OBJECTIVE:
To identify the key steps family physicians and nurse practitioners can take to strengthen effective smoking cessation interventions for their patients.
METHODS:
A multidisciplinary panel of health care practitioners involved with smoking cessation from across Canada was convened to discuss best practices derived from international guidelines, including those from the United States, Europe, and Australia, and other relevant literature. The panellists subsequently refined their findings in the form of the present article.
RESULTS:
The present paper outlines best practices for brief and effective counselling for, and treatment of, tobacco addiction. By adopting a simple series of questions, taking 30 s to 3 min to complete, health care professionals can initiate smoking cessation interventions. Integrating these strategies into daily practice provides opportunities to significantly improve the quality and duration of patients’ lives.
CONCLUSION:
Tobacco addiction is the most important preventable cause of morbidity and mortality in Canada. Family physicians, nurse practitioners and other front-line health care professionals are well positioned to influence and assist their patients in quitting, thereby reducing the burden on both personal health and the public health care system.
PMCID: PMC2734439  PMID: 19707607
Behavioural intervention; Smoking cessation; Tobacco
18.  Effect of incorporating a 10 minute point of care test for salivary nicotine metabolites into a general practice based smoking cessation programme: randomised controlled trial 
BMJ : British Medical Journal  2005;331(7523):999.
Objective To investigate the effect of immediate feedback from a point of care test for salivary nicotine metabolites in promoting smoking cessation and reduction in tobacco use.
Design Prospective, operator blinded, randomised controlled trial.
Setting General dental practice, London.
Participants 100 adult smokers.
Interventions Participants completed a questionnaire on smoking, undertook a clinical examination, and received counselling in smoking cessation. Saliva samples were analysed at presentation and at eight weeks for salivary nicotine metabolites using a 10 minute semiquantitative point of care test.
Main outcome measures Smoking cessation measured by salivary nicotine metabolite values (scale 0-6), patient feedback on the perceived value of the test (visual analogue scale) in quitting, and reduction in tobacco use.
Results A higher smoking quit rate was achieved with the point of care test (23% cases v 7% controls; P < 0.039), and overall tobacco use also decreased (68% cases v 28% controls; P < 0.001). Baseline values for salivary nicotine metabolites did not differ between the groups (cases, mean 4.1, SD 1.3 and 4.3, 1.4; P = 0.51). 87 participants reattended at eight weeks (44 cases, 43 controls). Mean nicotine metabolite values at eight weeks were 2.58 (2.0) for cases and 4.29 (1.8) for controls (P < 0.001).
Conclusion Incorporation of individualised personal feedback using a point of care test for salivary nicotine metabolites into a general practice based smoking cessation programme increased quit rates by 17% at eight weeks and reduced tobacco use.
doi:10.1136/bmj.38621.463900.7C
PMCID: PMC1273454  PMID: 16210250
19.  Self-reported smoking cessation activities among Swiss primary care physicians 
BMC Family Practice  2009;10:22.
Background
Individual counselling, pharmacotherapy, and group therapy are evidence-based interventions that help patients stop smoking. Acupuncture, hypnosis, and relaxation have no demonstrated efficacy on smoking cessation, whereas self-help material may only have a small benefit. The purpose of this study is to assess physicians' current clinical practice regarding smokers motivated to stop smoking.
Methods
The survey included 3385 Swiss primary care physicians. Self-reported use of nine smoking cessation interventions was scored. One point was given for each positive answer about practicing interventions with demonstrated efficacy, i.e. nicotine replacement therapy, bupropion, counselling, group therapy, and smoking cessation specialist. No points were given for the recommendation of acupuncture, hypnosis, relaxation, and self-help material. Multivariable logistic analysis was performed to identify factors associated with a good practice score, defined as ≥ 2.
Results
The response rate was 55%. Respondents were predominately over the age of 40 years (88%), male (79%), and resided in urban areas (74%). Seventeen percent reported being smokers. Most of the physicians prescribed nicotine replacement therapy (84%), bupropion (65%), or provided counselling (70%). A minority of physicians recommended acupuncture (26%), hypnosis (8%), relaxation (7%), or self-help material (24%). A good practice score was obtained by 85% of respondents. Having attended a smoking cessation-training program was the only significant predictor of a good practice score (odds ratio: 6.24, 95% CI 1.95–20.04).
Conclusion
The majority of respondents practice recommended smoking cessation interventions. However, there is room for improvement and implementing an evidence-based smoking cessation-training program could provide additional benefit.
doi:10.1186/1471-2296-10-22
PMCID: PMC2667163  PMID: 19320964
20.  A randomised controlled trial of a smoking cessation intervention delivered by dental hygienists: a feasibility study 
BMC Oral Health  2007;7:5.
Background
Tobacco use continues to be a global public health problem. Helping patients to quit is part of the preventive role of all health professionals. There is now increasing interest in the role that the dental team can play in helping their patients to quit smoking. The aim of this study was to determine the feasibility of undertaking a randomised controlled smoking cessation intervention, utilising dental hygienists to deliver tobacco cessation advice to a cohort of periodontal patients.
Methods
One hundred and eighteen patients who attended consultant clinics in an outpatient dental hospital department (Periodontology) were recruited into a trial. Data were available for 116 participants, 59 intervention and 57 control, and were analysed on an intention-to-treat basis. The intervention group received smoking cessation advice based on the 5As (ask, advise, assess, assist, arrange follow-up) and were offered nicotine replacement therapy (NRT), whereas the control group received 'usual care'. Outcome measures included self-reported smoking cessation, verified by salivary cotinine measurement and CO measurements. Self-reported measures in those trial participants who did not quit included number and length of quit attempts and reduction in smoking.
Results
At 3 months, 9/59 (15%) of the intervention group had quit compared to 5/57 (9%) of the controls. At 6 months, 6/59 (10%) of the intervention group quit compared to 3/57 (5%) of the controls. At one year, there were 4/59 (7%) intervention quitters, compared to 2/59 (4%) control quitters. In participants who described themselves as smokers, at 3 and 6 months, a statistically higher percentage of intervention participants reported that they had had a quit attempt of at least one week in the preceding 3 months (37% and 47%, for the intervention group respectively, compared with 18% and 16% for the control group).
Conclusion
This study has shown the potential that trained dental hygienists could have in delivering smoking cessation advice. While success may be modest, public health gain would indicate that the dental team should participate in this activity. However, to add to the knowledge-base, a multi-centred randomised controlled trial, utilising biochemical verification would be required to be undertaken.
doi:10.1186/1472-6831-7-5
PMCID: PMC1871574  PMID: 17475005
21.  Medical Students’ Use of the Stages of Change Model in Tobacco Cessation Counseling 
Background
Many medical schools have incorporated the Stages of Change Model into their curricula with specific application to tobacco cessation.
Objective
This study examined the extent to which medical students were prepared to provide stage-based interventions to treat nicotine dependence.
Design
Using a quasi-experimental design, medical students’ counseling interactions were evaluated with a standardized patient portraying a smoker in either the precontemplation or preparation stage of change.
Participants
Participants were 147 third-year medical students at the University of California, San Francisco.
Measurements
Checklists completed by standardized patients evaluated students’ clinical performance. Surveys administered before and after the encounters assessed students’ knowledge, attitudes, confidence and previous experience with treating smoking.
Results
Most students asked about tobacco use (89%), advised patients of the health benefits of quitting (74%), and assessed the patient’s readiness to quit (76%). The students were more likely to prescribe medications and offer referrals to patients in the preparation than in the precontemplation stage of change (P < 0.001); however, many students had difficulty identifying patients ready to quit, and few encouraged patients to set a quit date or arranged follow-up to assess progress. Students’ tobacco-related knowledge, but not their attitudes, confidence, or previous experience predicted their clinical performance.
Conclusions
The findings indicated evidence of students tailoring their counseling strategies to the patients’ stage of change; however, they still could do more to assist their patients in quitting. Additional training and integration of cessation counseling into clinical rotations are needed.
doi:10.1007/s11606-006-0040-0
PMCID: PMC1824739  PMID: 17356990
tobacco treatment; smoking cessation; medical education; training; standardized patients; stages of change model
22.  Medical Students’ Use of the Stages of Change Model in Tobacco Cessation Counseling 
Background
Many medical schools have incorporated the Stages of Change Model into their curricula with specific application to tobacco cessation.
Objective
This study examined the extent to which medical students were prepared to provide stage-based interventions to treat nicotine dependence.
Design
Using a quasi-experimental design, medical students’ counseling interactions were evaluated with a standardized patient portraying a smoker in either the precontemplation or preparation stage of change.
Participants
Participants were 147 third-year medical students at the University of California, San Francisco.
Measurements
Checklists completed by standardized patients evaluated students’ clinical performance. Surveys administered before and after the encounters assessed students’ knowledge, attitudes, confidence and previous experience with treating smoking.
Results
Most students asked about tobacco use (89%), advised patients of the health benefits of quitting (74%), and assessed the patient’s readiness to quit (76%). The students were more likely to prescribe medications and offer referrals to patients in the preparation than in the precontemplation stage of change (P < 0.001); however, many students had difficulty identifying patients ready to quit, and few encouraged patients to set a quit date or arranged follow-up to assess progress. Students’ tobacco-related knowledge, but not their attitudes, confidence, or previous experience predicted their clinical performance.
Conclusions
The findings indicated evidence of students tailoring their counseling strategies to the patients’ stage of change; however, they still could do more to assist their patients in quitting. Additional training and integration of cessation counseling into clinical rotations are needed.
doi:10.1007/s11606-006-0040-0
PMCID: PMC1824739  PMID: 17356990
tobacco treatment; smoking cessation; medical education; training; standardized patients; stages of change model
23.  Review: The need for smoking cessation among HIV-positive smokers 
Most HIV-positive persons in the U.S. smoke cigarettes. Despite substantial clinical advances in HIV care in the era of highly active antiretroviral therapy (HAART), HIV-positive persons are at high risk of tobacco-related disease and death. HIV-positive persons have complex social, economic, psychiatric, and medical needs which may impact smoking behavior and response to smoking cessation interventions, but there is a dearth of research on smoking cessation interventions tailored to HIV-positive persons. HIV care providers should treat tobacco use with the array of evidence-based smoking cessation treatments available, updating their clinical practice as new data emerge. This paper reviews the literature on the health consequences of tobacco use in HIV-positive persons, the treatment of tobacco dependence, and the research to date on smoking cessation interventions in HIV-positive persons, and presents recommendations for future research and intervention.
doi:10.1521/aeap.2009.21.3_supp.14
PMCID: PMC2704483  PMID: 19537951
HIV; Tobacco; Smoking cessation
24.  Correlates of tobacco cessation counseling among Hispanic physicians in the US: A cross-sectional survey study 
BMC Public Health  2008;8:5.
Background
Physician advice is an important motivator for attempting to stop smoking. However, physicians' lack of intervention with smokers has only modestly improved in the last decade. Although the literature includes extensive research in the area of the smoking intervention practices of clinicians, few studies have focused on Hispanic physicians. The purpose of this study was to explore the correlates of tobacco cessation counseling practices among Hispanic physicians in the US.
Methods
Data were collected through a validated survey instrument among a cross-sectional sample of self-reported Hispanic physicians practicing in New Mexico, and who were members of the New Mexico Hispanic Medical Society in the year 2001. Domains of interest included counseling practices, self-efficacy, attitudes/responsibility, and knowledge/skills. Returned surveys were analyzed to obtain frequencies and descriptive statistics for each survey item. Other analyses included: bivariate Pearson's correlation, factorial ANOVAs, and multiple linear regressions.
Results
Respondents (n = 45) reported a low level of compliance with tobacco control guidelines and recommendations. Results indicate that physicians' familiarity with standard cessation protocols has a significant effect on their tobacco-related practices (r = .35, variance shared = 12%). Self-efficacy and gender were both significantly correlated to tobacco related practices (r = .42, variance shared = 17%). A significant correlation was also found between self-efficacy and knowledge/skills (r = .60, variance shared = 36%). Attitudes/responsibility was not significantly correlated with any of the other measures.
Conclusion
More resources should be dedicated to training Hispanic physicians in tobacco intervention. Training may facilitate practice by increasing knowledge, developing skills and, ultimately, enhancing feelings of self-efficacy.
doi:10.1186/1471-2458-8-5
PMCID: PMC2267183  PMID: 18179722
25.  Design and Baseline Characteristics from the KAN-QUIT Disease Management Intervention for Rural Smokers in Primary Care 
Preventive medicine  2008;47(2):200-205.
Objective
To describe the design, implementation, baseline data, and feasibility of establishing a disease management program for smoking cessation in rural primary care.
Method
The study is a randomized clinical trial evaluating a disease management program for smoking cessation. The intervention combined pharmacotherapy, telephone counseling, and physician feedback, and repeated intervention over two years. The program began in 2004 and was implemented in 50 primary care clinics across the State of Kansas.
Results
Of eligible patients, 73% were interested in study participation. 750 enrolled participants were predominantly Caucasian, female, employed, and averaged 47.2 years of age (SD=13.1). In addition to smoking, 427 (57%) had at least one additional major risk factor for cardiovascular disease (diabetes, hypertension, high cholesterol, heart disease or stroke). Participants smoked on average 23.7 (SD=10.4) cigarettes per day, were contemplating (61%) or preparing to quit (30%), were highly motivated and confident of their ability to quit smoking, and reported seeing their physicians multiple times in the past twelve months (Median=3.50; Mean=5.48; SD=6.58).
Conclusion
Initial findings demonstrate the willingness of patients to enroll in a two-year disease management program to address nicotine dependence, even among patients not ready to make a quit attempt. These findings support the feasibility of identifying and enrolling rural smokers within the primary care setting.
doi:10.1016/j.ypmed.2008.04.013
PMCID: PMC2577567  PMID: 18544464
disease management; smoking cessation; tobacco use; nicotine dependence; rural health; primary care

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