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1.  "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.
Background
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.
Methods
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.
Results
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.
Conclusion
"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.
doi:10.1186/1471-2296-12-42
PMCID: PMC3132720  PMID: 21627833
Decisions; general medical practice; qualitative; smoking cessation; spouse
2.  Changing behaviour 
Clinical Evidence  2006;2006:0203.
Key Points
Individual change in behaviour has the potential to decrease the burden of chronic disease due to smoking, diet and low physical activity.
Smoking quit rates can be increased by simple advice from a physician or trained counsellor, overall and in people at high risk of smoking related disease, with low intensity advice as effective as high intensity advice. Advice from a nurse, telephone counselling, individualised self help materials and taking exercise may also be beneficial. Training health professionals increases the frequency of offering antismoking interventions but may not increase their effectiveness. Nicotine replacement therapy, bupropion and nortriptyline may improve short term quit rates as part of smoking cessation strategies.Moclobemide, selective serotonin reuptake inhibitors, anxiolytics and acupuncture have not been shown to be beneficial.Smoking cessation programmes increase quit rates in pregnant women, but nicotine patches may not be beneficial compared with placebo.
Physical activity in sedentary people may be increased by counselling, with input from exercise specialists possibly being more effective than physicians, in women over 80 years and in younger adults.
Advice on eating a low cholesterol diet leads to a mean 0.2 to 0.3 mmol/L decrease in blood cholesterol concentration in the long term, but no consistent effect of this on morbidity or mortality has been shown. Intensive interventions to reduce sodium intake lead to small decreases in blood pressure, but may not reduce morbidity or mortality. Advice to lose weight leads to greater weight loss than no advice, and cognitive behavioural therapy may be more effective than dietary advice. Maintenance strategies involving personal or family contact, walking training or multifactorial approaches may be more effective at maintaining weight loss compared with no strategies, but have resource implications.We don't know whether lifestyle advice, with or without financial incentives, can prevent weight gain, or whether training health professionals leads to greater weight loss in people in their care.
PMCID: PMC2907629
3.  Practice nurses and antismoking education. 
A questionnaire on antismoking activities and education was sent to 369 nurses in general practice. The response rate was 80%. Although most of the nurses sometimes advised patients about smoking, routine antismoking education occurred less frequently. Only a few regularly referred smokers to other agencies for help, recommended aids to stop smoking, or used antismoking literature. Although the nurses thought that they had an important role in helping smokers to give up, they expressed little confidence in their effectiveness, believing that advice from the general practitioner and the smoker's personal determination to give up have more impact. The nurses expressed a need for training in antismoking education. Seventy seven per cent were interested in attending seminars and listed information about smoking, techniques for stopping, and counselling skills as priorities. If practice nurses are to use opportunities in primary care to help smokers there is clearly a need to provide further training and to establish the effectiveness of nurses in their role as smoking educators.
PMCID: PMC1339358  PMID: 3080183
4.  Parental Perspectives on Antismoking Discussions With Adolescents in Rural African American Households, May 2004-January 2005 
Preventing Chronic Disease  2009;6(2):A43.
Introduction
The purpose of this study was to use qualitative interviews to examine antismoking discussions African American parents and adult family members have with adolescent children. This study is one of the first studies to examine the content of family discussions about not smoking among rural African American families from the perspective of parents and extended family members.
Methods
Interview topics included discussions with their children, how their children reacted to those discussions, expected and actual consequences for their children trying a cigarette, and perspectives on how best to keep their children from becoming cigarette smokers. A total of 72 African American households participated in the overall study, and 112 people were interviewed.
Results
Major themes that emerged included discussing the negative health and economic aspects of smoking and the influence of peer pressure. Likely consequences for trying a cigarette included talking to the child about the dangers of smoking and taking away privileges. Making cigarettes less accessible, continued discussions, leading by example, and not smoking around children were suggested as strategies to keep children from smoking.
Conclusion
This study provides insight into antismoking socialization efforts in rural African American families and confirms that African American families are actively engaged in keeping their children from smoking.
PMCID: PMC2687849  PMID: 19288986
5.  Out of the smokescreen II: will an advertisement targeting the tobacco industry affect young people's perception of smoking in movies and their intention to smoke? 
Tobacco Control  2007;16(3):177-181.
Objective
To evaluate the effect of an antismoking advertisement on young people's perceptions of smoking in movies and their intention to smoke.
Subjects/setting
3091 cinema patrons aged 12–24 years in three Australian states; 18.6% of the sample (n = 575) were current smokers.
Design/intervention
Quasi‐experimental study of patrons, surveyed after having viewed a movie. The control group was surveyed in week 1, and the intervention group in weeks 2 and 3. Before seeing the movie in weeks 2 and 3, a 30 s antismoking advertisement was shown, shot in the style of a movie trailer that warned patrons not to be sucked in by the smoking in the movie they were about to see.
Outcomes
Attitude of current smokers and non‐smokers to smoking in the movies; intention of current smokers and non‐smokers to smoke in 12 months.
Results
Among non‐smokers, 47.8% of the intervention subjects thought that the smoking in the viewed movie was not OK compared with 43.8% of the control subjects (p = 0.04). However, there was no significant difference among smokers in the intervention (16.5%) and control (14.5%) groups (p = 0.4). A higher percentage of smokers in the intervention group indicated that they were likely to be smoking in 12 months time (38.6%) than smokers in the control group (25.6%; p<0.001). For non‐smokers, there was no significant difference in smoking intentions between groups, with 1.2% of intervention subjects and 1.6% of controls saying that they would probably be smoking in 12 months time (p = 0.54).
Conclusions
This real‐world study suggests that placing an antismoking advertisement before movies containing smoking scenes can help to immunise non‐smokers against the influences of film stars' smoking. Caution must be exercised in the type of advertisement screened as some types of advertising may reinforce smokers' intentions to smoke.
doi:10.1136/tc.2006.017194
PMCID: PMC2598498  PMID: 17565137
6.  Health, smoking and doctors' advice 
One hundred and sixty-seven individuals with chronic conditions were interviewed about their smoking history and current habits as part of two larger studies on health care. The interviews were lengthy and permitted individuals to comment freely on reasons for stopping or continuing smoking and the role of doctors' advice in these decisions. Only 22 per cent had never smoked. The youngest and males were most likely to have smoked. At time of interview, 51 per cent of those who had ever smoked were still smoking. Those with circulatory disorders, in contrast to respiratory or musculoskeletal disorders, were most likely to have stopped. Perceptions of doctors' advice varied by both age and diagnosis, with the elderly claiming to have received little medical advice. Those with histories of circulatory disorders reported receiving advice more frequently. Doctors may have advised these individuals more frequently because there was threat to life, but it is also possible that individuals with life-threatening disorders are more likely to recall such advice.
PMCID: PMC1972264  PMID: 7086751
7.  Effectiveness of Antismoking Media Messages and Education Among Adolescents in Malaysia and Thailand: Findings From the International Tobacco Control Southeast Asia Project 
Nicotine & Tobacco Research  2012;15(2):482-491.
Introduction:
Finding ways to discourage adolescents from taking up smoking is important because those who begin smoking at an earlier age are more likely to become addicted and have greater difficulty in quitting. This article examined whether anti smoking messages and education could help to reduce smoking susceptibility among adolescents in two Southeast Asian countries and to explore the possible moderating effect of country and gender.
Methods:
Data came from Wave 1 of the International Tobacco Control Southeast Asia Project (ITC-SEA) survey conducted in Malaysia (n = 1,008) and Thailand (n = 1,000) where adolescents were asked about receiving antismoking advice from nurses or doctors, being taught at schools about the danger of smoking, noticing antismoking messages, knowledge of health effects of smoking, beliefs about the health risks of smoking, smoking susceptibility, and demographic information. Data were analyzed using chi-square tests and logistic regression models.
Results:
Overall, significantly more Thai adolescents reported receiving advice from their nurses or doctors about the danger of smoking (p < .001), but no country difference was observed for reported antismoking education in schools and exposure to antismoking messages. Multivariate analyses revealed that only provision of antismoking education at schools was significantly associated with reduced susceptibility to smoking among female Malaysian adolescents (OR = 0.26). Higher knowledge of smoking harm and higher perceived health risk of smoking were associated with reduced smoking susceptibility among Thai female (OR = 0.52) and Malaysian male adolescents (OR = 0.63), respectively.
Conclusions:
Educating adolescents about the dangers of smoking in schools appears to be the most effective means of reducing adolescents’ smoking susceptibility in both countries, although different prevention strategies may be necessary to ensure effectiveness for male and female adolescents.
doi:10.1093/ntr/nts161
PMCID: PMC3545717  PMID: 22949569
8.  “What kind of general practitioner do I need for smoking cessation?” Results from a qualitative study in Poland 
BMC Family Practice  2013;14:159.
Background
Cigarette smoking remains the leading preventable cause of death and disease. Thus, all activities aiming to reduce smoking play an important role in improving population health. The positive role of the general practitioner (GP) in smoking cessation could increase the success rate for quitting smoking, if compared with unassisted cessation. The aim of this study was to determine what kind of general practitioner smokers need in order to stop smoking.
Methods
Four focus groups with 12 current and 12 former smokers (aged 20-59, 11 women and 13 men), were arranged in the city of Toruń, Poland, with a view to describe their opinions on the GP’s role in smoking cessation. The data were subjected to descriptive qualitative content analysis.
Results
Two major themes emerged in the analysis: the smokers’ positive and negative experiences of the GP in smoking cessation and their expectations regarding the role of the GP in smoking cessation. The first theme embraced the following subthemes: (1) GP’s passivity, (2) routine questions about the patient’s smoking during the visit, (3) lack of time during the visit, and (4) the role model of the GP in smoking cessation. Within the second theme, the respondents identified the following subthemes: (1) bringing up the topic of smoking cessation, even in situations when the patient is unprepared for this; (2) the necessity of a tailored approach to the patient; (3) access to information and evidence confirming the harms of smoking tobacco; (4) prescription of pharmacological and other treatment; and (5) referral to specialists in smoking cessation.
Conclusions
Patients expect their GP to actively participate in smoking cessation through a more tailored approach to the patient’s needs. The patients’ experiences did not match their expectations: the smokers rarely got advice on smoking cessation from their GPs. Finally, they emphasized the importance of the GP as a role model in smoking cessation.
doi:10.1186/1471-2296-14-159
PMCID: PMC3853716  PMID: 24138475
Smoking cessation; Primary care; Qualitative research
9.  One year effectiveness of an individualised smoking cessation intervention at the workplace: a randomised controlled trial 
Aims: To assess the effectiveness of a smoking cessation intervention at the workplace. The intervention was adapted to smokers‘ tobacco dependence, and included minimal structured counselling at the first visit (5–8 minutes), nicotine patches for three months, and three sessions of counselling for reinforcement of abstinence (2–3 minutes) over a three month period.
Methods: Open randomised trial with two groups: the intervention group, and the control group which was subjected to standard clinical practice, consisting of short (30 seconds to one minute) sporadic sessions of unstructured medical antismoking advice. The trial was carried out among 217 smokers of both sexes, aged 20–63 years, motivated to quit smoking and without contraindications for nicotine patches, who were employees at a public transport company and at two worksites of an electric company. The main outcome measure was self reported tobacco abstinence confirmed by carbon monoxide in expired air ≤10 ppm. Analysis was performed according to intention-to-treat.
Results: The rate of continuous abstinence at 12 months was 20.2% for the intervention versus 8.7% for the control group (OR: 2.58; 95% CI: 1.13 to 5.90; p = 0.025). In subgroup analyses, effectiveness of the intervention did not vary substantially with age, tobacco dependence, number of cigarettes smoked per day, number of years of tobacco consumption, degree of desire to quit smoking, time spent with smokers, subjective health, and presence of tobacco related symptoms. Weight gain at 12 months was similar for both groups (1.69 kg in the intervention v 2.01 kg in the control group; p = 0.21).
Conclusions: A simple and easily generalisable intervention at the workplace is effective to achieve long term smoking cessation. In a setting similar to ours, nine subjects would have to be treated for three months for one to achieve continuous abstinence for 12 months.
doi:10.1136/oem.60.5.358
PMCID: PMC1740534  PMID: 12709522
10.  DETERMINANTS OF OUTCOME AMONG SMOKERS IN A SMOKING CESSATION PROGRAM 
Background:
Tobacco consumption is now one of the most serious problems in the world and is receiving renewed attention in the current health promotion.
Objectives:
This study was carried out to elucidate the psychosocial and behavioural aspects of smokers associated with participation, attrition and outcome in smoking cessation programs.
Methodology:
This prospective cohort design included three hundred and twenty six smokers from the antismoking center - King Fahd Specialist Hospital, Buraydah, Kingdom of Saudi Arabia. The selected patients were subjected to a history taking, the assessment of causes of smoking, motives for quitting and belief problems arising from quitting; then they were made to join the clinic's antismoking program and were followed up after six months to assess the success of the program, which was measured by the rate of recidivism.
Results and conclusion:
The results showed that the important psychosocial and behavioural factors affecting the success in quitting smoking were: previous history of an attempt to stop tension, anxiety, anger, health beliefs and attitudes, importance of quitting, duration of smoking, period of last attempt to stop and the method used. These factors can be modified in order to increase the likelihood of success in quitting smoking.
PMCID: PMC3437158  PMID: 23008552
Smoking; Causes; Quitting; Beliefs; Cessation; Outcome
11.  Evaluating the effectiveness of using personal tailored risk information and taster sessions to increase the uptake of smoking cessation services: study protocol for a randomised controlled trial 
Trials  2012;13:195.
Background
Although government-funded specialist smoking cessation services in England offer advice and support to smokers motivated to quit, only a small proportion of smokers make use of this service. Evidence suggests that if smokers are proactively and personally invited to use services, use will be higher than with a standard referral made by health professionals. Computer-based systems generating personalised tailored communications also have the potential to engage with a larger proportion of the smoking population. In this study smokers are proactively invited to use the NHS Stop Smoking Service (SSS), with a personal computer-tailored letter and the offer of a no-commitment introductory session designed to give more information about the service. The primary objective is to assess the relative effectiveness on attendance at the NHS SSS, of proactive recruitment by a brief personal letter, tailored to individual characteristics, and invitation to a taster session, over a standard generic letter advertising the service.
Method/design
This randomised controlled trial will recruit smokers from general practice who are motivated to quit and have not recently attended the NHS SSS. Smokers aged 16 years and over, identified from medical records in participating practices, are sent a brief screening questionnaire and cover letter from their GP. Smokers giving consent are randomised to the Control group to receive a standard generic letter advertising the local service, or to the Intervention group to receive a brief personal, tailored letter with risk information and an invitation to attend a ‘Come and Try it’ taster session. The primary outcome, assessed 6 months after the date of randomisation, is the proportion of people attending the NHS SSS for at least one session. Planned recruitment is to secure 4,500 participants, from 18 regions in England served by an NHS SSS.
Discussion
Personal risk information generated by computer, with the addition of taster sessions, could be widely replicated and delivered cost effectively to a large proportion of the smoking population. The results of this trial will inform the potential of this method to increase referrals to specialised smoking cessation services and prompt more quit attempts.
Trial registration
Current Controlled Trials ISRCTN76561916
doi:10.1186/1745-6215-13-195
PMCID: PMC3563550  PMID: 23078797
Smoking cessation; Stop smoking clinics; Computer-tailoring; Personalisation; Risk information
12.  Controlled trial of three different antismoking interventions in general practice. 
Of 6052 adult patients who consulted their doctors in six Oxfordshire general practices between October 1980 and February 1981, 2110 (35%) were smokers. The smokers were allocated to one of four study groups--a control (non-intervention) group; a group that received verbal and written antismoking advice from the general practitioner; a group that received this advice and also a demonstration of exhaled carbon monoxide; and a group that received the advice plus the offer of further help from a health visitor. After one year 72% of smokers replied to a postal follow up questionnaire: 11% of the control group claimed to have stopped smoking compared with 15% in the group that received advice alone, 17% in the exhaled carbon monoxide group, and 13% in the health visitor group. Validation of these findings by assays of urinary concentrations of cotinine showed that between 24% and 40% of subjects may have misreported their smoking habits, but there was no indication that the rate of misreporting was higher in the intervention groups than in the control group. Giving advice routinely against smoking has a useful effect, and showing an immediate, personal, and potentially harmful consequence of smoking using a CO-oximeter may improve this, particularly in lower socioeconomic groups.
Images
PMCID: PMC1441184  PMID: 6426618
13.  Smoking Cessation Interventions with Female Smokers Living with HIV/AIDS: A Randomized Pilot Study of Motivational Interviewing 
AIDS care  2012;25(7):820-827.
Smoking among people living with HIV, particularly women living with HIV, is associated with higher morbidity and mortality rates when compared to non-smoking individuals with HIV. Despite patients’ higher risk of adverse health outcomes, in particular preventable smoking-related diseases for smokers living with HIV, few smoking cessation interventions have been examined with this population. The aim of the current study was to test the potential efficacy of a brief motivational intervention for smoking cessation with HIV infected women smokers. Participants (N = 30) were randomly assigned to receive a single session of Motivational Interviewing or Prescribed Advice. The primary outcome was 7-day point prevalence abstinence at the one-month follow-up interview. Secondary outcome measures included mean cigarettes smoked per day, desire to quit smoking, perceived difficulty in quitting smoking, and expectation of success. We detected no significant differences between intervention and control groups in self-reported 7-day point prevalence abstinence at the one-month follow-up. However, participants in the MI condition reported a significant decrease in the mean cigarettes smoked per day when compared to the Prescribed Advice condition. There were no significant between-group differences in participants’ desire to quit, perceived difficulty and expectation of success. The results of this pilot study indicate that MI may be an effective smoking cessation intervention for HIV positive women smokers and should be studied further in a larger clinical trial.
doi:10.1080/09540121.2012.733331
PMCID: PMC3625696  PMID: 23116051
14.  Promoting Smoking Cessation in Pregnancy with Video Doctor plus Provider Cueing: A Randomized Trial 
Objective
This study examined the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy.
Design
A randomized clinical trial was conducted from 2006 to 2008.
Setting
Five, community, prenatal clinics in the San Francisco Bay Area of the United States.
Participants
410 pregnant patients completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (N = 42) were randomized regardless of their intention to quit smoking.
Methods
Participants were assigned to either usual care or intervention. Intervention participants received 15-minute Video Doctor sessions plus provider cueing, at baseline and 1 month, prior to their routine prenatal visit. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants and a cueing sheet for providers.
Main outcome measures
Receipt of advice from the provider and 30-day smoking abstinence, both by self report.
Results
Intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (61% vs 16%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. The 30-day abstinence rate at 2 months post baseline was 2.5 times greater in the intervention group; the difference was not statistically significant (26.1% vs 10.5%, p = 0.12).
Conclusions
The Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers.
doi:10.3109/00016341003678419
PMCID: PMC3312043  PMID: 20196678
smoking cessation; pregnancy; prenatal care; patient education; randomized controlled trial
15.  Role of Regulatory Approach in the Prevention of Smoking among Professional Students in India 
Background: This study was done to know the effect of antismoking legislation among different professional students as, in this age group individuals tend to involve in such adverse habits.
Materials & Methods: In this cross-sectional study, three different professional students (Arts, Engineering and Dental) were considered. A pretested self administered structured questionnaire was used to know the attitude of students towards anti smoking legislation like smoking habits, awareness of antismoking legislation etc. Statistical analysis used: Data was analysed using ANOVA and students’t test. p<0.05 was considered as the level of significance.
Results: The total study subjects were 990 including 396 -smokers and 594 – non smokers. 84.7% knew about antismoking legislation and around 70.2% answered that it was good to ban smoking in public places. Non smokers gave significantly more positive response towards law against smoking.
Conclusion: Overall results were supporting for the antismoking legislation. But there is a lack of enforcing mechanism in support of legislation, so a total ban on smoking may give us better and healthy results.
How to cite the article: Vadvadgi VH, Sanjay V, Gupte A, Kamatagi L, Kathariya MD, Gugawad SC. Role of Regulatory Approach in the Prevention of Smoking among Professional Students in India. J Int Oral Health 2014;6(1):95-9.
PMCID: PMC3959145  PMID: 24653611
Anti-smoking legislation; professional students; smoking
16.  “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.
doi:10.3390/ijerph10020623
PMCID: PMC3635167  PMID: 23380914
smoking cessation; workplace; qualitative research; blue-collar smokers
17.  Smoking Characteristics and Comorbidities in the Power To Quit Randomized Clinical Trial for Homeless Smokers 
Nicotine & Tobacco Research  2012;15(1):22-28.
Introduction:
Smoking prevalence in homeless populations is strikingly high (∼70%); yet, little is known about effective smoking cessation interventions for this population. We conducted a community-based clinical trial, Power To Quit (PTQ), to assess the effects of motivational interviewing (MI) and nicotine patch (nicotine replacement therapy [NRT]) on smoking cessation among homeless smokers. This paper describes the smoking characteristics and comorbidities of smokers in the study.
Methods:
Four hundred and thirty homeless adult smokers were randomized to either the intervention arm (NRT + MI) or the control arm (NRT + Brief Advice). Baseline assessment included demographic information, shelter status, smoking history, motivation to quit smoking, alcohol/other substance abuse, and psychiatric comorbidities.
Results:
Of the 849 individuals who completed the eligibility survey, 578 (68.1%) were eligible and 430 (74.4% of eligibles) were enrolled. Participants were predominantly Black, male, and had mean age of 44.4 years (S D = 9.9), and the majority were unemployed (90.5%). Most participants reported sleeping in emergency shelters; nearly half had been homeless for more than a year. Nearly all the participants were daily smokers who smoked an average of 20 cigarettes/day. Nearly 40% had patient health questionnaire-9 depression scores in the moderate or worse range, and more than 80% screened positive for lifetime history of drug abuse or dependence.
Conclusions:
This study demonstrates the feasibility of enrolling a diverse sample of homeless smokers into a smoking cessation clinical trial. The uniqueness of the study sample enables investigators to examine the influence of nicotine dependence as well as psychiatric and substance abuse comorbidities on smoking cessation outcomes.
doi:10.1093/ntr/nts030
PMCID: PMC3611988  PMID: 22589422
18.  Tobacco cessation via doctors of chiropractic: Results of a feasibility study 
Nicotine & Tobacco Research  2010;12(3):305-308.
Introduction:
There is a sizeable and growing body of empirical literature on the effects of physician advice to quit smoking. Because of the association between tobacco use and the health problems that may provoke referral to chiropractic care, doctors of chiropractic (DCs) may be able to give patients personalized proximal health feedback that may motivate them to quit. However, DCs have not been utilized in this role. The primary aim of this study was to design and refine a brief office-based tobacco intervention for use within chiropractic settings.
Methods:
This study was conducted in 20 private chiropractic practices in 2 phases: (a) intervention development, in which we created and focus tested practitioner and patient materials, and (b) feasibility, in which we evaluated the impact of the intervention on 210 tobacco-using chiropractic patients.
Results:
Analyses were conducted on 156 patients who exclusively smoked cigarettes. Using an intent-to-treat approach, assuming all nonresponders to be smokers, 13 (8.3%) reported 7-day abstinence at 6 weeks, 22 (14.1%) at the 6-month follow-up, and 35 (22.4%) at the 12-month assessment. Eleven participants (7.1%) reported prolonged abstinence at the 6-month follow-up, and 15 (9.6%) reported prolonged abstinence at 12 months.
Conclusions:
To our knowledge, this is the first study to refine a brief office-based treatment for tobacco dependence for use in chiropractic settings. The results of this study were promising and will lead to a randomized clinical trial. If found to be effective, this model could be disseminated to chiropractic practitioners throughout the United States.
doi:10.1093/ntr/ntp203
PMCID: PMC2825104  PMID: 20097840
19.  Smoking: can we really make a difference? 
Heart  2003;89(Suppl 2):ii25-ii27.
The enormous health benefits of stopping smoking are now well established. Doctors have a vital role in motivating smokers and initiating quit attempts. The mainstay of National Health Service smoking cessation strategy should be the routine provision of brief opportunistic intervention in primary care, backed up by referral to a specialist smoking cessation service. There is an urgent need to increase substantially the numbers of smokers referred by general practitioners, other members of the primary care team, and those working in acute hospital trusts, to specialist smoking cessation services and for better channels of communication between the various agencies. Use of pharmacotherapy (nicotine replacement therapy or bupropion) in combination with behavioural support achieves higher cessation rates than either component alone and is the most effective way of helping smokers to stop. Smokers who quit often relapse and hence will need repeated help.
doi:10.1136/heart.89.suppl_2.ii25
PMCID: PMC1876294  PMID: 12695432
20.  Efficacy of Ask Advise Connect in a Safety Net Healthcare System 
Background
Since smoking has a profound impact on socioeconomic disparities in illness and death, it is crucial that vulnerable populations of smokers be targeted with treatment. The US Public Health Service recommends that all patients be asked about their smoking at every visit, and that smokers be given brief advice to quit and referred to treatment.
Purpose
Initiatives to facilitate these practices include the 5 A’s (i.e., Ask, Advise, Assess, Assist, Arrange) and Ask Advise Refer (AAR). Unfortunately, primary care referrals are low, and most smokers referred fail to enroll. This study evaluated the efficacy of the Ask Advise Connect (AAC) approach to linking smokers with treatment in a large, safety-net public healthcare system.
Design
Pair-matched-two-treatment arm group-randomized trial.
Setting/participants
Ten safety-net clinics in Houston, TX.
Intervention
Clinics were randomized to AAC (n=5; intervention) or AAR (n=5; control). Licensed Vocational Nurses (LVNs) were trained to assess and record the smoking status of all patients at all visits in the electronic health record (EHR). Smokers were given brief advice to quit. In AAC, the names and phone numbers of smokers who agreed to be connected were sent electronically to the Texas Quitline daily, and patients were proactively called within 48 hours. In AAR, smokers were offered a Quitline referral card and encouraged to call on their own. Data were collected between June 2010 and March 2012 and analyzed in 2012.
Main Outcome Measure
The primary outcome – impact – was defined as the proportion of identified smokers that enrolled in treatment.
Results
The impact (proportion of identified smokers who enrolled in treatment) of AAC (14.7%) was significantly greater than the impact of AAR (0.5%), t (4) = 14.61, p = 0.0001, OR = 32.10 (95% CI 16.60–62.06).
Conclusions
AAC has tremendous potential to reduce tobacco-related health disparities.
doi:10.1016/j.amepre.2013.07.011
PMCID: PMC4023543  PMID: 24237916
21.  “I know it’s bad for me and yet I do it”: exploring the factors that perpetuate smoking in Aboriginal Health Workers - a qualitative study 
Background
Aboriginal Health Workers (AHWs) have a mandate to deliver smoking cessation support to Aboriginal people. However, a high proportion of AHWs are smokers and this undermines their delivery of smoking cessation programs. Smoking tobacco is the leading contributor to the burden of disease in Aboriginal Australians and must be prevented. Little is known about how to enable AHWs to quit smoking. An understanding of the factors that perpetuate smoking in AHWs is needed to inform the development of culturally relevant programs that enable AHWs to quit smoking. A reduction of smoking in AHWs is important to promote their health and also optimise the delivery of smoking cessation support to Aboriginal clients.
Methods
We conducted a fundamental qualitative description study that was nested within a larger mixed method participatory research project. The individual and contextual factors that directly or indirectly promote (i.e. perpetuate) smoking behaviours in AHWs were explored in 34 interviews and 3 focus groups. AHWs, other health service staff and tobacco control personnel shared their perspectives. Data analysis was performed using a qualitative content analysis approach with collective member checking by AHW representatives.
Results
AHWs were highly stressed, burdened by their responsibilities, felt powerless and undervalued, and used smoking to cope with and support a sense of social connectedness in their lives. Factors directly and indirectly associated with smoking were reported at six levels of behavioural influence: personal factors (e.g. stress, nicotine addiction), family (e.g. breakdown of family dynamics, grief and loss), interpersonal processes (e.g. socialisation and connection, domestic disputes), the health service (e.g. job insecurity and financial insecurity, demanding work), the community (e.g. racism, social disadvantage) and policy (e.g. short term and insecure funding).
Conclusions
An extensive array of factors perpetuated smoking in AHWs. The multitude of personal, social and environmental stressors faced by AHWs and the accepted use of communal smoking to facilitate socialisation and connection were primary drivers of smoking in AHWs in addition to nicotine dependence. Culturally sensitive multidimensional smoking cessation programs that address these factors and can be tailored to local needs are indicated.
doi:10.1186/1472-6963-12-102
PMCID: PMC3394210  PMID: 22533609
22.  Interest in technology-based and traditional smoking cessation programs among adult smokers in Ankara, Turkey 
Tobacco Induced Diseases  2011;9(1):10.
Background
Little is known about the demand for smoking cessation services in settings with high smoking prevalence rates. Furthermore, acceptability of text messaging and Internet as delivery mechanisms for smoking cessation programs in non-developed countries is under-reported. Given the cost effectiveness of technology-based programs, these may be more feasible to roll out in settings with limited public health resources relative to in-person programs.
Findings
148 adult smokers took part in a community-based survey in Ankara, Turkey. Two in five (43%) respondents reported typically smoking their first cigarette within 30 minutes of waking. Many participants expressed a desire to quit smoking: 27% reported seriously thinking about quitting in the next 30 days; 53% reported at least one quit attempt in the past year. Two in five smokers wanting to quit reported they were somewhat or extremely like to try a smoking cessation program if it were accessible via text messaging (45%) or online (43%).
Conclusions
Opportunities for low-cost, high-reach, technology-based smoking cessation programs are under-utilized. Findings support the development and testing of these types of interventions for adult smokers in Turkey.
doi:10.1186/1617-9625-9-10
PMCID: PMC3199750  PMID: 21806793
smoking cessation; Turkey; middle income country; technology-based interventions
23.  Institutionalizing a Comprehensive Tobacco-Cessation Protocol in an Indigenous Health System: Lessons Learned 
Background
Native Hawaiians have high smoking prevalence and high lung cancer mortality rates.
Objectives
To describe a comprehensive tobacco cessation protocol and share lessons learned in institutionalizing it across the five Native Hawaiian Health Care Systems (NHHCS).
Methods
NHHCS representatives worked together to culturally tailor the Agency for Healthcare Research and Quality protocol for smoking cessation. Process objectives included number of staff trained in tobacco cessation, inclusion of the Tobacco User Guide Sheet (TUGS) in the intake process and medical record, and expansion of programs for smokers who want to quit. Outcome objectives included percent of individuals asked about smoking status and percent of identified smokers that received brief intervention, set a quit date, were linked to services, and remained smoke-free for 90 days.
Results
After 18 months, the NHHCS were at different stages of protocol adoption. More successful NHHCS were more likely to have several champions for the program and administrative support for staff training, new programs, and integrating the TUGS into client charts. They also showed greater success in getting smokers to set a quit date and remain smoke-free for 90 days.
Conclusion
Although the five NHHCS helped design the protocol, each operates independently. More effort and time are needed to help each system overcome internal barriers to institutionalizing a new protocol and to facilitate support for tobacco-cessation champions among medical records and data management supervisors. These lessons may be useful to other organizations that want to institutionalize a comprehensive tobacco-cessation protocol.
doi:10.1353/cpr.0.0038
PMCID: PMC2862696  PMID: 20208308
Community health centers; guideline adherence; minority; nicotine; organizational change; organizational innovation; Native Hawaiian; Pacific Islander; smoking
24.  Smoking Cessation in the Chicago Coronary Prevention Evaluation Program 
Quit-rates for cigarette smokers in a lifestyle intervention program aimed at reducing coronary risk were 24 percent for all participants and 34 percent for non-dropouts. Recidivism remained very low during participation in the program. Half of the smokers who quit did so after being in the program more than two years. These data suggest that while engaging in an effort to make other changes in lifestyle, many smokers can be helped to quit. Sustained antismoking efforts in the clinical practice of medicine can be expected to share these same positive aspects. While mass public health programs to eliminate smoking and prevent young people from taking up the habit are being developed, health practitioners can make a significant contribution by including vigorous efforts at smoking cessation as part of routine practice.
PMCID: PMC2552876  PMID: 7120470
25.  Provider advice about smoking cessation and pharmacotherapy among cancer survivors who smoke: practice guidelines are not translating 
ABSTRACT
Smoking among childhood and young adult cancer survivors may increase risk for late effects of treatment, and survivors need assistance in quitting. This paper reports on the prevalence of discussions between childhood cancer survivors and their health care providers about smoking cessation and pharmacotherapy and explores factors that are associated with these discussions. This is a longitudinal study that included 329 smokers who were childhood or young adult cancer survivors, recruited from five cancer centers in the USA and Canada. Fifty-five percent of smokers reported receiving advice to quit smoking from their regular provider during the study period, and only 36 % of smokers reported discussing pharmacotherapy with their provider. Receipt of advice was associated with being female and having a heavier smoking rate. Pharmacotherapy discussions were associated with readiness to quit, heavier smoking rate, and previous provider advice to quit. Health care providers are missing key opportunities to advise cancer survivors about cessation and evidence-based interventions. Systematic efforts are needed to ensure that survivors who smoke get the treatment that they need.
doi:10.1007/s13142-013-0202-7
PMCID: PMC3717972  PMID: 23894256
Smoking cessation; Childhood cancer survivors; Pharmacotherapy; Cancer

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