Predictors of long-term outcome of a smoking cessation programme in primary care.

BACKGROUND: It would be helpful for general practitioners to know which smokers are the most or the least likely to achieve long-term cessation, so that efforts in promoting lifestyle changes can be prioritised. AIM: To identify predictors of abstinence and assess effectiveness over a two-year follow-up of a smoking cessation programme in routine general practice. DESIGN OF STUDY: Quasi-experimental non-randomised controlled trial. SETTING: Primary healthcare centres of the Basque Health Service, Spain. METHOD: All smokers attending seven intervention (n = 1203) and three control (n = 565) practices during one year (from September 1995 to October 1996) were included. The associations between attempts to stop smoking, relapses, and sustained biochemically confirmed abstinence between 12 and 24 months' follow-up, with baseline characteristics and patients' preference with regard to three possible therapeutic options, were assessed by means of logistic regression and survival analyses. RESULTS: Sustained abstinence was biochemically confirmed in 7.3% of smokers in the intervention practices (relative probability = 2.8, 95% confidence interval [CI] = 1.6 to 4.7; probability difference = 4.7%, 95% CI = 2.7% to 6.7%); in 5% of smokers who received advice and a handout (adjusted odds ratio [AOR] = 1.9, 95% CI = 1.0 to 3.4), in 16% who received advice, a handout and follow-up (AOR = 6.6, 95% CI = 2.9 to 14.6), and in 22% who received advice, a handout, follow-up and nicotine patches (AOR = 13.1, 95% CI = 6.6 to 25.9). Positive predictors included previous attempts to stop smoking (AOR = 1.8, 95% CI = 1.1 to 2.7), and age (for each 10 years AOR = 1.32, 95% CI = 1.13 to 1.44). The Fagerstr?m nicotine dependence score was negatively associated (for each point AOR = 0.89, 95% CI = 0.82 to 0.97). CONCLUSION: The intensity of the programme can be tailored to the probability of long-term cessation estimated by the statistical model including these predictors.     

Acculturation and cigarette smoking among Korean American men

This study examined the prevalence and correlated factors of cigarette smoking in a cross-sectional, epidemiological survey of Korean American men living in Maryland (n=333). In this sample, 26.1% were current smokers and 42.3% were former smokers. The older age group (> or = 40 years) was more likely to have quit smoking than the younger age group (< 40 years). In multiple logistic regression analysis, acculturation was associated with smoking status; those who stayed more than 20 years in the U.S. were less likely to be current smokers (OR=0.32, 95% CI 0.13-0.77) than those who stayed less than 10 years. Alcohol use was associated with smoking status; those who consumed alcohol were more likely to be current smokers (OR=5.24, 95% CI 2.33-11.79) or former smokers (OR=5.45, 95% CI=2.69-11.04) than those did not. Those with hypertension were more likely to have quit smoking (OR=3.11, 95% CI=1.33-7.24). The results suggest that the role of acculturation in smoking status among Korean American men deserves further attention by researchers as well as by health professionals who develop smoking prevention and cessation programs.     

Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England

Background

Brief interventions have a modest but meaningful effect on promoting smoking cessation and reducing excessive alcohol consumption. Guidelines recommend offering such advice opportunistically and regularly but incentives vary between the two behaviours.

Aim

To use representative data from the perspective of patients to compare the prevalence and characteristics of people who smoke or drink excessively and who receive a brief intervention.

Design and setting

Data was from a representative sample of 15 252 adults from household surveys in England.

Method

Recall of brief interventions on smoking and alcohol use, sociodemographic information, and smoking and alcohol consumption patterns were assessed among smokers and those who drink excessively (AUDIT score of ≥8), who visited their GP surgery in the previous year.

Results

Of 1775 smokers, 50.4% recalled receiving brief advice on smoking in the previous year. Smokers receiving advice compared with those who did not were more likely to be older (odds ratio [OR] 17-year increments 1.19, 95% confidence interval [CI] =1.06 to 1.34), female (OR 1.35, 95% CI =1.10 to 1.65), have a disability (OR 1.44, 95% CI = 1.11 to 1.88), have made more quit attempts in the previous year (compared with no attempts: one attempt, OR 1.65, 95% CI = 1.32 to 2.08; ≥2 attempts, OR 2.02, 95% CI =1.49 to 2.74), and have greater nicotine dependence (OR 1.17, 95% CI =1.05 to 1.31) but were less likely to have no post-16 qualifications (OR 0.81, 95% CI = 0.66 to 1.00). Of 1110 people drinking excessively, 6.5% recalled receiving advice in their GP surgery on their alcohol consumption in the previous year. Those receiving advice compared with those who did not had higher AUDIT scores (OR 1.17, 95% CI =1.12 to 1.23) and were less likely to be female (OR 0.44, 95% CI = 0.23 to 0.87).

Conclusion

Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, <10% of those who drink excessively report having received advice on their alcohol consumption.     

Bronchitis symptoms in young teenagers who actively or passively smoke cigarettes

This study was undertaken to examine the prevalence of bronchitis (cough with phlegm) symptoms in teenagers who either smoked cigarettes on a regular basis (active smokers) or were non-smokers but who are exposed to passive smoking (passive smokers) in the home. The study was undertaken in 1995 and repeated in 1998. The 1995 study was a cross sectional questionnaire survey of smoking habits in secondary school children aged 13-14 years and was undertaken as part of the ISAAC questionnaire survey. Thirty representative and randomly selected schools from throughout the Republic of Ireland took part in the study. In the 1995 study, 3066 students completed a questionnaire on their current smoking habits and symptoms of cough and phlegm. We found that 634 (20.7%) of these young teenagers actively smoked cigarettes with significantly more females smoking than males with 23.3% of girls compared to 17.6% boys (p = 0.0001). We found that 46.3% of non-smoking children were exposed to smoking in the home (passive smokers) with parental smoking accounting for most of the passive smoking. Bronchitis symptoms were more commonly reported in active smokers compared to non-smokers with an odds ratio of 3.02 (95% CI 2.34-3.88) (p < 0.0001) or in passive smokers compared to those not exposed to smoking with odds ratio of 1.82 (95% CI 1.32-2.52) (p < 0.0001). The 1998 study showed similar results for smoking habits, passive smoking and prevalence of bronchitis symptoms as with the 1995 study. These results document that increased bronchitis symptoms occur in teenagers exposed to active or passive smoking.     

An evidence-based programme for smoking cessation: effectiveness in routine general practice.

BACKGROUND: Smoking cessation clinical practice guidelines are based on randomised clinical trials reporting outcomes in persons who participate in these studies. However, many practitioners are sceptical about the effectiveness of these recommendations when applied to the general population in everyday routine consultation. AIM: To evaluate the results of a comprehensive smoking cessation programme in routine primary care practice. METHOD: All smokers consulting in 10 general practices during one year participated in a non-randomised controlled trial. The percentages of subjects in the intervention (n = 1203, seven practices) and control (n = 565, three practices) groups who reported sustained abstinence between six and 12 months follow-up and were validated biochemically were compared. The effect of the programme was adjusted to baseline differences in both groups by multiple logistic regression analyses. RESULTS: The programme resulted in an increase of five percentage points (95% CI = 3.1%-6.8%) in the validated and sustained one-year abstinence probability, with 7.1% for all of the intervention practices (adjusted OR = 3.7, 95% CI = 2.4-5.7). CONCLUSION: Programmes that combine advice to stop smoking to all smokers attending general practices with the offering of support, follow-up, and nicotine patches to those willing to stop are feasible and effective in routine practice, as primary care clinicians need only identify 20 smokers to get one additional success attributable to the programme.     

Factors associated with outcome in unaided smoking cessation, and a comparison of those who have never tried to stop with those who have.

AIM. This survey set out to determine the factors associated with outcome of unaided smoking cessation attempts and to compare the characteristics of smokers who had tried to stop with those who had never tried. METHOD. A postal questionnaire was sent to a random sample of 2000 adults in Aberdeen, Scotland. Those respondents who smoked or who were ex-smokers were sent a second questionnaire. The outcome measure for success in trying to stop smoking was abstinence for more than four months. RESULTS. Light and heavy smokers were more successful at smoking cessation than moderate smokers. Those who succeeded perceived that they had more social support than failures, and were more likely to have 'simply just stopped'. They were less likely to have used nicotine gum or to believe that smoking was harmful. Those who failed experienced more withdrawal symptoms, and were more likely to be tempted by the presence of others smoking. Eleven per cent of smokers had never tried to stop. These smokers were older and more dependent than those who had tried to stop. They were less likely to acknowledge the health risks of smoking or to conform to social pressures, but were more likely to consider stopping for financial reasons alone. CONCLUSION. Heavily dependent smokers may fare better in unaided cessation than the results of clinic-based research suggest. For those who have tried to stop, increasing motivation and social support, and minimizing withdrawal symptoms, may be more productive than further emphasis on health risks. Motivating smokers who have not previously tried to stop may involve more emphasis on the health risks of smoking and the health benefits of stopping, as well as on other non-financial benefits of stopping such as social acceptability. Fiscal measures may be particularly effective in motivating this group of smokers to try to stop.     

Glutathione S-transferase T1-null genotype interacts synergistically with heavy smoking on lung cancer risk

We studied the influence of genotype for glutathione S-transferase T1 (GSTT1) on susceptibility to lung cancer among 184 Swedish lung cancer patients (88 never-smokers and 96 ever-smokers) and 162 matched population controls (79 never-smokers and 83 ever-smokers), with special emphasis on gene-environment interactions. Cases had significantly lower frequency of the GSTT1-null genotype than that of controls among never-smokers (4.6 vs. 16.5%, P = 0.02), whereas the frequencies were very close to each other among smokers (7.4 vs. 7.2%). Cases with high packyears of smoking, however, had a significantly higher frequency of the GSTT1-null genotype compared to that of cases with low packyears (18.3 vs. 5.6%, P = 0.005). Adjusted for age and gender, the GSTT1-null genotype appeared to be protective against lung cancer among never-smokers (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.07-0.7), although it was associated with an increased risk for lung cancer among smokers (OR = 2.1, 95% CI = 0.8-5.9), mainly attributed to the group of heavy smokers (>23 packyears; OR = 3.5, 95% CI = 0.7-17.3). Heavy smoking conferred a threefold increased risk for lung cancer (OR = 2.6, 95% CI = 1.3-5.0) among GSTT1-positive individuals, but a ninefold increased risk when combined with the GSTT1-null genotype (OR = 9.3, 95% CI = 1.9-46.3, relative to GSTT1-positive light smokers). This joint effect was further demonstrated by a positive interaction between the GSTT1-null genotype and packyears of smoking. The risk of lung cancer increased steeply with increasing packyears among GSTT1-null smokers, whereas no such effect was seen among GSTT1-positive smokers. We conclude that the GSTT1-null genotype may strengthen the effect of heavy smoking on lung cancer risk.     

Randomized trial of nurse-assisted strategies for smoking cessation in primary care.

BACKGROUND: Brief advice to stop smoking from general practitioners (GPs) has been repeatedly shown to increase smoking cessation by a small, but measurable amount. Some studies have suggested that adding more intensive interventions to brief advice may increase its effectiveness, but it is unclear whether this is true in general practice. AIMS: To determine whether brief advice from a doctor together with counselling and follow-up from a trained practice nurse is more effective than brief advice alone in helping people to stop smoking. METHODS: The design was a randomized controlled trial. Four hundred and ninety-seven general practice patients aged older than 18 years and smoking at least one cigarette per day in six general practices in Oxfordshire, Berkshire, and Buckinghamshire were randomized to one of two interventions: brief verbal or written advice from a GP plus extended counselling and follow-up from a trained practice nurse; brief advice from a GP alone. The primary outcome was sustained abstinence from smoking at three and 12 months. A secondary outcome was forward movement in the stages of change cycle. RESULTS: The proportion showing sustained abstinence was 3.6% in the extended counselling group, and 4.4% in the brief advice group (difference = -0.8%; 95% confidence interval = -4.3% to 2.6%). Seventy-four (30%) of those randomized to extended counselling actually took up this offer. No significant progression in stages of change was detected between the two groups. CONCLUSIONS: In unselected general practice patients who smoke, brief advice from a GP combined with intensive intervention and follow-up by a practice nurse is no more effective than brief advice alone.     

The relationship of tobacco smoking with depressive symptomatology in the Third Mexican National Addictions Survey

BACKGROUND: While an association between cigarette smoking and depression has been established in Anglo populations, replication of tobacco-depression associations in countries where smoking is growing may provide important new insights. The objectives of this study were to estimate the association of depressive symptomatology with tobacco smoking, number of cigarettes smoked daily, and smoking cessation in a representative sample of the Mexican population. METHOD: The data come from the Third National Addictions Survey (1998) conducted by the Mexican Ministry of Health, representative of Mexico's civilian population residing in cities and towns with 2500+ inhabitants, aged 18-64. Part of a multi-stage, stratified, probability sample, 1935 men and women answered a version of the survey that also included the CES-D depression scale. Analyses addressed the survey's complex design and controlled for income and educational evel. RESULTS: Among women only, current smokers had twice the odds of elevated depressive symptomatology than never smokers (OR 2.1, 95% CI 1.3-3.5, p = 0.002). For men, only those smoking a pack or more a day had greater odds of depressive symptomatology (OR 5.9, 95% CI 1.6-21.9, p = 0.008). Overall, former smokers who ceased smoking within 6 months had lower odds of depressive symptomatology than current smokers (OR 0.4, 95% CI 0.1-1.0, p = 0.042). CONCLUSIONS: These findings add to the accumulating evidence for the association between smoking and depression in different cultures and populations.     

Mid-life smoking and late-life dementia: the Honolulu-Asia Aging Study

We studied the association between mid-life smoking and late-life dementia in the Honolulu Heart Program (1965-1971) and follow-up assessment for dementia (1991-1996) of 3734 Japanese-American men (80% of survivors). Neuropathologic data were available for 218 men. Adjusting for age, education and apolipoprotein E (APOE) genotype, the risk of Alzheimer's disease (AD) in smokers increased with pack-years of smoking at medium (odds ratio (OR)=2.18, 95% confidence interval (CI)=1.07-4.69) and heavy (OR=2.40; 95% CI=1.16-5.17) smoking levels. Very heavy smoking was not associated with AD (OR=1.08; 95% CI=0.43-2.63). Findings were similar when AD cases included those with cerebrovascular disease and for all dementias combined. Adjustment for cardiovascular and respiratory factors or stratification by apolipoprotein E genotype did not change these associations. In an autopsied subsample, the number of neuritic plaques increased with amount smoked. This study suggests that amount smoked is associated with an increasing risk of AD and Alzheimer-type neuropathology up to heavy smoking levels. The lack of association in very heavy smokers may be due to a hardy survivor effect.     

An investigation of beliefs about smoking among diabetes patients: information for improving cessation efforts

The purpose of this study was to identify differences between current smokers and ex-smokers in beliefs about the health effects of smoking. This information will enable educators to design better smoking cessation interventions for diabetes patients. A smoking behavior questionnaire was developed to collect information about demographics, personal lifestyle, and beliefs about smoking and diabetes. Participants were 40 current smokers and 30 ex-smokers located from a patient registry at the University of Virginia Diabetes Research and Training Center. Less than half of the diabetic smokers in the study reported receiving advice to quit from their physician and none of them reported having attended a formal smoking cessation program. Results indicate that demographic and lifestyle variables predict 21% of the variance between smokers and non-smokers in this sample. The group of health belief variables collectively raised the amount of variance that could be accounted for from 21% to 42%. It is recommended that health professionals who provide services to diabetes patients determine present smoking behavior of each diabetes patient, provide firm advice to stop smoking, assess the special circumstances of the smokers, and offer specific smoking cessation programs to meet the unique needs of diabetes patients.     

Triggering anti-smoking advice by GPs: mode of action of an intervention stimulating smoking cessation advice by GPs

OBJECTIVE: To assess the mode of action of an intervention (GP desktop resource, GDR) that increased the frequency of general practitioner (GP) advice to stop smoking. METHODS: Analyses were undertaken to differentiate between three hypotheses regarding the mode of action of the GDR. That the GDR acts: (1) by altering GPs' attitudes, (2) independently of attitudes in prompting GPs to intervene with smokers or (3) by altering the relationship between attitudes and behaviour. RESULTS: The GDR was an independent predictor of the number of patients advised to stop smoking (beta = .345, p < .001). Concern about the doctor-patient relationship was the only attitude variable that independently predicted advice giving, in this case negatively (beta = -.465, p < .001). Possession of the GDR did not alter GPs' views on whether intervening with smokers harmed the doctor-patient relationship, but did weaken the relationship between this attitude item and the number of patients advised to stop smoking (beta = .595, p < .001 for the interaction). CONCLUSION: This study is the first to show that concern over the doctor-patient relationship was an independent predictor of advice giving while in other studies it has merely been noted as something that GPs express concern about. A simple device designed to trigger action on the part of GPs appeared to work by mitigating the negative effect of an attitudinal barrier to action. It would be interesting to explore this phenomenon more generally in relation to health promotion activities on the part of health professionals. PRACTICE IMPLICATIONS: Recommendations that GPs engage in health promotion activities with their patients need to consider that GPs' concerns over harming the doctor-patient relationship may deter them from making such interventions. The GDR appears to be effective in prompting GPs to advise their smoking patients to stop and its widespread distribution to GPs should be considered.     

A randomized controlled trial of the simple advice given by obstetricians in Guangzhou, China, to non-smoking pregnant women to help their husbands quit smoking

This is a randomized controlled trial to examine the effects of obstetrician's simple advice given to non-smoking pregnant women with the aim to help their husbands to give up smoking. Non-smoking pregnant women who were attending the Guangzhou Women and Children Health Care Centre and whose husbands were smokers were each randomised to an intervention (N = 380) or a control (N = 378) group. The members of the intervention group each received simple advice on encouraging their husbands to give up smoking and an educational booklet at their first antenatal visit, and reminders during subsequent visits, whereas the control group received none, as is the usual practice. Husbands' not smoking for 7 and for 30 days were the main outcomes of the study; other outcomes included husbands' attempts to stop and any decrease in the number of cigarettes smoked. These outcomes were assessed by means of a questionnaire responded to in the last month of pregnancy, which was subjected to 'intention-to-treat' analysis. Results show that more husbands in the intervention group had attempted to stop smoking (30.0% versus 22.2%; p = 0.02), reduced the number of cigarettes smoked (39.7% versus 17.7%; p < 0.0001), and had not smoked any cigarettes for the last 7 days before their wives completed the questionnaire (8.4% versus 4.8%; p = 0.04). The difference between groups in the number of husbands who had abstained from cigarettes for at least 30 days was not significant (6.1% versus 4.2%; p = 0.26). Obstetricians should consider incorporating advice on passive smoking into the antenatal programme for non-smoking pregnant women with smoking husbands.     

Efficacy of a tailored tobacco control program on long-term use in a population of U.S. military troops

The authors evaluated the effect of a brief tailored smoking control intervention delivered during basic military training on tobacco use in a population of military personnel (N = 33,215). Participants were randomized to either a tobacco use intervention (smoking cessation, smokeless tobacco use cessation, or prevention depending on tobacco use history) or a health education control condition. Results indicated that smokers who received intervention were 1.16 (95% confidence interval [CI] = 1.04, 1.30) times (7-day point prevalence) and 1.23 (95% CI = 1.07, 1.41) times (continuous abstinence) more likely to be abstinent than controls from smoking cigarettes at the 1-year follow-up (p < .01); the cessation rate difference was 1.60% (31.09% vs. 29.49%) and 1.73% (15.47% vs. 13.74%) for point prevalence and continuous abstinence, respectively. Additionally, smokeless tobacco users were 1.33 (95% CI = 1.08, 1.63) times more likely than controls (p < .01) continuously abstinent at follow-up, an overall cessation rate difference of 5.44% (33.72% vs. 28.28%). The smoking prevention program had no impact on smoking initiation. These results suggest potential for large-scale tobacco control efforts.     

Past quit smoking assistance and doctors' advice for white and African-American smokers.

Data for 473 African-American and white smokers showed that whites were more likely than African Americans to use formal cessation programs to quit smoking, to report that their doctor told them to stop smoking, and to use nicotine replacement therapy. While physicians advised a high proportion of smokers of each race group to quit smoking and were quite aggressive in prescribing nicotine replacement therapy, they were deficient in providing necessary behavioral support to their patients.     

Factors associated with the provision of anti-smoking advice by general practitioners.

The acceptability of advice about smoking in the consultation has recently been questioned. We report a study that explored patients' attitudes to general practitioners' (GPs) anti-smoking advice and the characteristics of patients with whom GPs chose to discuss smoking. Patients who recalled the advice were generally positive about stopping smoking. This could be explained by the observation that GPs were more likely to advise smokers who perceived their problems to be smoking-related and were more motivated to stop smoking. The implications of this finding are discussed.     

A randomised controlled trial of motivational interviewing for smoking cessation

BACKGROUND: Motivational interviewing is a technique used to promote change in addictive behaviour, initially used to treat alcoholism. Despite this, its effectiveness has not been sufficiently demonstrated for giving up smoking. AIM: The aim of the study was to establish whether motivational interviewing, compared with anti-smoking advice, is more effective for giving up the habit. DESIGN OF STUDY: Randomised controlled trial. SETTING: Primary care in Albecete, Spain. METHOD: Random experimental study of 200 smokers assigned to two types of interventions: anti-smoking advice (n = 86) and motivational interviewing (n = 114). Subjects in both groups were offered bupropion when nicotine dependency was high (Fagerstr?m score >7). The success rate was evaluated by intention to treat; point prevalence abstinence was measured 6 and 12 months post intervention by personal testimony, confirmed by means of CO-oximetry (value < 6ppm). RESULTS: The measure of effectiveness of the treatment for giving up smoking after both 6 and 12 months, showed that the motivational interviewing action was 5.2 times higher than anti-smoking advice (18.4 % compared to 3.4%; 95% confidence interval = 1.63 to 17.13). CONCLUSION: The results of our study show that motivational interviewing is more effective than brief advice for giving up smoking.     

Cigarette smoking and Parkinson's disease: a meta-analysis

Many but not all studies have indicated that smoking is inversely associated with Parkinson's disease (PD). Meta-analysis of epidemiological studies on smoking and PD was performed to summarize data from published studies. Fifty-four epidemiological studies (48 case-control and 6 cohort studies, 53 publications) were identified for potential inclusion in meta-analysis. The summary risk estimates for current smokers, former smokers, and ever (current and former) smokers were 0.31 (95% confidence interval (CI) = 0.25-0.38), 0.72 (95% CI = 0.63-0.83) and 0.55 (95% CI = 0.51-0.59), respectively. In stratified analysis by study design, smoking had a somewhat greater impact on PD risk in cohort studies than in case-control studies. However, meta-regression indicated that the study design did not significantly contribute to heterogeneity. Additional analyses were restricted to case-control studies because of the sufficient number of studies. Stratified analysis by ethnicity indicated that the summary OR for ever-smokers was nonsignificantly smaller in Asian populations than in Caucasian populations. In stratified analysis by source of controls, former smoking was significantly associated with a decreased risk of PD in hospital-based case-control studies but was marginally associated with a decreased risk in population-based case-control studies. The source of controls did not contribute significantly to heterogeneity. PD risk associated with ever-smoking was significantly lower for a hospital-based approach than a population-based approach. Among current smokers, the association held true to the same extent for both approaches. This meta-analysis indicated that smokers have a lower risk of PD. As PD is a multifactorial disease, further investigation of the smoking-gene interaction on PD risk may lead to a better understanding of the pathogenesis of PD.