Racial/Ethnic Disparities in the Receipt of Smoking Cessation Interventions During Prenatal Care

To explore racial/ethnic disparities in the receipt of optimal smoking cessation counseling during prenatal care. We used data from Oregon’s perinatal surveillance system, the Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) from 2000 to 2001. A stratified random sample of postpartum women were asked questions about events before, during and after pregnancy, including smoking and provision of smoking cessation counseling. The weighted response rate was 78.8% (n = 3,895). Receipt of a clinician protocol for smoking cessation intervention, called the Five A’s (Ask, Advise, Assess, Assist, Arrange), was the outcome of interest. In the Oregon PRAMS survey, we asked women about three of the Five A’s (Ask, Advise, Assist). Of 594 first trimester pregnant smokers, the majority were asked and advised about smoking by a prenatal care provider. However, a substantial proportion of women did not receive assistance to quit and only 42.2% received all three steps. Significant racial/ethnic variations were found only in the Assist step. Compared to non-Hispanic (NH) White women, NH American Indian women had lower odds (adjusted odds ratio [ORa]: 0.45; 95% confidence interval [95% CI] 0.24, 0.85) of receiving all three steps. In contrast, NH Black women had increased odds of receiving all three steps (ORa: 2.43; 95% CI 1.16, 5.10). We conclude that there is a need for prenatal care providers to address tobacco use, especially to Assist quitting, with all pregnant smokers. Healthcare systems should implement system prompts and supports for providers to remind them to address tobacco use with pregnant smokers.     

Training Physicians to Do Office-based Smoking Cessation Increases Adherence to PHS Guidelines

Cigarette Smoking is the leading cause of preventable mortality and morbidity in the United States. Healthcare providers can contribute significantly to the war against tobacco use; patients advised to quit smoking by their physicians are 1.6 times more likely to quit than patients not receiving physician advice. However, most smokers do not receive this advice when visiting their physicians. The Morehouse School of Medicine Tobacco Control Research Program was undertaken to develop best practices for implementing the ??2000 Public Health Services Clinical Practice Guidelines on Treating Tobacco Use and Dependence?? and the ??Pathways to Freedom?? tobacco cessation program among African American physicians in private practice and healthcare providers at community health centers. Ten focus groups were conducted; 82 healthcare professionals participated. Six major themes were identified as barriers to the provision of smoking cessation services. An intervention was developed based on these results and tested among Georgia community-based physicians. A total of 308 charts were abstracted both pre- and post-intervention. Charts were scored using a system awarding one point for each of the five ??A??s?? recommended by the PHS guidelines (Ask, Advise, Assess, Assist, Arrange) employed during the patient visit. The mean pre-intervention five ??A??s?? score was 1.29 compared to 1.90 post-intervention (P < 0.001). All charts had evidence of the first ??A?? (??asked??) both pre- and post-intervention, and the other four ??A??s?? all had statistically significant increases pre-to post-intervention. Conclusions: The results demonstrate that, with training of physicians, compliance with the PHS tobacco guidelines can be greatly improved.     

Exploring Primary Care Providers’ Interest in Using Patient Navigators to Assist in the Delivery of Tobacco Cessation Treatment to Low Income, Ethnic/Racial Minority Patients

We examined attitudes and practices regarding tobacco cessation interventions of primary care physicians serving low income, minority patients living in urban areas with a high smoking prevalence. We also explored barriers and facilitators to physicians providing smoking cessation counseling to determine the need for and interest in deploying a tobacco-focused patient navigator at community-based primary care practice sites. A self-administered survey was mailed to providers serving Medicaid populations in New York City’s Upper Manhattan and areas of the Bronx. Provider counseling practices were measured by assessing routine delivery (≥80% of the time) of a brief tobacco cessation intervention (i.e., “5 A’s”). Provider attitudes were assessed by a decisional balance scale comprising 10 positive (Pros) and 10 negative (Cons) perceptions of tobacco cessation counseling. Of 254 eligible providers, 105 responded (41%). Providers estimated 22% of their patients currently use tobacco and nearly half speak Spanish. A majority of providers routinely asked about tobacco use (92%) and advised users to quit (82%), whereas fewer assisted in developing a quit plan (32%) or arranged follow-up (21%). Compared to providers reporting <80% adherence to the “5 A’s”, providers reporting ≥80% adherence tended to have similar mean Pros and Cons scores for Ask, Advise, and Assess but higher Pros and lower Cons for Assist and Arrange. Sixty four percent of providers were interested in providing tobacco-related patient navigation services at their practices. Although most providers believe they can help patients quit smoking, they also recognize the potential benefit of having a patient navigator connect their patients with evidence-based cessation services in their community.     

The impact of smoking-cessation intervention by multiple health professionals

BACKGROUND: Smokers have contact with many different types of health professionals. The impact of tobacco intervention by multiple types of heath professionals is not known. METHODS AND MATERIALS: As part of the 2003 Minnesota Adult Tobacco Survey, smokers (n=1723) reported on tobacco treatment by medical doctors, nurses, dentists, pharmacists, or other health professionals. This analysis examined: (1) smokers' report of tobacco intervention by different types of healthcare providers, (2) the proportion of smokers who report intervention by multiple provider types, and (3) the relationship between smokers' report of intervention by multiple provider types and readiness to quit, quit attempts, and recent quitting. RESULTS: Among past-year smokers, 65% had visits with two or more types of health professionals. Among smokers who visited health professionals (n=1523), only 34% reported being asked about smoking by two or more types of professionals. Among current smokers (n=1324), advice or assistance from more than one type of professional was uncommon (26% and 7%, respectively). Being asked about smoking by two or more types of professionals substantially increased the odds of recent quitting (OR=2.37; 95% CI=1.15-4.88). Among current smokers, being advised to quit by two or more types of professionals increased the odds of having made a quit attempt in the past year (OR=2.92; 95% CI=1.56-5.45) or intending to quit in the next 6 months (OR=2.17; 95% CI=1.10-4.29). CONCLUSIONS: Smoking-cessation interventions by more than one type of health professional have the potential to substantially increase quitting and readiness to quit in the population.     

Survey of Tobacco Control Among Florida Dentists

Cigarette smoking contributes to the largest number of preventable deaths with a recent report estimating that nearly 5 million annual deaths worldwide and 400,000 in the United States were attributed to cigarette smoking. Dentists, in particular, are in a unique position to educate their patients about the health effects of tobacco. Tobacco cessation knowledge, behaviors, and compliance of Florida dentists were assessed using survey methodology. The survey was administered to a random sample of 6,000 dentists, which was provided by the Florida Department of Health. The survey inquired about (1) general demographic information, (2) Ask, Advise, Assess, Assist, and Arrange behaviors, (3) barriers to the incorporation of tobacco cessation activities, and (4) willingness to participate in further training. A large majority of dentists (88%) are not familiar with the concept of the Ask, Advise, Assess, Assist, and Arrange behaviors when asked directly. When asked about each individual component of this approach, however, dentists had much higher response rates. Dentists were best at routinely asking (59%), advising (46%), & assessing (32%) their patients about their smoking. However, they were much less helpful when assisting and arranging follow-up (70% stated that they never arrange follow-up). This study discovered that the majority of dentists who counsel patients spend only 1?C4 min. Sixty-six percent of the dentists surveyed were willing to receive specific training, with 50% preferring an online course and 42% preferring a continued education course.     

Smoking, smoking cessation, and use of smoking cessation aids and support services in South Derbyshire, England

OBJECTIVES: To describe smoking behaviour, motivation to quit and quit rates, and the effect of advice and support for smoking cessation among smokers from more and less disadvantaged socio-economic groups in South Derbyshire, a mixed urban and rural area of central England. STUDY DESIGN: Cross-sectional study. METHODS: A cross-sectional study with a random, stratified sample of people aged 25-44 years and people aged 65-74 years with over-sampling of populations living in disadvantaged areas. Main outcome measures included the proportion of smokers wishing to quit and quitting in the last year; reported advice to quit from family and friends and health professionals; and awareness and use of NHS smoking-cessation services. RESULTS: Over half of smokers aged 25-44 years, about one-third of women smokers and 40% of male smokers aged 65-74 years wished to quit. This varied little by socio-economic status. Quit rates were generally lower among smokers of lower socio-economic status (SES), especially among people aged 25-44 years. Smokers of lower SES reported slightly less advice to quit from family and friends, and more so from health professionals. Awareness and use of cessation services was about 30% and 5%, respectively, among smokers and recent quitters. Awareness varied little but accessing services was generally higher among smokers of lower SES. CONCLUSIONS: Despite evidence that health professionals and cessation services were targeting smokers with lower SES and of similar motivation to quit, quit rates were lower. Broader tobacco control interventions targeting the social and environmental contexts that create and maintain socio-economic differentials in smoking are required.     

Physician-delivered advice to quit smoking among Italian smokers

OBJECTIVE: A clinical practice guideline for smoking cessation was released in Italy in 2002, but to date little is known about the implementation of these recommendations among primary care physicians. The objectives of this study were to estimate the prevalence of receiving physician-delivered advice to quit smoking and to determine what factors were related to the receipt of advice among adult Italian smokers. METHODS: The data were collected as part of the Italian 2004-2006 adult tobacco surveys (analyzed in 2007), conducted by DOXA, the Italian branch of the Gallup International Association, and representative of the population aged>or=18 years. Each year smokers were asked whether they had received advice to quit smoking from their family physician during the previous year. Demographic, socioeconomic, tobacco-related, and physician-related variables were examined for their association with the receipt of advice. A logistic regression model was then fit to the data to determine which variables were related to receiving advice to quit smoking. RESULTS: Overall, 22% of smokers reported receiving advice to quit smoking from their physician in the previous year. Less likely to receive advice to quit were smokers who: were single (compared to divorced, widowed, or separated); lived in the South; had a higher level of education; were lighter smokers; had no previous quit attempts; and had physicians who likely smoked. CONCLUSIONS: The data suggest that Italian physicians are not advising smokers to quit at a high rate. Future research should focus on methods that encourage physicians to counsel smokers to quit during a patient-provider encounter.     

Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey

BACKGROUND: Recent national surveys document racial and ethnic disparities in receipt of smoking-cessation advice. This study updates and expands prior analyses using survey data for 2005, and evaluates the association between smokers' race and ethnicity and three separate measures of healthcare-encounter-based tobacco interventions: screening, smoking-cessation advice, and use of smoking-cessation aids. METHODS: Analyses are based on 4756 smokers (aged 18 and older) reporting a healthcare encounter within the past year who participated in the 2005 National Health Interview Survey (NHIS). Multivariate-adjusted OR and 95% CI for receipt of tobacco interventions in non-Hispanic black and Hispanic smokers were compared to those of non-Hispanic white smokers, adjusted for smokers' characteristics (sociodemographics, health status, and healthcare-utilization factors, and smoking-related characteristics). Analyses were done in 2006. RESULTS: Results show that compared to white smokers, black and Hispanic smokers had significantly lower odds of (1) being asked about tobacco use (AOR=0.70 and AOR=0.69, respectively); (2) being advised to quit (AOR=0.72 and AOR=0.64, respectively); or (3) having used tobacco-cessation aids during the past year in a quit attempt (AOR=0.60 and AOR=0.59, respectively). Compared to 2000 NHIS published data, the prevalence of receipt of advice to quit from a healthcare provider increased from 52.9% in 2000 to 61.2% in 2005, with increases across racial and ethnic groups. CONCLUSIONS: Despite progress in smokers' being advised to quit during healthcare encounters in the past 5 years, black and Hispanic smokers continue to be less likely than whites to receive and use tobacco-cessation interventions, even after control for socioeconomic and healthcare factors. Further actions are needed to understand and eliminate this disparity.     

Comparing prenatal providers' approaches to four different risks: alcohol, tobacco, drugs, and domestic violence

OBJECTIVE: We explored prenatal care providers' methods for addressing four behavioral risks in their pregnant patients: alcohol use, smoking, drug use, and domestic violence. DESIGN: We used qualitative, purposively sampled, focus group data. SETTING: Groups met in professional focus group settings. PARTICIPANTS: We conducted six focus groups (five with OB/Gyn physicians, one with nurse practitioners and certified nurse midwives), with a total of N = 49. MEASUREMENTS: The moderator used a focus group guide with open-ended questions, with probes where appropriate. FINDINGS: Providers' discussions reflected differences in how they approach each risk, including: (1) ambivalence about abstinence messages for alcohol; (2) relative comfort and confidence about assessing smoking and counseling to reduce smoking; (3) disparities across practice settings for toxicology screening for drugs; and (4) discomfort and pessimism with domestic violence. Investigators also analyzed providers' statements for each risk within the framework of the "Five A's" construct (Assess, Advise, Agree, Assist, and Arrange) for evaluating risk behavior interventions. CONCLUSIONS: A comparison of each risk across the Five A's illuminates the gaps between recommended and actual prevention methods and suggests directions for development of interventions and educational efforts.     

Factors associated with Taiwanese junior high school personnel advising students to quit smoking

BACKGROUND: Most smokers in developing countries begin smoking before age 18, and smoking prevalence is rising among adolescents. School personnel represent a target group for tobacco‐control efforts because they interact daily with students, are role models for students, teach about tobacco‐use prevention in school curricula, and implement school tobacco‐control policies. The prevalence of teenage smoking has been examined in numerous studies, but few have focused on the influence of school personnel and the characteristics of school personnel who enforce school nonsmoking policy. The purpose of this study was to determine the factors associated with junior high school personnel advising students to quit smoking. METHODS: School personnel (N = 7129) were recruited by cluster sampling from 60 junior high schools in Taiwan; of these, 5280 voluntarily returned self‐administered, anonymous questionnaires (response rate = 74.06%) in 2004. RESULTS: Most personnel (70%) had advised students to quit smoking. School personnel who were older, male, responsible for teaching health, smokers, with positive attitude against tobacco, or with more knowledge of tobacco hazards were more likely to advise students to quit smoking. Personnel with more interest in and access to tobacco‐related materials were more likely to advise students to quit smoking. Personnel who had received tobacco‐prevention training were 2.41 times more likely to persuade students to quit smoking after adjusting for other factors. However, only half of the participants had ever had access to educational materials about tobacco use, and 8% had ever received training to prevent tobacco use. CONCLUSIONS: To reduce youth smoking prevalence, school tobacco‐control programs should support tobacco‐prevention training for school personnel.     

Cancer prevention in primary care: predictors of patient counseling across four risk behaviors over 24 months

OBJECTIVE: Rates of preventive counseling remain below national guidelines. We explored physician and patient predictors of preventive counseling across multiple cancer risk behaviors in at-risk primary care patients. METHODS: We surveyed 3557 patients, with at least one of four cancer risk behaviors: smoking, diet, sun exposure, and/or mammography screening, at baseline and 24 months. Patients reported receipt of 4A's (Ask, Advise, Assist, Arrange follow-up); responses were weighted and combined to reflect more thorough counseling (Ask=1, Advise=2, Assist=3, Arrange=4, score range 0-10) for each target behavior. A series of linear-regression models, controlling for office clustering, examined patient, physician and other situational predictors at 24 months. RESULTS: Risk behavior topics were brought up more often for mammography (90%) and smoking (79%) than diet (56%) and sun protection (30%). Assisting and Arranging follow-up were reported at low frequencies across all behaviors. More thorough counseling for all behaviors was associated with multiple visits and higher satisfaction with care. Prior counseling predicted further counseling on all behaviors except smoking, which was already at high levels. Other predictors varied by risk behavior. CONCLUSIONS: More thorough risk behavior counseling can be delivered opportunistically across multiple visits; doing so is associated with more satisfaction with care.     

Statewide evaluation of a tobacco cessation curriculum for pharmacy students

BACKGROUND: Previous studies suggest that healthcare professionals are inadequately trained to treat tobacco use and dependence. Because even brief interventions from clinicians improve patient quit rates, widespread implementation of effective tobacco cessation training programs for health professional students is needed. METHODS: Pharmacy students received 7-8 h of comprehensive tobacco cessation training. Participants completed pre- and post-program surveys assessing perceived overall abilities for cessation counseling, skills for key facets of cessation counseling (Ask, Advise, Assess, Assist, Arrange), and self-efficacy for counseling. RESULTS: A total of 493 students (82.3%) completed linkable pre- and post-training evaluations. Self-reported abilities, measured on a five-point scale, increased significantly from 1.89 +/- 0.89 to 3.53 +/- 0.72 (P < 0.001). Twenty-two percent of students rated their overall counseling abilities as good, very good, or excellent before the training versus 94% of students after the training. Eighty-seven percent of students indicated the training will increase the number of patients that they counsel; 97% believed it will increase the quality of their cessation counseling. CONCLUSIONS: Comprehensive training significantly improved pharmacy students' perceived confidence and ability to provide tobacco cessation counseling. The curriculum is applicable to other health professional training programs and currently is being used to train pharmacy, medical, nursing, and dental students.     

Tobacco use patterns and attitudes among teens being seen for routine primary care

PURPOSE: To describe the tobacco-related attitudes, behaviors, and needs of smoking and nonsmoking teens being seen for routine pediatric care and to identify predictors of tobacco use. DESIGN: Cross-sectional survey of adolescent primary care patients who completed self-administered questionnaires in medical office waiting rooms while waiting for routine care visits. SETTING: A group-practice HMO in the Pacific Northwest. SUBJECTS: A sample of 2526 teenagers, ages 14 to 17, who consented to receive health promotion interventions as a part of a randomized trial in seven pediatric and family practice offices. MEASURES: A 38-item questionnaire assessed tobacco use history, attitudes, quit attempts, and stage of acquisition or cessation along with gender, age, race/ethnicity, body mass index, educational plans, frequency of exercise, attempts to lose weight, and depressed mood. RESULTS: Sixty-seven percent of teens approached (2526 of 3747) consented to complete a questionnaire and receive tobacco- or diet-related interventions as a part of their medical visit. About 23% of teen patients reported smoking at least one cigarette in the last month, although only 14% described themselves as current "smokers." Most current smokers (84%) smoked at least 20 days in the last month. Logistic regression predictors of smoking included older age, Native American ethnicity, lower educational aspirations, lower body mass index, smoking among half or more friends, smokers at home, and a positive depression screen. Among ever-regular smokers, most were in the action (28%), preparation (21%), or contemplation (22%) readiness to quit smoking stages, and 77% of current smokers had made one or more serious quit attempts in the last year. CONCLUSIONS: Most teens in these medical facilities consented to receive tobacco and diet interventions, and most self-described current smokers were contemplating or preparing to quit. Medical visits provide attractive opportunities for tobacco intervention, but messages should be tailored based on the patient's tobacco status and stage of acquisition or cessation.     

Physician advice about smoking and drinking: are U.S. adults being informed?

BACKGROUND: Population-based estimates for the prevalence of smokers receiving advice from a health professional to quit smoking and the prevalence of binge drinkers being talked to about alcohol use are lacking for U.S. adults. This information is useful for clinicians and public health professionals. METHODS: Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digit-dial telephone survey of U.S. adults. In 1997, 10 states collected data on these health interventions for tobacco and alcohol use. The prevalence of professional advice to quit smoking and about alcohol use was calculated and examined by demographic characteristics. The number of at-risk adults who had a routine checkup in the last year and had not received these interventions was also estimated. RESULTS: By self-report, 70% of smokers were advised to quit, and 23% of binge drinkers were talked to about their alcohol use. Using multivariate logistic regression analyses, we found among smokers that women and older persons were more likely to receive advice; among binge drinkers, health intervention was more likely to occur for men and non-Hispanic blacks. Across the 10 states, approximately 2 million smokers and 2 million binge drinkers with a routine checkup in the past 12 months were not advised to quit smoking or talked to about their alcohol use. CONCLUSIONS: Many opportunities to intervene with smokers and binge drinkers are lost. Efforts to increase physician education and to identify and reduce other barriers may help.     

Smoking patterns and use of cessation interventions during pregnancy

BACKGROUND: Pregnant smokers should be counseled to quit smoking and offered effective cessation interventions. To improve understanding of how best to increase smoking-cessation rates during pregnancy, this study analyzed population-based surveillance data to describe women's smoking patterns and the use of cessation services during pregnancy. METHODS: Data were analyzed from the 2004 and 2005 New Jersey Pregnancy Risk Assessment Monitoring System, a population-based survey of postpartum women (n=4473). Measures of behaviors included the timing of quit relative to the learning of pregnancy, provider assistance, the use of cessation interventions, and barriers to quitting. Analyses were done in 2007 and 2008. RESULTS: An estimated 16.2% (95% CI=15.1, 17.3) of women smoked before pregnancy. Of these, 49.8% quit before entering prenatal care, and 5.2% quit after entering prenatal care. Almost all women reported that their prenatal care provider asked if they smoked, but only 56.7% reported that a provider counseled them to quit smoking. Only 11.5% of women who smoked in late pregnancy used a cessation method, including self-help materials (6.3%); medications (3.9%); face-to-face counseling (1.7%); telephone-based counseling (1.5%); Internet-based counseling (1.3%); and a class or program (1.0%). The most frequently reported barriers to quitting were cravings for a cigarette, stress, and being around people who smoked. CONCLUSIONS: Nearly half of pregnant New Jersey smokers quit before prenatal care, and very few quit later. Few continuing smokers used a smoking-cessation method when trying to quit or cut back. Efforts should be intensified to increase the knowledge, promotion, and referral to effective interventions to help pregnant smokers quit.     

简短戒烟干预在北京市各级综合医院门诊应用的效果

目的评价简短戒烟干预技术在北京市各级综合医院门诊应用的效果。方法方便抽取北京市一级、二级、三级综合医院各1家,在一级医院全科及中医科门诊、二级和三级医院呼吸内科门诊开展为期4周的研究,期间所有门诊患者为调查对象。在门诊后1周内,对现在吸烟患者采用电话调查形式进行随访,了解简短戒烟干预技术的应用效果。结果研究共调查门诊患者2460人,其中278人现在吸烟,占11．3％。门诊后1周内成功随访了122名现在吸烟患者,成功随访率43．9％。成功随访者中14．8％的现在吸烟患者因1次简短戒烟干预发生戒烟意愿的正向改变,且具有统计学意义（z=3．551,P〈0．01）。其中,三级医院的此种改变有统计学意义（Z=3．035,P〈0．01）。有戒烟服务需求的门诊患者简短戒烟干预前后戒烟意愿的改变有统计学意义（Z=3．420,P〈0．01）。结论综合医院门诊应用简短戒烟干预技术有效果,三级医院干预效果更好。对有戒烟服务需求的门诊患者实施简短戒烟干预,效果更好。     

甘肃省15～69岁现在吸烟者戒烟意愿及影响因素

  目的  了解甘肃省现在吸烟者的戒烟意愿以及影响因素,为烟草防控工作提供科学依据。  方法  采用多阶段抽样方法,随机抽取15~69岁现在吸烟者作为调查对象。采用《全国居民吸烟情况调查问卷》开展面对面调查,分析不同特征现在吸烟者的戒烟意愿,采用Logistic回归分析模型分析现在吸烟者戒烟意愿的影响因素。  结果  甘肃省现在吸烟者的戒烟意愿为16.4%（95%CI:15.5%~17.3%）,农村地区（OR=1.199,95%CI:1.022~1.408,P=0.026）、家中禁止吸烟（OR=1.767,95%CI:1.273~2.454,P=0.001）、12个月内就医时医务人员劝阻吸烟（OR=1.599,95%CI:1.359~1.842,P < 0.001）、去过戒烟门诊（OR=3.089,95%CI:2.031~4.698,P < 0.001）、初中、高中、大专及以上文化程度（OR=1.383,95%CI:1.101~1.736;OR=1.627,95%CI:1.252~2.116;OR=1.374,95%CI:1.009~1.873,均有P < 0.05）、高烟草危害知识得分为1~,3~,5~6（OR=1.248,95%CI:1.030~1.514;OR=1.574,95%CI:1.289~1.922;OR=2.288,95%CI:1.879~2.786,均有P < 0.05）是现在吸烟者戒烟意愿的促进因素;年龄20~、30~岁组以及烟龄20~、30~年是现在吸烟者戒烟意愿的阻碍因素。  结论  甘肃省现在吸烟者戒烟意愿总体不高,今后应进一步在全社会普及烟草危害知识,加强医务人员戒烟服务能力培训,在诊疗过程中开展戒烟服务,同时应鼓励和支持医疗机构加快戒烟门诊建设。