Alessandra Kazura

Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders

Objective:To test the hypothesis that among adolescent smokers hospitalised for psychiatric and substance use disorders, motivational interviewing (MI) would lead to more and longer quit attempts, reduced smoking, and more abstinence from smoking over a 12 month follow up. Design:Randomised control trial of MI versus brief advice (BA) for smoking cessation, with pre- and post-intervention assessment of self efficacy and intentions to change, and smoking outcome variables assessed at one, three, six, nine, and 12 month follow ups. Setting:A private, university affiliated psychiatric hospital in Providence, Rhode Island, USA. Patients or other participants:Consecutive sample (n = 191) of 13–17 year olds, admitted for psychiatric hospitalisation, who smoked at least one cigarette per week for the past four weeks, had access to a telephone, and did not meet DSM-IV criteria for current psychotic disorder. Interventions:MI versus BA. MI consisted of two, 45 minute individual sessions, while BA consisted of 5–10 minutes of advice and information on how to quit smoking. Eligible participants in both conditions were offered an eight week regimen of transdermal nicotine patch upon hospital discharge. Main outcome measures:Point prevalence abstinence, quit attempts, changes in smoking rate and longest quit attempt. Proximal outcomes included intent to change smoking behaviour (upon hospital discharge), and self efficacy for smoking cessation. Results:MI did not lead to better smoking outcomes compared to BA. MI was more effective than BA for increasing self efficacy regarding ability to quit smoking. A significant interaction of treatment with baseline intention to quit smoking was also found. MI was more effective than BA for adolescents with little or no intention to change their smoking, but was actually less effective for adolescents with pre-existing intention to cut down or quit smoking. However, the effects on these variables were relatively modest and only moderately related to outcome. Adolescents with comorbid substance use disorders smoked more during follow up while those with anxiety disorders smoked less and were more likely to be abstinent. Conclusions:The positive effect of MI on self efficacy for quitting and the increase in intention to change in those with initially low levels of intentions suggest the benefits of such an intervention. However, the effects on these variables were relatively modest and only moderately related to outcome. The lack of overall effect of MI on smoking cessation outcomes suggests the need to further enhance and intensify this type of treatment approach for adolescent smokers with psychiatric comorbidity.

An academic detailing intervention to disseminate physician-delivered smoking cessation counseling: smoking cessation outcomes of the Physicians Counseling Smokers Project.

BACKGROUND Little is known about the effectiveness of interventions to disseminate smoking cessation interventions among a population of primary care physicians. This studys objective was to determine the effect of a community-based academic detailing intervention on the quit rates of a population-based sample of smokers. METHODS This community-based, quasi-experimental study involved representative samples of 259 primary care physicians and 4295 adult smokers. An academic detailing intervention was delivered to physicians in intervention areas over a period of 15 months. Analyses were performed on the data from the 2346 subjects who reported at least one physician visit over 24 months. Multivariate regression analyses were conducted to determine the impact of the intervention on self-reported smoking quit rates, reported by adjusted odds ratios. RESULTS Among smokers reporting a physician visit during the study period, there was a borderline significant effect for those residing in intervention areas versus control areas (OR = 1.35; 95% CI.99-1.83; P = 0.057). Among a subgroup of 819 smokers who reported a visit with an enrolled physician, we observed a significant effect for those residing in intervention areas (OR = 1.80; 95% CI 1.16-2.75; P = 0.008). CONCLUSION An academic detailing intervention to enhance physician delivered smoking cessation counseling is an effective strategy for disseminating smoking cessation interventions among community-based practices.

Dissemination of the AHCPR clinical practice guideline in community health centres

Objective: To evaluate dissemination of the Agency for Health Care Policy and Research (AHCPR) Smoking cessation clinical practice guideline in community health centres. Design: Pre- and post-trial. Setting: Fourteen community health centres in Rhode Island. Subjects: Provider performance was assessed with 1798 and 1591 patient contacts, in pre-post cross sectional consecutive samples, respectively, and 891 contacts at one year follow up. Interventions: Three, one hour on-site provider training sessions, on review of effective tobacco interventions, use of office systems, and tobacco counselling skill building. Outcome measures: Chart documentation of four A’s (Ask, Advise, Assist, and Arrange follow up) at most recent primary care visit. Results: While average performance rates increased for Ask and Advise (from 30% to 44%, and 19% to 26%, pre-post, respectively), significant increases were found only for some visit types, with further differences by patient sex. There were significant increases for Ask for all except obstetric/gynaecological (ob/gyn) visit types. Patients at yearly physicals and first visits were more likely to be asked at all time points, while males were more likely to be asked at acute visits than were females. There were no significant increases for Advise, Assist, and Arrange across time, although female patients showed a differential increase in Advise post-training. Advise was significantly more likely in yearly physicals and first visits, and less likely in ob/gyn visits, at all time points. Conclusions: This guideline dissemination effort resulted in quite different provider counselling rates across patient sexes, and visit types. Guideline implementation may require more sustained efforts, with multiple strategies, which are reinforced at higher policy levels, to more fully integrate tobacco interventions into routine primary care practice with all patients who smoke.

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 4As (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.

HIV-Risk Behaviors Among Psychiatrically Hospitalized Adolescents With and Without Comorbid SUD

ABSTRACT Objective: The purpose of this study was to examine HIV-risk behaviors among a sample of psychiatric inpatient adolescents with and without comorbid SUD. Method: 239 adolescents (60.7% female; mean age = 15.3) were interviewed while hospitalized in a psychiatric inpatient treatment facility. Adolescents with and without substance use disorder (SUD) were compared on a number of HIV-risk behaviors and the association between HIV-risk behaviors and other types of mental health problems were examined. Results: Compared to those without SUD, adolescents with SUD, after controlling for age, gender, and other psychiatric disorders, were at an increased risk for being currently sexually active (AOR = 2.01, CI = 1.00–4.04, p < .05) and for having used alcohol or drugs prior to last sexual intercourse (AOR = 5.48, CI = 1.91–15.72, p < .01). HIV-risk behaviors were more evident among adolescents with externalizing disorders and those with higher levels of self-reported distress. Conclusion: Adolescents in psychiatric settings, especially those with substance use disorders and/or externalizing problems, are an important population for whom prevention efforts are needed to reduce the risk of HIV infection.

Medical marijuana and teens: does an adjective make a difference?

t t b a i t p c n a i t i h c n a I n the featured article, Salomonsen-Sautel et al. assessed the prevalence and frequency of diverted medical marijuana use in a sample of adolescents recruited for a genetics study at two substance-abuse treatment programs in metropolitan Denver, Colorado. The study idea was stimulated by clinical reports that adolescents were using diverted medical marijuana. Using a simple but scientifically sound design for their study, the investigators hoped to shed light on a potential new threat to adolescent health in a state that was in the first wave to legalize dispensation of marijuana to individuals who registered for medical use after recommendation from a physician. Although their exploratory study has acknowledged limitations, it rises above anecdotal evidence by using a well-defined sample, systematic questioning about medical marijuana experience and risk perception, and assessment of mental health symptoms and disorders with standardized measurements. In the tradition of many important public health discoveries, the investigators made good use of an existing research opportunity to better understand and inform observations made in the treatment setting. For centuries, humans have discovered and used plants for healing, and marijuana is no exception. Documentation of marijuana use for medical conditions occurs as far back in history as 2700 b.c. in China. Use in England increased in the mid1800s after the dissemination of observations of its analgesic and other useful properties by a British physician practicing in India. In the past few decades, assertions of benefits from medical marijuana have increased, and the list includes a wide range of conditions, such as pain control, nausea and vomiting, glaucoma, seizures, premenstrual symptoms, inflammatory bowel disease, arthritis, asthma, dementia, and more. Given that consumer safety in the United States has been supported for decades by the w