Catherine J. Segan

The potential of quitlines to increase smoking cessation

Quitlines are increasingly becoming a core smoking cessation resource. This paper canvasses the potential of quitlines and briefly reviews the evidence for their utility. Quitlines can be an effective means of helping smokers quit. They can provide a triage service helping to direct smokers to the most appropriate assistance, and they can provide cessation help, either one-off sessions or systematic programmes of call-back counselling. Quitlines have features that uniquely place them to provide effective, accessible and affordable cessation help to large numbers and they can be modified readily to meet the needs of groups with special needs, including the capacity to act as part of co-ordinated care with face-to-face services. Quitlines are likely to become an even more important part of tobacco control infrastructure over the next few years.

In-practice management versus quitline referral for enhancing smoking cessation in general practice: a cluster randomized trial

BACKGROUND AND OBJECTIVE GPs are an important source of smoking cessation advice. This research examined whether a model encouraging GP referral of patients who smoke to a specialist service would be acceptable and effective for increased smoking cessation when compared with a model of in-practice management. METHODS The study design was cluster randomized controlled trial. Practices were randomized to one of two interventions, at a rate of 1:2: (i) standard in-practice GP management or (ii) referral to a quitline service. The main outcome measures were sustained abstinence of >or=1 month duration at 3-month follow-up and >or=10 months duration at 12 months, using intention to treat analysis. RESULTS At 3-month follow-up, patients in the referral condition were twice as likely to report sustained abstinence than those in the in-practice condition [12.3% compared with 6.9%; odds ratio (OR) = 1.92 (95% confidence interval (CI) 1.17-3.13]. At 12-month follow-up, patients in the referral condition had nearly three times the odds of sustained abstinence [6.5% compared with 2.6%; OR = 2.86 (95% CI 0.94-8.71)]. The intervention effect was mediated by the amount of help received outside the practice. CONCLUSIONS This research provided evidence that GPs referring smokers to an evidence-based quitline service results in increased cessation. The benefit is largely due to patients in the referral condition receiving more external help than patients in the in-practice condition, as they received equivalent practice-based help. Where suitable services exist, we recommend that referral become the normative strategy for management of smoking cessation in general practice to complement any practice-based help provided.

Do Transtheoretical Model Measures Predict the Transition from Preparation to Action in Smoking Cessation

This study tested the predictive value of the Transtheoretical Model (TTM) for the preparation to action stage transition by conducting a detailed examination of changes in TTM components in the days leading up to, and following, a planned quit attempt. Participants were 193 callers to a Quitline telephone service. Only limited support for the TTM was found. Consistent with the TTM, measures of self-efficacy were related to making an attempt and to achieving 7 + days of abstinence. Contrary to the TTM, the behavioral change processes were unrelated to making quit attempts and to short-term abstinence, with the exception of self-liberation, which is conceptually related to self-efficacy. New non-TTM measures assessing commitment to quitting were predictive of outcomes. The results provide strong support for the preparation to action transition being discontinuous, and thus consistent with a stage model. However, they bring into question many of the other postulates of the TTM. Further critical testing and evaluation of the TTM is required.

A systematic review of barriers and facilitators to participation in randomized controlled trials by Indigenous people from New Zealand, Australia, Canada and the United States

Issue: Many randomized controlled trials (RCTs) are conducted each year but only a small proportion is specifically designed for Indigenous people. In this review we consider the challenges of participation in RCTs for Indigenous peoples from New Zealand, Australia, Canada and the United States and the opportunities for increasing participation. Approach: The literature was systematically searched for published articles including information on the barriers and facilitators for Indigenous people’s participation in health-related RCTs. Articles were identified using a key word search of electronic databases (Scopus, Medline and EMBASE). To be included, papers had to include in their published work at least one aspect of their RCT that was either a barrier and/or facilitator for participation identified from, for example, design of intervention, or discussion sections of articles. Articles that were reviews, discussions, opinion pieces or rationale/methodology were excluded. Results were analysed inductively, allowing themes to emerge from the data. Key findings: Facilitators enabling Indigenous people’s participation in RCTs included relationship and partnership building, employing Indigenous staff, drawing on Indigenous knowledge models, targeted recruitment techniques and adapting study material. Challenges for participation included both participant-level factors (such as a distrust of research) and RCT-level factors (including inadequately addressing likely participant barriers (phone availability, travel costs), and a lack of recognition or incorporation of Indigenous knowledge systems. Implication: The findings from our review add to the body of knowledge on elimination of health disparities, by identifying effective and practical strategies for conducting and engaging Indigenous peoples with RCTs. Future trials that seek to benefit Indigenous peoples should actively involve Indigenous research partners, and respect and draw on pertinent Indigenous knowledge and values. This review has the potential to assist in the design of such studies.

Testing the Transtheoretical Model for Smoking Change: Victorian Data

Abstract The transtheoretical model (TTM) is an important theory of behaviour change, and one that has been applied extensively to smoking cessation. This paper explores the internal validity of the model by exploring relationships between key TTM variables across four of its proposed stages of change. It utilises a community sample of 304 smokers and recent quitters. Respondents were administered the short-form of the TTM inventory, which included measures of stage of change, pros and cons of smoking, 3 temptation subscales, and the 10 processes of change scales. The results generally replicate earlier findings and extend them by demonstrating predicted declines in the processes of consciousness raising and self re-evaluation from preparation to action. The results indicate problems with (at least) the measurement of social liberation, dramatic relief, and helping relationships, and validate changes to item wording introduced for consciousness raising and reinforcement management. It is concluded that, w...

Effect of a Family-Centered, Secondhand Smoke Intervention to Reduce Respiratory Illness in Indigenous Infants in Australia and New Zealand: A Randomized Controlled Trial

Introduction: Secondhand smoke (SHS) is a significant cause of acute respiratory illness (ARI) and 5 times more common in indigenous children. A single-blind randomized trial was undertaken to determine the efficacy of a family centered SHS intervention to reduce ARI in indigenous infants in Australia and New Zealand. Methods: Indigenous mothers/infants from homes with ≥1 smoker were randomized to a SHS intervention involving 3 home visits in the first 3 months of the infants’ lives (plus usual care) or usual care. The primary outcome was number of ARI-related visits to a health provider in the first year of life. Secondary outcomes, assessed at 4 and 12 months of age, included ARI hospitalization rates and mothers’ report of infants’ SHS exposure (validated by urinary cotinine/creatinine ratios [CCRs]), smoking restrictions, and smoking cessation. Results: Two hundred and ninety-three mother/infant dyads were randomized and followed up. Three quarters of mothers smoked during pregnancy and two thirds were smoking at baseline (as were their partners), with no change for more than 12 months. Reported infant exposure to SHS was low (≥95% had smoke-free homes/cars). Infant CCRs were higher if one or both parents were smokers and if mothers breast fed their infants. There was no effect of the intervention on ARI events [471 intervention vs. 438 usual care (reference); incidence rate ratio = 1.10, 95% confidence intervals (CI) = 0.88–1.37, p = .40]. Conclusions: Despite reporting smoke-free homes/cars, mothers and their partners continue to smoke in the first year of infants’ lives, exposing them to SHS. Emphasis needs to be placed on supporting parents to stop smoking preconception, during pregnancy, and postnatal.

Reducing Smoking Among indigenous Populations: New evidence From a Review of Trials

INTRODUCTION Previous reviews have concluded that to be effective, evidence-based tobacco control interventions should be culturally adapted to indigenous populations. We undertook a systematic review to critically examine this hitherto conclusion. METHODS We searched MEDLINE, PsychInfo, EMBASE, and Cochrane databases from 1980 to May 2012 for controlled trials. We included studies that recruited nonindigenous and indigenous participants to assess differences in impact of nonadapted interventions across ethnic groups and whether adapted interventions are more effective for indigenous participants. RESULTS Five studies were included. Three tested the effectiveness of enhanced Quitline protocols with cessation products over usual Quitline care, and two trialed a culturally adapted cessation counseling intervention using mobile phones. Three studies did not demonstrate a significant effect of the intervention for both indigenous and nonindigenous participants; two were pharmacotherapy studies using nicotine replacement therapy and the third was a trial of a multimedia phone intervention. The fourth study found a significant effect of a behavioral intervention using text messaging for indigenous and nonindigenous participants. The final study found a significant effect in favor of very low nicotine cigarettes compared with usual care; results were similar across ethnic groups. DISCUSSION There is likely no significant difference between indigenous and nonindigenous populations regarding the efficacy of smoking cessation products, and we provide some promising evidence on the efficacy of behavioral interventions delivered via mobile phone technology. We demonstrate that not all tobacco control interventions can or necessarily need to be culturally adapted for indigenous populations although there are circumstances when this is important.

Does extended telephone callback counselling prevent smoking relapse

This randomized controlled trial tested whether extended callback counselling that proactively engaged ex-smokers with the task of embracing a smoke-free lifestyle (four to six calls delivered 1-3 months after quitting, i.e. when craving levels and perceived need for help had declined) could reduce relapse compared with a revised version of Quitlines standard service (four calls in the first month after quitting which focused primarily on the task of helping ex-smokers deal with daily cravings and now also systematically alerted clients to the upcoming task of adapting to life as a non-smoker). One thousand and four hundred and forty-four smokers or recent ex-smokers were randomized at recruitment: 734 usual care and 710 intervention. An inclusion criterion of subsequently quitting for at least 1 week gave 346 usual care and 352 intervention participants. Seventy-four per cent of intervention participants accepted extra calls and received 4.3 on average but only 1.7 more post-quitting calls than usual care group. No significant differences were found between extended contact and usual care groups on continuous abstinence (both 27% at 12 months) or any other cessation outcome. The tasks of quitting framework introduced in preparation for the trial might have contributed to service improvement in relapse prevention (10% increased quit rate compared with an earlier trial). However, the extra sessions did not provide any benefit.

Development and evaluation of a brochure on sun protection and sun exposure for tourists

Holidays in the sun have been identified as a risk factor for the development of melanoma. This paper describes the development and evaluation of a brochure designed to reduce sun exposure in tourists travelling to high-risk destinations. The tourists came from an area where there are strong social norms for sun protection, so the focus of the brochure was to highlight the extra risks associated with their destination, ie the higher ambient levels of ultraviolet radiation (UVR) closer to the equator. The effectiveness of the brochure was tested using a randomised controlled trial (n=373). Results suggest that the brochure was appreciated, and that those who received the brochure may have spent more of the four-hour peak UVR period out of the sun. However, receiving the brochure does not appear to have resulted in lowered sunburn rates. Brochures about sun protection and sun exposure on holi days distributed at the point of embarkation may be a useful priming strategy as part of more comprehensive programmes which should include structural interventions at the holiday destinations.

Nicotine Withdrawal, Relapse of Mental Illness, or Medication Side-Effect? Implementing a Monitoring Tool for People With Mental Illness Into Quitline Counseling

ABSTRACT Background: Smokers with mental illness and their health care providers are often concerned that smoking cessation will worsen mental health. Smokers with mental illness tend to be more nicotine-dependent and experience more severe symptoms of nicotine withdrawal, some of which are difficult to distinguish from psychiatric symptoms. In addition, smoking cessation can increase the blood levels and hence side effects of some psychotropic medications. Improved monitoring of nicotine withdrawal and medication side effects may help distinguish temporary withdrawal symptoms from psychiatric symptoms and facilitate targeted treatment to help smokers with mental illness manage the acute phase of nicotine withdrawal. Objective: The aim of this research was to examine the acceptability and feasibility to quitline counselors of implementing structured assessments of nicotine withdrawal and common medication side effects in people with mental illness who are quitting smoking using a telephone smoking cessation service. Methods: Monitoring involves administering (once pre-cessation and at each contact post-cessation) (1) the Minnesota Nicotine Withdrawal Scale, assessing eight symptoms: anger, anxiety, depression, cravings, difficulty concentrating, increased appetite, insomnia, and restlessness and (2) an adverse side effects checklist of 5 to 10 symptoms, for example, dry mouth and increased thirst. Following a 1-day update training in mental health, quitline counselors were asked to offer these assessments to callers disclosing mental illness in addition to usual counseling. Group interviews with counselors were conducted 2 months later to examine implementation barriers and benefits. Results: Barriers included awkwardness in integrating a new structured practice into counseling, difficulty in limiting some callers to only the content of new items, and initial anxieties about how to respond to changes in some symptoms. Benefits included the ability to provide objective feedback on changes in symptoms, as this identified early benefits of quitting, provided reassurance for clients, and provided an opportunity for early intervention where symptoms worsened. Conclusions: Structured monitoring of withdrawal symptoms and medication side effects was able to be integrated into the quitlines counseling and was valued by counselors and clients. Given evidence of its benefits in this limited pilot study, we recommend it be considered for larger-scale adoption by quitlines.