Denise G. Jolicoeur

Impact of patient characteristics on physician’s smoking cessation strategies

BACKGROUND The effectiveness of smoking cessation interventions may be influenced by a variety of patient characteristics, including level of nicotine addiction and readiness to change. We conducted this study to examine the relationship between these characteristics and the frequency of physician-initiated smoking cessation interventions. METHODS We identified smokers seen during office visits to 1 of 38 primary care physicians in rural Kansas. Trained students observed the frequency and nature of doctor-patient discussions related to tobacco. Telephone surveys were conducted with these patients 1 to 3 days after the office visit. RESULTS We completed observations and telephone surveys on 259 smokers. Tobacco-related discussions occurred during 66% of doctor-patient encounters. Although discussions overall were unrelated to a patients readiness to quit, specific assistance with smoking cessation was offered less often to precontemplators (15%) than to contemplators (31%) or those preparing to quit (37%) (P < 0.05). While bupropion was discussed with 23% of smokers, nicotine replacement therapy was discussed with 12% and was unrelated to markers of nicotine addiction. CONCLUSIONS Current efforts to promote smoking cessation are only marginally related to patient characteristics. Doctors are missing many opportunities to effectively intervene with patients who are contemplating smoking cessation or preparing to quit.

Keeping a Step Ahead: formative phase of a workplace intervention trial to prevent obesity

Objective: Ecological interventions hold promise for promoting overweight and obesity prevention in worksites. Given the paucity of evaluative research in the hospital worksite setting, considerable formative work is required for successful implementation and evaluation. This paper describes the formative phases of Step Ahead, a site‐randomized controlled trial of a multilevel intervention that promotes physical activity and healthy eating in six hospitals in central Massachusetts. The purpose of the formative research phase was to increase the feasibility, effectiveness, and likelihood of sustainability of the intervention.

Smoking Cessation, Smoking Reduction, and Delayed Quitting Among Smokers Given Nicotine Patches and a Self-Help Pamphlet

Over‐the‐counter nicotine replacement raises questions regarding its “real world”; efficacy. This was an open‐label, prospective study of 223 smokers who received 42 free nicotine patches and a self‐help booklet via shopping mall distribution. The overall quit rate 6 months following distribution of the nicotine patches was 22% (50/223), almost the same quit rate found 6 weeks following patch distribution (21%, 47/223). Twelve percent (27/223) were abstinent at both 6 weeks and 6 months. Among the 83 participants who did not quit, cigarettes smoked per day dropped from 28 to 18. A substantial subgroup of quitters (14%) who, although still smoking at 6 weeks, were smoke free at 6 months, and it appears they had purposefully delayed a serious quit attempt. These results support the usefulness of nicotine patches in helping smokers quit, even with only minimal intervention such as a self‐help manual.

An evaluation of tobacco treatment specialist counseling performance using standardized patient interviews

In the United States, tobacco treatment specialists are professionals from a variety of backgrounds trained to deliver moderate to intensive evidence-based tobacco treatment in a variety of settings across the country. This paper reports the results of a study that examined the extent to which specialists participating in a larger study adhered to clinical practice guidelines for tobacco dependence using standardized patient assessments. A total of 64 tobacco treatment specialists completed a survey and two audiotaped standardized patient interviews. Overall, 41% and 31% of tobacco treatment specialists demonstrated 80% or more of session content and interviewing skills assessed, respectively, when required to demonstrate the skill in both standardized patient interactions. These rates increased to 85% and 56%, respectively, when using the less stringent criteria of demonstrating the skill in at least one of the two standardized patient interactions. Tobacco treatment specialists who had attended a greater number of types of tobacco treatment training exhibited both greater coverage of session content (p<.06) and greater interviewing skills (p<.02). Those who had achieved certification as a tobacco treatment specialist exhibited greater coverage of session content (p<.02), and those perceiving more positive support from their agency for their services exhibited greater interviewing skills (p=.02). Although the tobacco treatment specialists evaluated appear to have the necessary skills to deliver guideline-based intervention, they demonstrated only moderate adherence to the guidelines when expected to do so consistently across multiple assessments. Findings suggest specific components of tobacco treatment and interviewing skills that would benefit from strengthening through training and support.

Medical school curriculum characteristics associated with intentions and frequency of tobacco dependence treatment among 3rd year U.S. medical students

OBJECTIVE Physicians play a critical role in addressing tobacco dependence, yet report limited training. Tobacco dependence treatment curricula for medical students could improve performance in this area. This study identified student and medical school tobacco treatment curricula characteristics associated with intentions and use of the 5As for tobacco treatment among 3rd year U.S. medical students. METHODS Third year medical students (N=1065, 49.3% male) from 10 U.S. medical schools completed a survey in 2009-2010 assessing student characteristics, including demographics, tobacco treatment knowledge, and self-efficacy. Tobacco curricula characteristics assessed included amount and type of classroom instruction, frequency of tobacco treatment observation, instruction, and perception of preceptors as role models. RESULTS Greater tobacco treatment knowledge, self-efficacy, and curriculum-specific variables were associated with 5A intentions, while younger age, tobacco treatment self-efficacy, intentions, and each curriculum-specific variable were associated with greater 5A behaviors. When controlling for important student variables, greater frequency of receiving 5A instruction (OR=1.07; 95%CI 1.01-1.12) and perception of preceptors as excellent role models in tobacco treatment (OR=1.35; 95%CI 1.04-1.75) were significant curriculum predictors of 5A intentions. Greater 5A instruction (B=.06 (.03); p<.05) and observation of tobacco treatment (B=.35 (.02); p<.001) were significant curriculum predictors of greater 5A behaviors. CONCLUSIONS Greater exposure to tobacco treatment teaching during medical school is associated with both greater intentions to use and practice tobacco 5As. Clerkship preceptors, or those physicians who provide training to medical students, may be particularly influential when they personally model and instruct students in tobacco dependence treatment.

Implementing state tobacco treatment services: lessons from the Massachusetts experience.

This case study was conducted between 2000 and 2003 to examine the implementation of community based tobacco treatment programs funded by the Massachusetts Department of Public Health Tobacco Control Program (MTCP). Four dimensions of implementation, drawn from several models of program evaluation are explored: (a) quantity of services, (b) quality of services, (c) implementation/use of systems, and (d) sustainability. The quantity of services delivered was high, reflecting MTCP’s focus on increasing availability of services, particularly in underserved populations. The quality of physician-delivered tobacco intervention did not meet national benchmarks for delivery of all 5As (Ask, Advise, Assess, Assist, Arrange follow-up) and only about half of organizations reported routine systems for auditing tobacco use documentation. Implementation of systems to identify tobacco users and deliver tobacco treatment varied widely by community health settings, with low rates of tobacco use documentation found. Finally, in an era of greater competition for scarce prevention dollars, sustainability of services over time must be planned for from the outset, as indicated by the success of programs that sustained services by proactively and creatively incorporating tobacco treatment into their organizations. This case study can inform states’ policies in their design of tobacco treatment services in community health settings.

Head Start Staff Reactions to a Novel Tobacco Intervention: A Qualitative Analysis.

OBJECTIVES As tobacco use becomes increasingly concentrated in communities of low socio-economic position (SEP), scalable cessation interventions are needed. Head Start programs offer one setting in which a family-focused intervention can be implemented in low SEP communities. We assessed the experiences of Head Start (HS) staff who received training in a pilot motivational interviewing (MI) tobacco intervention, to improve future feasibility. METHODS Focus group interviews were conducted with HS staff to assess their reactions to MI training and their use of MI in their work with families. Transcripts were analyzed using thematic analysis and a 4-step approach informed by grounded theory. RESULTS HS staff reported advantages of MI beyond its use as a tobacco intervention, despite systematic barriers to broad implementation. Facilitators of MI use included enhanced engagement with families, and opportunities for professional development. Barriers to MI use included limited institutional support and low priority for a tobacco intervention among families with pressing social and financial concerns. CONCLUSIONS HS Staff voiced support for broader training in MI interventions in HS programs. System-wide standards to ensure adequate training and support for an MI tobacco intervention were identified as priorities.