Edward Lichtenstein

Why don't we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition.

The gap between research and practice is well documented. We address one of the underlying reasons for this gap: the assumption that effectiveness research naturally and logically follows from successful efficacy research. These 2 research traditions have evolved different methods and values; consequently, there are inherent differences between the characteristics of a successful efficacy intervention versus those of an effectiveness one. Moderating factors that limit robustness across settings, populations, and intervention staff need to be addressed in efficacy studies, as well as in effectiveness trials. Greater attention needs to be paid to documenting intervention reach, adoption, implementation, and maintenance. Recommendations are offered to help close the gap between efficacy and effectiveness research and to guide evaluation and possible adoption of new programs.

Understanding and preventing relapse.

This chapter examines relapse by integrating knowledge from the disorders of alcoholism, smoking, and obesity in an attempt to emphasize in a prototypical manner the overlap in etiological mechanisms and treatment rationales for disorders with powerful, underlying biological self-regulation components. Commonalities across these areas suggest at least three basic stages of behavior change: motivation and commitment, initial change, and maintenance. A distinction is made between the terms lapse and relapse, with lapse referring to the process (slips or mistakes) that may or may not lead to an outcome (relapse). The natural history of relapse is discussed, as are the consequences of relapse for patients and the professionals who treat them. Information on determinants and predictors of relapse is evaluated, with the emphasis on the interaction of individual, environmental, and physiological factors. Methods of preventing relapse are proposed and are targeted to the three stages of change. Specific research needs in these areas are discussed.

Perceived stress, quitting smoking, and smoking relapse.

Assessed perceptions of stress prior to quitting and at 1, 3, and 6 months following quit date. Self-reported smoking status was augmented by a bogus pipeline procedure at each interview, and abstinence at 6 months was verified by carbon monoxide and saliva cotinine. The analyses provide strong evidence for a relation between changes in stress levels and changes in smoking status. Those who failed to quit smoking for more than 24 hr maintained a relatively high and consistent level of stress over the entire 6-month period. For those remaining continuously abstinent over the course of the study, stress decreased as duration of abstinence increased. Increases in stress with relapse were found across all three panel lags (prequit to 1 month, 1 to 3 months, and 3 to 6 months), and decreases in stress with quitting were found across the two lags where that comparison was possible. The possibility that the relation between smoking and stress is bidirectional is discussed as a possible interpretation of the results.

Nurse-Assisted Counseling for Smokers in Primary Care

Physician-delivered, stop-smoking interventions significantly improve quit rates among smoking patients [1-6]. Unfortunately, only about one half of physicians in nonresearch settings consistently counsel smokers [7-11], and fewer than one half of all smokers report that a physician has ever advised them to quit [12-14]. Given the pressures of routine medical practice, it is not surprising that physicians do not take 3 to 5 minutes to counsel every smoking patient they see. Tobacco counseling competes with other pressing clinical tasks; physicians are often too busy to routinely and repeatedly counsel all patients who smoke [11, 15-17]. Physicians will deliver a cessation protocol as part of a study [5, 6, 18], but barriers such as a lack of time, training, and confidence make counseling in nonresearch settings less likely [1, 4, 19, 20]. New approaches [21-23], such as involving other office staff in counseling [17, 24, 25], are needed if tobacco counseling is to become a consistent and sustainable part of medical care delivery [26]. Because physicians see roughly 70%, or 38 million, of the 53 million smokers in the United States each year [15], even a modestly effective physician-driven intervention would have considerable impact on the nations health. This study tested the feasibility and effectiveness of a team counseling approach designed to minimize the burden on physicians by using non-physician clinic staff to provide the more time-consuming parts of cessation counseling. Key features of the team approach were a brief (30-second) physician-delivered cessation message, referral to an on-site nurse or other staff for additional cessation support, and the use of videos to deliver much of the intervention in an efficient and standardized manner. A previous report of process and short-term outcome measures showed that this organized team approach proved practical and sustainable [27]. The participating physicians and other providers delivered brief advice to 86% of identified smokers during the 1-year intake period, and most patients (87%) saw the counselor for materials and additional counseling. Nurse-Assisted counseling led to significantly improved quit rates at 3 months compared with brief physician advice alone. We present the effects of the intervention on long-term abstinence at 1 year. Methods Setting We conducted our study in two large primary care facilities of Kaiser Permanente Northwest Region, a group-practice health maintenance organization (HMO) in Portland, Oregon. Receptionists asked patients between 18 and 70 years of age to complete a health habit survey while waiting for their visit. The patients were seeing 1 of 60 primary care physicians (n = 42), physician assistants (n = 7), or nurse practitioners (n = 11) in outpatient internal medicine and family practice offices. Intervention Regular clinic nurses and clinical assistants collected the surveys as patients were taken to examination rooms and attached a notice to the medical charts of smokers (n = 3161) to alert providers to deliver a brief stop-smoking advice message. Providers were oriented to their role in a 1-hour training session. They were encouraged to use their own words but to not go beyond the following basic 30-second message: The best thing you can do for your health is to stop smoking and I want to advise you to stop as soon as possible. I know it can be hard and many try several times before they finally make it. You may or may not want to stop now, but I want you to talk briefly with our health counselor, who has some tips to make stopping easier when you decide the time is right. The 2707 (86%) smokers who received the provider advice message were considered participants in the study, regardless of whether they were willing to see the counselor or had any interest in quitting smoking. By the end of follow-up, 16 patients died, leaving a total sample of 2691. At the conclusion of the physician consultation, patients were seen by an on-site project nurse or health counselor who described what would be offered and obtained verbal consent to proceed. Patients who would not see the health counselor were mailed materials appropriate to their treatment assignment. Two random digits contained in the patients health record number were used to assign patients to one of the following four interventions: advice, self-quit, group-referral, or combination treatment. Physicians remained blind to treatment assignment. Advice participants received the 30-second provider advice message and a brief pamphlet, Why Do You Smoke?, from the health counselor. This clear and systematic advice would probably be more effective than no treatment or usual care, which were not included for logistic and ethical reasons. The self-quit condition included cessation advice, a carbon monoxide assessment, and a 10-minute How to Quit Smoking video designed specifically for this population. The video focused on the need to make a personal decision to quit, the steps to successful quitting, the frequent need for repeated efforts, and the importance of setting a specific quit date and using substitutes to smoking. The counselor provided a stop-smoking kit including smoking substitutes such as gum, toothpicks, and cinnamon sticks. A choice of one of three stop-smoking manuals was offered. Most participants chose the National Cancer Institutes manual, Quit for Good (54%), although others chose Calling it Quits (17%) or a two-part workbook produced by the American Lung Association titled, Freedom from Smoking in 20 Days and A Lifetime of Freedom from Cigarettes, respectively (29%). Patients were encouraged to set a specific quit date or some other specific plan of action and the counselor arranged to call the patient, usually within 2 to 4 weeks, to check on progress toward cessation. Patients were also mailed a set of stop-smoking tip sheets and a series of six professionally designed bimonthly newsletters devoted to smoking cessation. Group-referral participants also received advice, the carbon monoxide assessment, and a video. In this case, however, the video encouraged patients to join the HMOs intensive stop-smoking group program known as Freedom from Cigarettes. This program entails nine group meetings over 2 months. In a recent study, this program achieved roughly a 35% biochemically verified 1-year quit rate [28]. Patients were provided a brochure, a schedule of group sessions, and a time-limited coupon to waive the program fee. Efforts were made to schedule the patient for an upcoming group. Reminder postcards were sent 1 week before the scheduled meeting, and patients were called several days after the meeting to check on progress and, if necessary, to reschedule. Combination participants also received advice, the carbon monoxide assessment, and a third video, which described both the self-directed and the professionally led group approaches to smoking cessation. Self-directed cessation techniques, as well as the pros and cons of joining a professionally run program, were presented. Participants were asked to choose an approach that made sense for them. The self-help manual, stop-smoking kit, group materials, and fee-waiver coupon were all provided. Participants were encouraged to either set a quit date or sign up for a specific group session, and a telephone call was arranged to check on progress. Tip sheets and the bimonthly newsletters were mailed to all combination participants. Follow-up and Analyses Participants were surveyed by mail 3 and 12 months after their initial visits. Nonresponders were interviewed by telephone by an assessor who was blind to treatment assignment. Participants reporting abstinence from tobacco for at least 7 days before the 12-month assessment were asked to schedule appointments at a convenient clinic location or at their homes to provide saliva samples for biochemical confirmation. The primary end point was a two-point prevalence measure, which was defined as consecutive abstinence at both the 3- and 12-month assessments. Nonrespondents and those lost to follow-up were considered to be smokers. Results As shown in Table 1, participants in the four treatment groups were similar in terms of baseline age, sex, race, education, occupation, cigarettes smoked per day, stage of change, confidence in ability to quit, perceived degree of overweight, and subjective health status [27]. Table 1. Baseline Characteristics by Treatment Group* Self-reported smoking status was obtained on a high percentage of participants at both the 3-month (88%) and 12-month (86%) follow-up assessments. Response rates did not differ significantly across treatment groups. The proportion of participants who reported one or more serious attempts to quit in the year following their clinic visit was significantly higher (P < 0.004) among self-quit participants (53%) relative to advice participants (46%). Group-referral (48%) and combination participants (50%) did not differ from advice participants in terms of quit attempts. All three nurse-assisted interventionsself-quit, group referral, and combinationresulted in higher 3-month point prevalence quit rates than did the advice treatment (Table 2). At the 12-month follow-up, a larger percentage of participants reported abstinence, although differences between treatment arms were reduced. The 12-month point prevalence definition of abstinence, however, includes both long-term ex-smokers and those who quit as little as 1 week before the 1-year follow-up. With the more conservative primary end point, consecutive abstinence at both the 3-month and 12-month assessments, the three nurse-assisted interventions were superior to the advice intervention. Because quit rates for the three nurse-assisted interventions were similar for all analyses (P > 0.2), they were collapsed and compared to the advice intervention. Quit rates in the nurse-assisted groups were significantly higher than advice for the 3-month (6.

Work site-based cancer prevention: primary results from the Working Well Trial.

OBJECTIVES This paper presents the behavioral results of the Working Well Trial, the largest US work site cancer prevention and control trial to date. METHODS The Working Well Trial used a randomized, matched-pair evaluation design, with the work site as the unit of assignment and analysis. The study was conducted in 111 work sites (n = 28,000 workers). The effects of the intervention were evaluated by comparing changes in intervention and control work sites, as measured in cross-sectional surveys at baseline and follow-up. The 2-year intervention targeted both individuals and the work-site environment. RESULTS There occurred a net reduction in the percentage of energy obtained from fat consumption of 0.37 percentage points (P = .033), a net increase in fiber densities of 0.13 g/1000 kcal (P = .056), and an average increase in fruit and vegetable intake of 0.18 servings per day (P = .0001). Changes in tobacco use were in the desired direction but were not significant. CONCLUSIONS Significant but small differences were observed for nutrition. Positive trends, but no significant results, were observed in trial-wide smoking outcomes. The observed net differences were small owing to the substantial secular changes in target behaviors.

The behavioral assessment of social competence in males.

College male undergraduates, either high frequency (HFD) or low frequency daters (LFD), were compared on a variety of self-report, peer rating, and behavioral measures of social competence in heterosexual interactions. Self-report measures of social anxiety and peer ratings of social anxiety and skill showed highly significant differences between the two groups. On an audiotaped social performance task, HFD subjects responded with shorter latencies and more words per response than did LFD subjects. There were relatively few behavioral differences between the groups on two social performance tasks involving live interaction with a female confederate. Only rated social skill and number of silences in the conversations significantly discriminated between the groups. Further, intercorrelations within and across tasks suggested that many of the specific verbal activity measures were highly intercorrelated, and were also related to other indices of social competence, including self-report, observer rating, and peer rating indices. The discussion centered around an analysis of the behavioral components of social competence, and the need for more refined behavioral analysis of interactional sequences, apart from simple frequency measures.

Smoking onset among teens: An empirical analysis of initial situations

This study attempted to identify factors associated with smoking onset among teens. It was hypothesized that initial cigarette smoking is largely prompted by peers, and that these prompts and subsequent social reinforcement may account for smoking participation. An in-depth structured interview investigating the first three smoking or smoking pressure experiences was conducted with 157 teens, including persistent experimental smokers (who smoked more than 10 cigarettes), minimal experimental smokers (who smoked less than 10 cigarettes), and nonsmokers. Analyses confirmed that prompting by peers is characteristic of a large majority of smoking onset situations. Initial situations are much more likely to involve others of the same sex. In roughly half of the incidents another young person was trying a cigarette for the first time. Persistent experimenters, when compared with minimal experimenters, were exposed to significantly more influences to smoke. These influences included modeling and social encouragement. Additional data suggested that persistent experimenters were more primed to smoke than minimal experimenters. For example, they had engaged in more premeditation, accepted offers to smoke with less hesitation, and inhaled more frequently. Also, pleasant emotional and physiological effects discriminated continuers from quitters. Nonsmokers appeared to possess more effective response strategies to refuse cigarettes. Implications of these data for prevention program design are discussed.

Biochemical validation of smoking status: Pros, cons, and data from four low-intensity intervention trials

Biochemical validation of smoking status has long been considered essential, but recent reports have questioned its utility in certain kinds of field trials. We describe efforts to biochemically validate self-reports of smoking cessation from participants in four large-scale randomized trials in outpatient clinics, hospitals, worksites, and dental clinics. These studies included over 5,000 adults smokers who participated in the population-based low-intensity intervention evaluations. At a 1-year follow-up, 798 subjects reported no tobacco use. We attempted to verify these reports using saliva continine/carbon monoxide validation procedures. Overall, there was a moderately high nonparticipation rate (27%), a low disconfirmation rate (4%), and a high self-reported relapse rate (12%) in the interval between survey and biochemical validation. There were no differences between intervention and control conditions on any of the above variables. Longer durations of self-reported abstinence were strongly related to increased probability of biochemical confirmation. Differences in results across projects were related to how biochemical validation was conducted. These results, as well as statistical power considerations, raise questions about whether biochemical validation procedures are practical, informative, or cost-effective in such population-based, low-intensity intervention research.

Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office.

OBJECTIVES Primary care medical clinics are good settings for smoking interventions. This study extends this strategy with a smokeless tobacco intervention delivered by dentists and dental hygienists in the course of routine dental care. METHODS Male users of moist snuff and chewing tobacco (n = 518) were identified by questionnaire in clinic waiting rooms and then randomly assigned to either usual care or intervention. The intervention included a routine oral examination with special attention to the part of the mouth in which tobacco was kept and an explanation of the health risks of using smokeless tobacco. After receiving unequivocal advice to stop using tobacco, each patient viewed a 9-minute videotape, received a self-help manual, and was briefly counseled by the dental hygienist. RESULTS Long-term success was defined as no smokeless tobacco use at both 3- and 12-month follow-ups, with those lost to follow-up counted as smokeless tobacco users. The intervention increased the proportion of patients who quit by about one half (12.5% vs 18.4%, P < .05). CONCLUSIONS These results demonstrate the efficacy of a brief dental office intervention for the general population of smokeless tobacco users.

A SMOKING-CESSATION INTERVENTION FOR HOSPITAL PATIENTS

Many patients attempt to stop smoking during hospitalization, but most relapse after discharge. This study developed and evaluated a brief smoking-cessation and relapse-prevention program for hospitalized smokers. All hospitalized smokers (n=1,119) were identified by questionnaire at hospital admission and then received either usual care or usual care plus a hospital-based smoking- cessation intervention regardless of interest in stopping smoking. Intervention components included a 20-minute bedside counseling session, a 12-minute videotape, a variety of self-help materials, and a follow-up telephone call. Special attention was given to techniques for preventing relapse after hospital discharge. Defining ex-smokers as those who reported no tobacco use at both 3- and 12-month follow-up assessments, and counting those lost to follow-up as smokers, the intervention increased the proportion of patients who quit smoking by one half (9.2%vs 13.5%, P<0.05). These results demonstrate the efficacy of a brief in-hospital intervention and suggest that relapse-prevention efforts are needed to convert temporary cessation during hospitalization into longterm abstinence.