Jeannette Rüge

Proactive interventions for smoking cessation in general medical practice: a quasi-randomized controlled trial to examine the efficacy of computer-tailored letters and physician-delivered brief advice*

Aims To test the efficacy of (i) computer-generated tailored letters and (ii) practitioner-delivered brief advice for smoking cessation against an assessment-only condition; and to compare both interventions directly. Design Quasi-randomized controlled trial. Setting A total of 34 randomly selected general practices from a German region (participation rate 87%). Participants A total of 1499 consecutive patients aged 18–70 years with daily cigarette smoking (participation rate 80%). Interventions The tailored letters intervention group received up to three individualized personal letters. Brief advice was delivered during routine consultation by the practitioner after an onsite training session. Both interventions were based on the Transtheoretical Model of behaviour change. Measurements Self-reported point prevalence and prolonged abstinence at 6-, 12-, 18- and 24-month follow-ups. Findings Among participants completing the last follow-up, 6-month prolonged abstinence was 18.3% in the tailored letters intervention group, 14.8% in the brief advice intervention group and 10.5% in the assessment-only control group. Assuming those lost to follow-up to be smokers, the rates were 10.2%, 9.7% and 6.7%, respectively. Analyses including all follow-ups confirmed statistically significant effects of both interventions compared to assessment only. Using complete case analysis, the tailored letters intervention was significantly more effective than brief advice for 24-hour [odds ratio (OR) = 1.4; P = 0.047] but not for 7-day point prevalence abstinence (OR = 1.4; P = 0.068) for prolonged abstinence, or for alternative assumptions about participants lost to follow-up. Conclusions The study demonstrated long-term efficacy of low-cost interventions for smoking cessation in general practice. The interventions are suitable to reach entire populations of general practices and smoking patients. Computer-generated letters are a promising option to overcome barriers to provide smoking cessation counselling routinely.

Predictors and moderators of outcome in different brief interventions for smoking cessation in general medical practice.

OBJECTIVE To explore demographic-, health-, and smoking-related predictors and moderators of outcome in smokers who participated in two different brief smoking cessation interventions. METHODS Data were acquired using a quasi-randomized controlled trial that tested the efficacy of computer-generated tailored letters and physician-delivered brief advice against assessment only. Daily smokers (n=1499) were recruited from 34 general medical practices. We used Generalized Estimating Equation analyses to investigate the relationship between 6-month prolonged smoking abstinence assessed at 12-, 18-, and 24-month follow-ups and potential predictors and moderators. RESULTS Female gender (OR=1.49, 95% CI=1.01-2.19), higher level of education (OR=1.82, 95% CI=1.18-2.82), intention to quit smoking (OR=1.66, 95% CI=1.16-2.38), and smoking cessation self-efficacy (OR=1.30, 95% CI=1.03-1.64) were positively, nicotine dependence (OR=0.84, 95% CI=0.76-0.94) and the presence of a smoking partner (OR=0.60, 95% CI=0.42-0.85) were negatively associated with smoking abstinence. Compared to assessment only, physician advice was less effective for people without an intention to quit smoking and for unemployed. CONCLUSION Smoking cessation interventions might be improved by tailoring them to demographic- and smoking-related variables which were identified as predictors in this study. PRACTICE IMPLICATIONS The results suggest that tailored letters are a more universally applicable brief intervention in general medical practice than physician advice.

Intention to quit smoking: is the partner's smoking status associated with the smoker's intention to quit?

Background: Smoking behavior among couples is often similar.Purpose: The aim of the study was to examine the relationship between the partner’s smoking status and the intention to stop smoking of the index person. Method: Cross-sectional data of 1,044 patients in a random sample of 34 general medical practices in northeastern Germany were analyzed.Results: Among smokers with a non-smoking partner (SNP), more intended to quit smoking in the next six months (37.0% vs. 31.4%), compared to smokers with a smoking partner (SSP). Also, more SNP intended to quit in the next four weeks (4.7% vs. 2.7%) compared to SSP. SNP were more active in the use of self-change strategies than SSP.Conclusion: The data confirm that the partner’s smoking status is related to the intention to quit smoking. Interventions should address the different needs of both smokers with a smoking partner and those with a non-smoking partner.

Does Precontemplation Represent a Homogeneous Stage Category? A Latent Class Analysis on German Smokers.

The authors examined the subtype structure of smokers classified in the precontemplation stage of change within the transtheoretical model. From a general practice-based sample of 1,499 daily smoking patients from Germany (participation rate 80%), they used a subgroup of 929 smokers who were classified in the precontemplation stage and applied latent class analysis, using the pros and cons of nonsmoking and smoking cessation self-efficacy as the defining variables. Cross-sectional validation of the emerging classes was based on smoking behavior and processes of change variables. For longitudinal validation, generalized estimation equation analyses were used on motivational and abstinence criteria from 6-, 12-, 18-, and 24-month follow-ups. A 4-class model best represented the data. Three subtypes (labeled progressive, immotive, and disengaged pessimistic) were similar to clusters identified in U.S. studies. The 4th (disengaged optimistic), by contrast, was reminiscent of a type that had previously only emerged in a Dutch study. Cross-sectional and longitudinal validation results confirmed the distinctiveness and predictive power of the classes. The findings highlight the importance of tailoring interventions for smoking behavior change to the needs of different subgroups of precontemplating smokers.

Computer-generated tailored feedback letters for smoking cessation: Theoretical and empirical variability of tailoring

PURPOSE This study examines tailored feedback letters of a smoking cessation intervention that is conceptually based on the transtheoretical model, from a content-based perspective. METHODS Data of 2 population-based intervention studies, both randomized controlled trials, with total N=1044 were used. The procedure of the intervention, the tailoring principle for the feedback letters, and the content of the intervention materials are described in detail. Theoretical and empirical frequencies of unique feedback letters are presented. RESULTS The intervention system was able to generate a total of 1040 unique letters with normative feedback only, and almost half a million unique letters with normative and ipsative feedback. Almost every single smoker in contemplation, preparation, action, and maintenance had an empirically unique combination of tailoring variables and received a unique letter. In contrast, many smokers in precontemplation shared a combination of tailoring variables and received identical letters. CONCLUSION The transtheoretical model provides an enormous theoretical and empirical variability of tailoring. However, tailoring for a major subgroup of smokers, i.e. those who do not intend to quit, needs improvement. Conceptual ideas for additional tailoring variables are discussed.

Workplace smoking restrictions: smoking behavior and the intention to change among continuing smokers

ObjectivesIn this study, the association between three levels of workplace smoking restrictions and smoking behavior and variables related to the intention to quit among continuing smokers was examined.MethodsAdult smokers were recruited from consecutive patients attending a random sample of 34 general medical practices from a pre-defined, north-eastern German region. Self-reported data were gathered in the waiting room by questionnaire. Cross-sectional data of 1,012 employees were analyzed using ordered logistic regression analyses.ResultsAmong the sample, 12% reported a smoke-free workplace, 51% had partial, and 37% no smoking restrictions. Daily cigarette consumption was lower when there were higher levels of restriction. No association was found between smoking restrictions and previous attempts to quit, nicotine dependence, or indicators of adjusted inhalation to compensate for the lower number of cigarettes (e.g. puffs per cigarette, darker coloring of filter). Smoking restrictions were positively associated with single psychological measures related to the intention to quit.ConclusionEmployees who continue to smoke may benefit from workplace smoking restrictions in terms of reduced, active smoke exposure and psychological effects increasing their readiness to quit.ZusammenfassungZielstellungIn der vorliegenden Studie wird der Zusammenhang zwischen drei Ausprägungsgraden von Rauchbeschränkungen am Arbeitsplatz und dem Rauchverhalten, sowie der Intention zur Beendigung des Tabakrauchens untersucht.MethodeErwachsene Raucher wurden aus einer Stichprobe von konsekutive Patienten in 34 zufällig ausgewählten hausärztlichen Praxen einer nordostdeutschen Region rekrutiert. Die Datenerhebung erfolgte per Fragebogen im Wartezimmer. Mittels ordinaler logistischer Regression wurden Daten von 1012 Berufstätigen analysiert.ErgebnisseIn der vorliegenden Stichprobe gaben 12% an, an einem rauchfreien Arbeitsplatz beschäftigt zu sein. Keine oder partielle Rauchbeschränkungen am Arbeitsplatz berichteten 37% bzw. 51%. Ein höherer Grad der Rauchbeschränkung ging mit niedrigerem täglichem Zigarettenkonsum einher. Zwischen Rauchbeschränkungen und früheren Abstinenzversuchen, Nikotinabhängigkeit oder Indikatoren für ein kompensatorisches Inhalationsverhalten bei reduziertem Zigarettenkonsum (z.B. Züge pro Zigarette, dunklere Verfärbung des Zigarettenfilters) fand sich kein statistisch bedeutsamer Zusammenhang. Für einzelne psychologische Variablen, die nach Vorbefunden mit der Bereitschaft zur Aufgabe des Rauchens in Zusammenhang stehen, fanden sich positive Zusammenhänge mit dem Grad der Rauchbeschränkungen am Arbeitsplatz.SchlussfolgerungenAuch weiterhin rauchende Arbeitnehmer profitieren von Rauchbeschränkungen am Arbeitsplatz durch eine verminderte aktive Tabakrauchexposition und psychologische Effekte, welche die Bereitschaft zu Aufgabe des Rauchens erhöhen.