Nicholas Zwar

Review of bupropion for smoking cessation

The advent of bupropion hydrochloride sustained release (Zyban) has heralded a major change in the options available for smoking cessation pharmacotherapy. Bupropion is a selective re-uptake inhibitor of dopamine and noradrenalin which prevents or reduces cravings and other features of nicotine withdrawal. Bupropion is a useful oral and non-nicotine form of pharmacotherapy for smoking cessation. For this review a total of 221 papers were reviewed plus poster presentations. This review examines in detail original clinical trials on efficacy, categorised according to whether they were acute treatment trials in healthy smokers; studies in specific populations such as people with depression, chronic obstructive pulmonary disease (COPD) or cardiovascular disease; or relapse prevention studies. Overall, these studies in varying populations comprising over four thousand subjects, showed bupropion consistently produces a positive effect on smoking cessation outcomes. The evidence highlights the major public health role that bupropion has in smoking cessation. The methodological issues of published clinical trials reporting one year outcomes were examined in detail including: completeness of follow-up; loss to follow-up; intention to treat analysis; blindness of assessment; and validation of smoking status. The review discusses contraindications, adverse effects, dose and overdose, addictive potential, and the role of bupropion in reducing cessation-related weight gain. Bupropion combined with or compared to other pharmacotherapies (nicotine patch; nortriptyline) is considered. Impressive evidence exists for the use of bupropion in smoking cessation among difficult patients who are hard-core smokers such as those with cardiovascular disease, chronic obstructive pulmonary disease (COPD) and depression. Bupropion reduces withdrawal symptoms as well as weight gain and is effective for smoking cessation for people with and without a history of depression or alcoholism. Serious side effects of bupropion use are rare. The major safety issue with bupropion is risk of seizures (estimated at approximately 0.1%) and it should not be prescribed to patients with a current seizure disorder or any history of seizures. In clinical trials of bupropion for smoking cessation no seizures were reported. Allergic reactions occur at a rate of approximately 3% and minor adverse effects are common including dry mouth and insomnia.

A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors

BackgroundTo evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW).MethodsA systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and <8; Low ≤ 3 points of contact hours) and setting (primary health, community or other).Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported.Results52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions.ConclusionGroup and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.

Barriers to the Use of Anticoagulation for Nonvalvular Atrial Fibrillation A Representative Survey of Australian Family Physicians

Background and Purpose— Anticoagulation reduces the risk of stroke in nonvalvular atrial fibrillation yet remains underused. We explored barriers to the use of anticoagulants among Australian family physicians. Methods— The authors conducted a representative, national survey. Results— Of the 596 (64.4%) eligible family physicians who participated, 15.8% reported having a patient with nonvalvular atrial fibrillation experience an intracranial hemorrhage with anticoagulation and 45.8% had a patient with known nonvalvular atrial fibrillation experience a stroke without anticoagulation. When presented with a patient at “very high risk” of stroke, only 45.6% of family physicians selected warfarin in the presence of a minor falls risk and 17.1% would anticoagulate if the patient had a treated peptic ulcer. Family physicians with less decisional conflict and longer-standing practices were more likely to endorse anticoagulation. Conclusion— Strategies to optimize the management of nonvalvular atrial fibrillation should address psychological barriers to using anticoagulation.

Role of the general practitioner in smoking cessation

This paper reflects on the role of general practitioners in smoking cessation and suggests initiatives to enhance general practice as a setting for effective smoking cessation services. This paper is one of a series of reflections on key issues in smoking cessation. In this article we highlight the extent that general practitioners (GPs) have contact with the population, evidence for effectiveness of GP advice, barriers to greater involvement and suggested future directions. General practice has an extensive population reach, with the majority of smokers seeing a GP at least once per year. Although there is level 1 evidence of the effectiveness of smoking cessation advice from general practitioners, there are substantial barriers to this advice being incorporated routinely into primary care consultations. Initiatives to overcome these barriers are education in smoking cessation for GPs and other key practice staff; teaching of medical students about tobacco and cessation techniques, clinical practice guidelines; support for guideline implementation; access to pharmacotherapies; and development of referral models. We believe the way forward for the role of the GPs is to develop the practice as a primary care service for providing smoking cessation advice. This will require education relevant to the needs of a range of health professionals, provision of and support for the implementation of clinical practice guidelines, access for patients to smoking cessation pharmacotherapies and integration with other cessation services such as quitlines.

Guideline for the diagnosis and management of hypertension in adults - 2016

The National Heart Foundation of Australia has updated the Guide to management of hypertension 2008: assessing and managing raised blood pressure in adults (updated December 2010).

Teaching about tobacco in medical schools: a worldwide study.

INTRODUCTION AND AIMS As medical practitioners of the future, medical students should be taught about tobacco control strategies and smoking cessation interventions. By including education about tobacco in the medical curricula, they can be informed about the health effects of tobacco use and learn to assist smokers to quit. Our study aimed to estimate the extent of teaching about tobacco and smoking cessation techniques in medical schools worldwide and compare with results we reported 10 years ago, to determine the content of curricula and range of teaching formats and to identify barriers to teaching about tobacco in medical schools and solutions. DESIGN AND METHODS A cross-sectional survey of all existing medical schools (n = 2090) in 171 countries was conducted. A questionnaire was designed, translated and sent to all medical schools. Main outcome measures included whether and how tobacco is taught; comparisons with the survey conducted 10 years ago; tobacco content in the curriculum; format of teaching; and barriers to teaching and solutions. RESULTS 665 medical schools from 109 countries completed the full questionnaire, with a response rate of 31.8% from medical schools and 64% of countries and consisting of 39% of medical schools in developed and 28% in less developed countries. A further 67 medical schools responded to a single question on whether they taught about tobacco. The total response rate was 35%. Of 561 medical schools responding to questions on teaching options, 27% of medical schools taught a specific module on tobacco compared with only 11% in our survey of medical schools conducted a decade ago; 77% integrated teaching on tobacco with other topics compared with 40% 10 years ago; 31% taught about tobacco informally as the topic arose (vs. 58%) and 4% did not teach about tobacco (vs. 12%). Most common topics taught were: health effects of smoking (94%), health effects of passive smoking (84.5%), epidemiology of tobacco use (81%), nicotine dependence (78%) and taking a smoking history (75%). Most popular method of teaching was by lectures (78%), case study discussions and problem-based learning exercises (51%), class readings 46%, in the clinical setting with real patients (45%), special projects and assignments (45%) and patient-centred teaching approaches, such as role plays (31%). Significantly, more barriers to teaching were identified by less developed countries (>60%) including: lack of available teaching time in the medical program, limited organisational ability to include new subjects, lack of staff resources to teach, lack of current plans to introduce a tobacco curriculum, lack of a key person to champion and organise teaching, lack of financial resources and lack of incentives or advantages to teach. A majority described solutions to these problems. A case study of education on tobacco throughout the medical curriculum is presented. DISCUSSION AND CONCLUSIONS We found an encouraging increase in the extent of teaching on tobacco in medical schools over 10 years. We report that although progress has been made to address the teaching of tobacco in medical schools worldwide, there is a great deal more effort required so that education on tobacco is an ongoing part of medical curricula. The teaching content is generally based on evidence-based smoking cessation guidelines

The International Primary Care Respiratory Group (IPCRG) Research Needs Statement 2010

AIM Respiratory diseases are a public health issue throughout the world, with high prevalence and morbidity. This Research Needs Statement from the International Primary Care Respiratory Group (IPCRG) aims to highlight unanswered questions on the management of respiratory diseases that are of importance to practising primary care clinicians. METHODS An informal but inclusive consultation process was instigated in 2009. Draft statements in asthma, rhinitis, COPD, tobacco dependence, and respiratory infections were circulated widely to IPCRG members, other recognised experts, and representatives from a range of economic and healthcare backgrounds. An iterative process was used to generate, prioritise and refine research questions in each section. RESULTS Two overarching themes emerged. Firstly, there is a real need for research to be undertaken within primary care, which recruits patients representative of primary care populations, evaluates interventions realistically delivered within primary care, and draws conclusions that will be meaningful to professionals working within primary care. Secondly, international and national guidelines exist, but there is little evidence on the best strategies for implementing recommendations. Disease-specific research questions focus on effective and cost-effective ways to prevent disease, confirm the diagnosis, assess control, manage treatment, and empower selfmanagement. Practical questions about how to deliver this comprehensive agenda in diverse primary care settings are highlighted. CONCLUSIONS We hope that this Research Needs Statement will be used by clinicians and patients campaigning for answers to relevant questions, by researchers seeking funding to provide answers to these questions, and by funding bodies to enable them to prioritise research agendas.

Supporting smoking cessation

#### Summary points Despite the decrease in prevalence of tobacco use in developed countries, smoking remains the most common preventable cause of disease and death in the world today. Advice on smoking cessation from doctors and other health professionals has been shown to improve quit rates and is highly cost effective.1 Given the importance to health of tobacco use and the benefits of cessation, every doctor should encourage attempts to stop, be able to provide brief smoking cessation intervention, and be aware of referral options (see box 1). Over the past decade there have been advances in the science and practice of smoking cessation support. These include new medicines to treat nicotine dependence, new ways of using existing medicines, and increasing use of technology to support behavioural change. This review provides an update on evidence based approaches to maximise the effectiveness of the treatment of tobacco dependence. #### Sources and selection criteria This review is based on evidence synthesis from relevant Cochrane systematic reviews; review and distillation of clinical practice guidelines from Australia, the United States, and New Zealand; information from UK National Centre for Smoking Cessation and Training (www.ncsct.co.uk); and other evidence from the authors’ personal libraries. We have focused on developments since the review by Aveyard and West in 2007.2 The prevalence of tobacco use varies around the world. Of …

Effect of a computer-guided, quality improvement program for cardiovascular disease risk management in primary health care: the treatment of cardiovascular risk using electronic decision support cluster-randomized trial

Background— Despite effective treatments to reduce cardiovascular disease risk, their translation into practice is limited. Methods and Results— Using a parallel arm cluster-randomized controlled trial in 60 Australian primary healthcare centers, we tested whether a multifaceted quality improvement intervention comprising computerized decision support, audit/feedback tools, and staff training improved (1) guideline-indicated risk factor measurements and (2) guideline-indicated medications for those at high cardiovascular disease risk. Centers had to use a compatible software system, and eligible patients were regular attendees (Aboriginal and Torres Strait Islander people aged ≥35 years and others aged ≥45 years). Patient-level analyses were conducted using generalized estimating equations to account for clustering. Median follow-up for 38 725 patients (mean age, 61.0 years; 42% men) was 17.5 months. Mean monthly staff support was <1 hour/site. For the coprimary outcomes, the intervention was associated with improved overall risk factor measurements (62.8% versus 53.4% risk ratio; 1.25; 95% confidence interval, 1.04–1.50; P=0.02), but there was no significant differences in recommended prescriptions for the high-risk cohort (n=10 308; 56.8% versus 51.2%; P=0.12). There were significant treatment escalations (new prescriptions or increased numbers of medicines) for antiplatelet (4.3% versus 2.7%; P=0.01), and BP lowering (18.2% versus 11.0%; P=0.02) but not lipid-lowering medications. Conclusions— In Australian primary healthcare settings, a computer-guided quality improvement intervention, requiring minimal support, improved cardiovascular disease risk measurement but did not increase prescription rates in the high-risk group. Computerized quality improvement tools offer an important, albeit partial, solution to improving primary healthcare system capacity for cardiovascular disease risk management. Clinical Trial Registration— URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336630. Australian New Zealand Clinical Trials Registry No. 12611000478910.

Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis

BackgroundPeople with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes.MethodsStudies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor.The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review.Results52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity.Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients.ConclusionCapacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.