Raoul A. Walsh

Where there's smoke, there's fire: high prevalence of smoking among some sub-populations and recommendations for intervention

In Australia, the prevalence of smoking is higher among certain sub-populations compared to the general population. These sub-populations include Aboriginal and Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, as well as people with mental and substance use disorders and prisoners. The aims of this paper are to: describe the high prevalence of smoking among these particular sub-populations and harms associated with smoking; explore possible reasons for such high prevalence of smoking; review the evidence regarding the efficacy of existing smoking cessation interventions; and make recommendations for smoking interventions and further research among these groups. In addition to low socio-economic status, limited education and other factors, there are social, systems and psychobiological features associated with the high prevalence of smoking in these sub-groups. General population-based approaches to reducing smoking prevalence have been pursued for decades with great success and should be continued with further developments that aim specifically to affect Aboriginal and Torres Strait Islander people and some cultural groups. However, increasing attention, more specific targeting and flexible goals and interventions are also required for these and other distinct sub-populations with high smoking prevalence. Recommendations include: more funding and increased resources to examine the most appropriate education and treatment strategies to promote smoking cessation among people from Aboriginal and Torres Strait Islander and some culturally and linguistically diverse backgrounds; larger and better-designed studies evaluating smoking cessation/reduction interventions among distinct sub-groups; and system-wide interventions requiring strong leadership among clients and staff within mental health, drug and alcohol and prison settings.

Smoking cessation interventions in Australian drug treatment agencies: a national survey of attitudes and practices

A cross-sectional survey was mailed to all Australian drug and alcohol treatment agencies to assess their smoking cessation policies and practices and related staff attitudes. Barriers to smoking cessation interventions were also examined. Completed questionnaires were returned by 213 managers and 204 other staff representing 260 agencies (59.8% consent rate). Approximately one-quarter of agencies have smoking cessation intervention policies and one-third of clients receive adequate smoking advice. Of 12 intervention strategies, only the recording of smoking status on file occurs in a majority of cases. Concerns about the potential negative impact of smoking interventions and lack of client interest were endorsed as very important barriers by the highest percentage of respondents. 12.6% of managers and 16.5% of other staff agreed that it is occasionally useful for staff to smoke with a client. Smoking cessation receives little systematic attention from drug and alcohol agencies. Training and policy initiatives are needed urgently to address negative staff attitudes impeding progress in this area.

Smoking status in pregnant women Assessment of self-report against carbon monoxide (CO)

Smoking according to self-report and to carbon monoxide (CO) were examined in 7,405 pregnant women who agreed to complete a breath test and questionnaire. The sensitivity and specificity of self-report against CO, and predictors of a high CO among reported nonsmokers, were examined. The prevalence of reported smoking was 23% (95% CI: 19.4-26.4), and 20% had a CO of 9 or more (95% CI: 17.0-23.1). The sensitivity and specificity against CO were 87% (95% CI: 83.1-91.6) and 93% (95% CI: 91.9-94.6). The positive predictive value was 76% (95% CI: 73.2-79.8), reflecting COs inability to detect light smoking. The negative predictive value was 97% (95% CI: 95.6-97.8). The best predictors of high CO among reported nonsmokers were being divorced/separated (9.8% had high CO), quitting during pregnancy (8.5% had high CO), being third trimester, and high passive exposure. Some pregnant women may report inaccurately despite validation. Difficulties remain in determining the contributions of passive exposure and inaccurate report to inconsistencies between biochemical and self-report measures.

Smoking care provision in hospitals: a review of prevalence

Hospitals are key settings for the provision of smoking cessation care. Limited data are available that describe the prevalence and type of such care delivered routinely in this setting. We reviewed studies conducted in hospitals and published between 1994 and 2005 that reported levels of smoking care delivery. This review describes the proportion of patients receiving, and the proportion of health professionals providing, various smoking cessation care practices. We used both descriptive and meta-analytic methods. According to the meta-analysis, smoking status was assessed in 60% of patients, 42% were advised or counseled to quit, 14% were provided with or advised to use nicotine replacement therapy (NRT), and 12% received referrals or follow-up. Significantly fewer patients received follow-up or referrals than were assessed for smoking status or received advice or counseling to quit. Some 81% of health professionals reported they assessed smoking status, 70% advised or counseled patients to quit, 13% provided NRT or advised its use, and 39% provided referrals or follow-up. Significantly fewer health professionals advised or prescribed NRT than assessed smoking status or advised or counseled patients to quit. Statistical heterogeneity was indicated for all smoking care practices. Levels of smoking cessation care are less than optimal in hospitals, and the levels of some important care practices are particularly low. Future research should identify effective methods for increasing smoking care provision in this setting. In addition, standardized measures of smoking care should be developed. Hospital organizations should enhance and continue to monitor their delivery of smoking care.

Proactive Telephone Counseling for Smoking Cessation: Meta-analyses by Recruitment Channel and Methodological Quality

BACKGROUND Systematic reviews demonstrated that proactive telephone counseling increases smoking cessation rates. However, these reviews did not differentiate studies by recruitment channel, did not adequately assess methodological quality, and combined different measures of abstinence. METHODS Twenty-four randomized controlled trials published before December 31, 2008, included seven of active recruitment, 16 of passive recruitment, and one of mixed recruitment. We rated methodological quality on selection bias, study design, confounders, blinding, data collection methods, withdrawals, and dropouts, according to the Quality Assessment Tool for Quantitative Studies. We conducted random effects meta-analysis to pool the results according to abstinence type and follow-up time for studies overall and segregated by recruitment channel, and methodological quality. The level of statistical heterogeneity was quantified by I(2). All statistical tests were two-sided. RESULTS Methodological quality ratings indicated two strong, 10 moderate, and 12 weak studies. Overall, compared with self-help materials or no intervention control groups, proactive telephone counseling had a statistically significantly greater effect on point prevalence abstinence (nonsmoking at follow-up or abstinent for at least 24 hours, 7 days before follow-up) at 6-9 months (relative risk [RR] = 1.26, 95% confidence interval [CI] = 1.11 to 1.43, P < .001, I(2) = 21.4%) but not at 12-15 months after recruitment. This pattern also emerged when studies were segregated by recruitment channel (active, passive) or methodological quality (strong/moderate, weak). Overall, the positive effect on prolonged/continuous abstinence (abstinent for 3 months or longer before follow-up) was also statistically significantly greater at 6-9 months (RR = 1.58, CI = 1.26 to 1.98, P < .001, I(2) = 49.1%) and 12-18 months after recruitment (RR = 1.40, CI = 1.23 to 1.60, P < .001, I(2) = 18.5%). CONCLUSIONS With the exception of point prevalence abstinence in the long term, these data support previous results showing that proactive telephone counseling has a positive impact on smoking cessation. Proactive telephone counseling increased prolonged/continuous abstinence long term for both actively and passively recruited smokers.

Increasing smoking cessation care provision in hospitals: A meta-analysis of intervention effect

INTRODUCTION Levels of hospital smoking cessation care are less than optimal. This study aimed to synthesize the evidence regarding the effectiveness of interventions in increasing smoking cessation care provision in hospitals. METHODS A review identified relevant studies published between 1994 and 2006. A description of studies, including methodological quality, was undertaken. Intervention effectiveness in increasing smoking cessation care practices was examined for controlled studies using meta-analysis. Care practices examined were assessment of smoking status; advice to quit; counseling or assistance to quit; advising, offering, or providing nicotine replacement therapy (NRT); and follow-up or referral. RESULTS Of the 25 identified studies, 18 were U.S. based and in inpatient settings. Of the 10 controlled trials, 4 addressed cardiac patients, 5 measured one smoking cessation care practice, and 9 implemented multistrategic interventions (e.g., combining educational meetings with reminders and written resources). The methodology described in these studies was generally of poor quality. Meta-analysis of controlled trials demonstrated a significant intervention effect for provision of assistance and counseling to quit (pooled risk difference = 16.6, CI = 4.9-28.3) but not for assessment of smoking status, advice to quit, or the provision or discussion of NRT. Statistical heterogeneity was indicated for all smoking cessation care practices. An insufficient number of studies precluded the use of meta-analysis for follow-up or referral for further assistance. DISCUSSION Interventions can be effective in increasing the routine provision of hospital smoking cessation care. Future research should use more rigorous study design, examine a broader range of smoking cessation care practices, and focus on hospital-wide intervention implementation.

Training medical practitioners in information transfer skills: the new challenge

Summary. Traditionally, undergraduate medical education has concentrated on teaching students how to gather information or take medical histories from their patients. However, research increasingly indicates that there is a need for medical practitioners to improve their skills in information transfer in a way which will increase the probability that patients are active collaborators in their treatment. Consequently, Newcastle Medical School has sought to develop training packages for medical students in information transfer skills. This paper describes the resulting training programme with particular emphasis on the areas selected for training, the methods by which students are taught, the necessary interactional skills and the assessment procedures which are applied.

Has the investment in public cancer education delivered observable changes in knowledge over the past 10 years

During the 1990s, Western countries, such as Australia, directed substantial funds toward public cancer education. An important indicator of whether this investment has been worthwhile is a shift over time in the proportion of the population who have accurate knowledge regarding cancer.

A randomised controlled trial of proactive telephone counselling on cold-called smokers' cessation rates

Objectives Active telephone recruitment (‘cold calling’) can enrol almost 45 times more smokers to cessation services than media. However, the effectiveness of proactive telephone counselling with cold-called smokers from the broader community is unknown. This study examined whether proactive telephone counselling improved abstinence, quit attempts and reduced cigarette consumption among cold-called smokers. Methods From 48 014 randomly selected electronic telephone directory numbers, 3008 eligible smokers were identified and 1562 (51.9%) smokers recruited into the randomised controlled trial. Of these, 769 smokers were randomly allocated to proactive telephone counselling and 793 to the control (ie, mailed self-help) conditions. Six counselling calls were offered to intervention smokers willing to quit within a month and four to those not ready to quit. The 4-month, 7-month and 13-month follow-up interviews were completed by 1369 (87.6%), 1278 (81.8%) and 1245 (79.9%) participants, respectively. Results Proactive telephone counselling participants were significantly more likely than controls to achieve 7-day point prevalence abstinence at 4 months (13.8% vs 9.6%, p=0.005) and 7 months (14.3% vs 11.0%, p=0.02) but not at 13 months. There was a significant impact of telephone counselling on prolonged abstinence at 4 months (3.4% vs 1.8%, p=0.02) and at 7 months (2.2% vs 0.9%, p=0.02). At 4 months post recruitment, telephone counselling participants were significantly more likely than controls to have made a quit attempt (48.6% vs 42.9%, p=0.01) and reduced cigarette consumption (16.9% vs 9.0%, p=0.0002). Conclusions Proactive telephone counselling initially increased abstinence and quitting behaviours among cold-called smokers. Given its superior reach, quitlines should consider active telephone recruitment, provided relapse can be reduced. Trial registration Australian New Zealand Clinical Trial Registry; ACTRN012606000221550.

Is government action out‐of‐step with public opinion on tobacco control? Results of a New South Wales population survey

Objective: To assess community attitudes towards smoking bans, tobacco availability, promotion and product regulation, tobacco industry donations to political parties, and government spending on tobacco control activities. To compare public preferences on these issues with policies of the NSW and Commonwealth governments.