Tanja Tomson

Quitline in smoking cessation: A cost-effectiveness analysis

OBJECTIVES The cost-effectiveness of the Swedish quitline, a nation-wide, free of charge service, is assessed. METHODS The study was based on data of a sample of 1131 callers enrolled from February 1, 2000 to November 30, 2001. Outcome was measured as cost per quitter and cost per year of life saved. Cost per quitter was based on a calculation of the total cost of the quitline divided by the number of individuals who reported abstinence after 12 months. The cost per life year saved (LYS) was calculated by the use of data from the literature on average life expectancy for smokers versus quitters, the total cost of the quitline, and the cost of pharmacological treatment. RESULTS The number of smokers who used the quitline and reported abstinence after 1 year was 354 (31 percent). The accumulated number of life years saved in the study population was 2400. The cost per quitter was 1052-1360 USD, and the cost per life year saved was 311-401 USD. A sensitivity analysis showed that, for outcomes down to an abstinence rate of 20 percent, the cost per LYS rose modestly, from 311 to 482 USD. Discounting the cost per LYS showed the cost to be 135 USD for 3 percent and 283 USD for 5 percent. CONCLUSIONS The Swedish quitline is a cost-effective public health intervention compared with other smoking cessation interventions.

Are non-responders in a quitline evaluation more likely to be smokers?

BackgroundIn evaluation of smoking cessation programs including surveys and clinical trials the tradition has been to treat non-responders as smokers. The aim of this paper is to assess smoking behaviour of non-responders in an evaluation of the Swedish national tobacco cessation quitline a nation-wide, free of charge service.MethodsA telephone interview survey with a sample of people not participating in the original follow-up. The study population comprised callers to the Swedish quitline who had consented to participate in a 12 month follow-up but had failed to respond. A sample of 84 (18% of all non-responders) was included. The main outcome measures were self-reported smoking behaviour at the time of the interview and at the time of the routine follow-up. Also, reasons for not responding to the original follow-up questionnaire were assessed. For statistical comparison between groups we used Fischers exact test, odds ratios (OR) and 95% confidence intervals (CI) on proportions and OR.ResultsThirty-nine percent reported to have been smoke-free at the time they received the original questionnaire compared with 31% of responders in the original study population. The two most common reasons stated for not having returned the original questionnaire was claiming that they had returned it (35%) and that they had not received the questionnaire (20%). Non-responders were somewhat younger and were to a higher degree smoke-free when they first called the quitline.ConclusionTreating non-responders as smokers in smoking cessation research may underestimate the true effect of cessation treatment.

Becoming an educational leader – exploring leadership in medical education

Abstract Research on educational leadership emphasizes the importance of having institutional leaders heavily involved with advanced instructional programming. Best practices for developing educational leadership in higher education health care and medical faculties have to be better understood. Within the framework of a seminar series, researchers and practitioners were involved in a dialogical process of inquiry, coupled with an explicit activity-oriented approach emphasizing empowerment among educational leaders. In a reflective paper, 10 participants of the seminar series elaborated on what it meant to develop and to ‘take’ leadership in your professional role and which factors that were identified as adding value to the development of professional leadership expertise. Qualitative content analysis was conducted resulting in thirteen categories reported in relation to Wenger’s theory of communities of practice. The findings show that educational leadership involves processes on the levels of students, teachers as community and at the organizational level. The individuals created a place for backstage conversations at which they got opportunity to develop their thinking and inspiration to break new ideas into their own educational communities. In addition, a systemic approach is essential for the effective implementation of educational leadership to reach all levels via interaction and communication across an organization.

Perceptions and acceptability of pictorial health warning labels vs text only - a cross-sectional study in Lao PDR

BackgroundIn Lao PDR, health warnings were first introduced with printed warning messages on the side of the cigarette package in 1993 and again in 2004. Lao PDR same year ratified the Framework Convention on Tobacco Control (WHO FCTC) but has not yet implemented pictorial health warnings. This paper aims to examine the perception and opinion of policymakers on “text-only” and “pictorial” health warnings and to understand lay people’s perceptions on current health warnings and their opinions on the recommended types of health warnings.MethodsA combination of quantitative and qualitative methods were used in this cross-sectional study conducted in 2008. A purposive sample of 15 policymakers, and a representative sample of 1360 smokers and non-smokers were recruited. A range of different areas were covered including consumer attitudes towards current and proposed cigarette package design, views on health warning messages on the flip/slide and inserts, and views on the relative importance of the size, content and pictures of health warning messages. Descriptive statistics and content analysis were used.ResultsPolicy makers and survey respondents said that the current health warning messages were inappropriate, ineffective, and too small in size. All respondents perceived pictorial health warnings as a potentially powerful element that could be added to the messages that can communicate quickly, and dramatically. The majority of policymakers and survey respondents strongly supported the implementation of pictorial health warnings.The non-smokers agreed that the graphic pictorial health warnings were generally more likely than written health warnings to stimulate thinking about the health risks of smoking, by conveying potential health effects, increasing and reinforcing awareness of the negative health effect of smoking, aiding memorability of the health effects and arousing fear of smoking among smokers.ConclusionsThe study suggested that current warnings are too small and that content is inadequate and designed to be hidden on the side pack. These findings are in line with FCTC’s requirements and provide strong support for introducing pictorial warning labels also in Lao PDR. Furthermore, the awareness of Members of Parliament about tobacco control measures holds promise at the highest political level.

Smoking among Lao medical doctors: challenges and opportunities for tobacco control

Background Smoking is an increasing threat to health in low-income and middle-income countries and doctors are recognised as important role models in anti-smoking campaigns. Objectives The study aimed to identify the smoking prevalence of medical doctors in Laos, their tobacco-related knowledge and attitudes, and their involvement in and capacity for tobacco prevention and control efforts. Methods This was a cross-sectional national survey by a researcher-administered, face-to-face questionnaire implemented at provincial health facilities throughout the central (including national capital), northern and southern regions of Laos in 2007. Both descriptive and inferential statistics were used. Results Of the 855 participants surveyed, 9.2% were current smokers and 18.4% were ex-smokers; smoking was least common in the central region (p<0.05) and far more prevalent in males (17.3% vs 0.4%; p<0.001). Smoking was concentrated among older doctors (p <0.001). Over 84% of current smokers wanted to quit, and 74.7% had made a recent serious attempt to do so. Doctors had excellent knowledge and positive attitudes to tobacco control, although smokers were relatively less knowledgeable and positive on some items. While 78% of doctors were engaged in cessation support, just 24% had been trained to do so, and a mere 8.8% considered themselves ‘well prepared’. Conclusion The willingness of doctors to take up their tobacco control role and the lower smoking rates among younger respondents offers an important window of opportunity to consolidate their knowledge, attitudes, skills and enthusiasm as cessation advocates and supports.

Health policymakers’ knowledge and opinions of physicians smoking and tobacco policy control in Lao PDR

BackgroundIn 2007, a regulation on smoke-free health facilities and institutions was adopted by the Lao government. Little is known about health policymakers’ knowledge and opinions regarding tobacco policy control, including physicians’ behaviour. This paper aims to describe the knowledge of Lao health policymakers and their opinions regarding physicians tobacco use and national smoking policy control.MethodsIn 2007, we made a qualitative explorative study with data from a purposive sample of 18 key informants through semi-structured, face-to-face interviews. The key informants, who were heads of departments, directors of hospitals and directors of centres, mainly worked at the national level, and some provincial levels. Content analysis was used.ResultsPolicymakers perceived the inadequate implementation of a smoke-free regulation and policy as being a barrier and that the general public may not accept physicians smoking, since they are regarded as role models. Most of the respondents mentioned that regulations or laws related to control of smoking in health institutions are available in Laos, but they lacked detailed knowledge of them probably because regulations as well as the smoke-free policy documents were not widely disseminated. The respondents agreed that anti-smoking education should be integrated in the training curricula, especially in the medical schools, and that the provision of counselling on health consequences from smoking and methods of smoking cessation was important.ConclusionThis study contributes to tobacco policy evidence and to knowledge regarding factors related to the uptake of evidence into policymaking. Dissemination and implementation of a tobacco control policy nationally, and integration of tobacco cessation training programs in the curricula were found to be productive approaches for improvement.

Smoking prevalence, determinants, knowledge, attitudes and habits among Buddhist monks in Lao PDR

BackgroundThis cross-sectional study, the first of its kind, uses baseline data on smoking prevalence among Buddhist monks in Northern and Central provinces of Lao PDR.FindingsBetween March and September 2006, 390 monks were interviewed, using questionnaires, to assess smoking prevalence including determinants, knowledge and attitudes. Data entry was performed with Epi-Info (version 6.04) and data analysis with SPSS version 11. Descriptive analysis was employed for all independent and dependent variables. Chi-square or Fishers exact test were used for categorical variables to compare smoking status, knowledge, attitudes and province. Logistic regression was applied to identify determinants of smoking. Daily current smoking was 11.8%. Controlling for confounding variables, age at start of monkhood and the length of religious education were significant determinants of smoking. The majority of the monks 67.9% were in favor of the idea that offerings of cigarettes should be prohibited and that they should refuse the cigarettes offered to them (30.3%) but, in fact, 34.8% of the monks who were current smokers accepted cigarettes from the public.ConclusionSome monks were smokers, whilst they, in fact, should be used as non-smoking role models. There was no anti-smoking policy in temples. This needs to be addressed when setting up smoke-free policies at temples.

Pathways to Smoking and Snus Use Cessation - Is Spontaneous Quitting Underrated?~!2009-12-10~!2010-03-18~!2010-04-20~!

Aim: To investigate to what extent smokers and snus users in Sweden consider and plan their quit attempts in advance, and to assess if spontaneity is associated with success. Methods: A sample of 5999 Swedish men and women between 16 and 80 years were interviewed via telephone about current and former smoking and snus use and their latest quit attempts. Results: Among 2272 ex-smokers and current smokers who had ever made a serious quit attempt 48% reported to not having planned their latest attempt in advance. Furthermore, 40% reported to not even having considered giving up smoking before they actually made the attempt. Of 809 former and current snus users 48% did not plan, and 44% did not consider quitting in advance. Smokers and ex-smokers were more likely to remain smoke-free for at least six months if the attempt was unplanned (sex and age adjusted OR=2.6; 95% CI=1.7-3.8). When dividing the smoking quit attempts into considered versus not considered the advantage of the spontaneous attempts remained (adjusted OR=1.9; CI=1.3-2.9). The corresponding analyses of snus use quitting showed similar advantages for the unplanned and the not considered quit attempts. Conclusions: In Sweden, a considerable proportion of the attempts to quit smoking, as well as to quit using snus, are made without prior consideration or planning. Spontaneous quit attempts appear to have a greater chance of long-term success than those preceded by consideration or planning.

Perceived feasibility of a primary care intervention for Tobacco Cessation on Prescription targeting disadvantaged groups in Sweden: a qualitative study

BackgroundThere is a lack of scientific evidence on how socioeconomically disadvantaged tobacco users can be reached with tobacco cessation interventions in Swedish primary healthcare (PHC). In this setting other lifestyle interventions are available by prescription, and there is the potential to develop a similar tool for tobacco cessation. The aim of this study was thus to explore the perceived feasibility and optimal design of Tobacco Cessation on Prescription (TCP) in PHC, targeting disadvantaged groups in Sweden.MethodsThis qualitative study is based on semi-structured interviews with 32 participants including (1) three experts in lifestyle interventions on prescription, (2) 14 healthcare providers and (3) 15 clients from three PHC centres in socioeconomically disadvantaged areas in Stockholm where tobacco use is high. The interviews were audio-recorded and transcribed verbatim. The manifest content of the transcripts was analysed according to a modified conventional approach to content analysis.ResultsThe interviewees proposed that TCP should include a template comprising the client’s information, evidence-based tobacco cessation options and choices for follow-up. They also suggested including information about the benefits of tobacco cessation, as well as empowerment and planning support tools. The participants also commented that other measures for tobacco cessation could be included on the prescription. From the clients’ point of view, the perceived advantages of TCP were often linked to an emotional meaning (e.g. increased motivation to quit tobacco use, sign of support from the healthcare system to seek care for tobacco cessation). For providers, advantages with TCP were frequently related to a practical meaning (e.g. improved documentation and facilitation of tobacco cessation treatment). The disadvantages identified were mainly connected with the future implementation of TCP (e.g. low self-efficacy among clients and providers).ConclusionsTCP was perceived to be a useful tool for both clients and providers, potentially facilitating a structured and effective approach to tobacco cessation in PHC, and targeting disadvantaged groups. More research is needed to develop the prescription and investigate its effectiveness and cost-effectiveness compared to current strategies for tobacco cessation in a PHC setting.

A Cluster-Randomized Controlled Trial Evaluating the Effectiveness and Cost-Effectiveness of Tobacco Cessation on Prescription in Swedish Primary Health Care: A Protocol of the Motivation 2 Quit (M2Q) Study

Background In Sweden, the prevalence of tobacco use is disproportionately high among socioeconomically disadvantaged groups. Previous research and clinical experience suggest that prescribed lifestyle interventions in the primary health care (PHC) setting such as Physical Activity on Prescription are effective in changing behavior. However, there is a lack of evidence for if and how such a prescription approach could be effectively transferred into the tobacco cessation context. Objective The aim of this trial is to evaluate the effectiveness and cost-effectiveness of Tobacco Cessation on Prescription (TCP) compared to current practice for tobacco cessation targeting socioeconomically disadvantaged groups in the PHC setting in Sweden. Methods The design is a pragmatic cluster-randomized controlled trial. The sample will consist of 928 daily tobacco users with Swedish social security numbers and permanent resident permits, recruited from 14-20 PHC centers located in socioeconomically disadvantaged areas in Stockholm County. The primary outcome will be measured in self-reported 7-day abstinence at 6 and 12 months after the intervention. The secondary outcomes will be measured in daily tobacco consumption, number of quit attempts, and health-related quality of life at 6 and 12 months after the intervention. Data will be collected through questionnaires and review of electronic medical records. Cost-effectiveness will be estimated through decision analytic modeling and measured by the incremental cost per quality-adjusted life year. Results In the first set of PHC centers participating in the study, eight centers have been included. Recruitment of individual study participants is currently ongoing. Inclusion of a second set of PHC centers is ongoing with expected study start in September 2016. Conclusions If TCP is found effective and cost-effective compared to standard treatment, the method could be implemented to facilitate tobacco cessation for socioeconomically disadvantaged groups in the PHC setting in Sweden. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 11498135; http://www.isrctn.com/ISRCTN11498135 (Archived by WebCite at http://www.webcitation.org/6kTu6giYQ)