The effectiveness of workplace smoking cessation programmes: a meta-analysis of recent studies.

OBJECTIVE: Using meta-analytic procedures, we compare the effectiveness of recent controlled trials of worksite smoking cessation during the 1990s with a previous meta-analysis of programmes conducted in the 1980s. DATA SOURCES: ABI/Inform, BRS, CHID, Dissertation Abstracts International, ERIC, Medline, Occupational Health and Safety Database, PsycInfo, Smoking and Health Database, SSCI, and Sociological Abstracts. STUDY SELECTION: Controlled smoking cessation interventions at the workplace with at least six months follow up published from 1989 to 2001 and reporting quit rates (QRs). DATA EXTRACTION: Two reviewers independently scanned titles/abstracts of relevant reports, and we reached consensus regarding inclusion/exclusion of the full text reports by negotiation. A third reviewer resolved disagreements. Two reviewers extracted data according to a coding manual. Consensus was again reached through negotiation and the use of a third reviewer. DATA SYNTHESIS: 19 journal articles were found reporting studies conforming to the study's inclusion criteria. Interventions included self help manuals, physician advice, health education, cessation groups, incentives, and competitions. A total of 4960 control subjects were compared with 4618 intervention subjects. The adjusted random effects odds ratio was 2.03 (95% confidence interval 1.42 to 2.90) at six months follow up, 1.56 (95% CI 1.17 to 2.07) at 12 months, and 1.33 (95% CI 0.95 to 1.87) at more than 12 months follow up. Funnel plots were consistent with strong publication bias at the first two follow ups but not the third. In Fisher et al's 1990 study, the corresponding ORs were 1.18, 1.66, and 1.18. CONCLUSIONS: Smoking cessation interventions at the worksite showed initial effectiveness, but the effect seemed to decrease over time and was not present beyond 12 months. Compared to the Fisher (1990) analysis, the effectiveness was higher for the six month follow up. Disappointingly, we found methodological inadequacies and insufficient reporting of key variables that were similar to those found in the earlier meta-analysis. This prevented us from determining much about the most effective components of interventions. It is advisable for researchers conducting studies in the future to report data on attrition and retention rates of participants who quit, because these variables can affect QRs.

Gender, weight concerns, and adolescent smoking.

This study examined the beliefs that adolescents' hold regarding smoking and weight. In particular, this study examined the relationship between smoking status and self-perceptions of body weight. In addition, it examined gender and age differences in adolescent male and female smokers' beliefs about smoking and weight control. Analyses were conducted on the telephone interview responses of 1,200 adolescent smokers and nonsmokers between the ages of 12 and 17. Chi-square analyses were utilized for univariate comparisons, and logistic regression for multivariate comparisons. Results revealed gender and age differences in perceptions of body weight. In addition, female smokers were more likely than male smokers to adhere to the belief that smoking controlled weight. While no relationship was observed between males' perceived weight and their smoking status, females who perceived themselves to be either overweight or underweight were more likely to smoke. Findings suggest a gender bias in processing social/environmental cues linking smoking and weight control.

The co-occurrence of smoking and binge drinking in adolescence.

The present work sought to determine adolescent rates of smoking and binge-drinking co-occurrence. Secondary analyses were conducted on the interview responses of more than 4,000 adolescents between the ages of 13 and 18 who took part in the 1995 National Household Survey on Drug Abuse. Results revealed that not only are adolescent smokers likely to be binge drinkers, but adolescent binge drinkers are also likely to be smokers. Conversely, those who abstain from involvement with one of these substances generally abstain from the other as well. The discussion highlighted race/ethnic and gender differences in co-occurrence rates as well as prevention and intervention implications.

The relationship between adolescent smoking and drinking and likelihood estimates of illicit drug use.

Using data from a recent national survey of adolescent substance use, the present work examined whether adolescents with different patterns of alcohol and cigarette use differed in their estimates of the likelihood they would use an illegal drug in the future. While nonusers of either substance were the most likely to indicate that they would never use drugs in the future, users of both substances were the most likely to indicate that they would use drugs. In addition, while users of both were most likely to indicate that they were likely to use illegal substances, only-smokers were more likely than only-drinkers to indicate that they were likely to use such substances in the future. Results are discussed in terms of the gateway theory of drug sequencing and cognitive precursors of experimentation with illegal substances.

Age-related differences in adolescent smokers' and nonsmokers' assessments of the relative addictiveness and health harmfulness of cigarettes, alcohol, and marijuana.

The present work was undertaken to determine how general beliefs about various substances and substance use behaviors change during adolescence. Secondary analyses were carried out on the telephone interview responses of 1,200 adolescent smokers and nonsmokers between the ages of 12 and 17. The specific beliefs regarding which substances were hardest to stop using and which were the most harmful to one's health by smoking status and age were compared using Chi-squared analyses for univariate comparisons, and polytomous logistic regression for multivariate analyses. Results revealed that the youngest cohort believed that marijuana was the substance most difficult to stop using while the oldest cohort believed that cigarettes were the hardest to stop using. A similar pattern was observed regarding which substance was the most harmful to one's health. While smokers believed that cigarettes were both the hardest to stop using and the most harmful, nonsmokers were divided between cigarettes and marijuana as the hardest to stop using, and indicated that marijuana, rather than cigarettes, were most harmful. Results are discussed in terms of their implications for substance abuse prevention and the development of relative risk assessments.

Concern about weight gain associated with quitting smoking: prevalence and association with outcome in a sample of young female smokers.

This study investigated the relationship between weight gain concern and outcomes of a large-scale smoking cessation study among 506 young female smokers attending Planned Parenthood clinics. Results of this prospective study did not support the clinical importance of weight gain concerns. Using an index of weight concern that was predictive in previous research, baseline weight concern was unrelated to smoking cessation efforts, whether participants made a quit attempt, reduced the number of cigarettes they smoked, or reported a change in self-efficacy for stopping smoking. Both the overall level of concern expressed in this sample of predominantly White young women and the lack of relationship between weight gain concern and smoking cessation outcomes suggest that weight gain concern may not be a critical factor for cessation programs targeting similar female smokers.

Evaluating the public health impact of health promotion interventions: the RE-AIM framework.

Progress in public health and community-based interventions has been hampered by the lack of a comprehensive evaluation framework appropriate to such programs. Multilevel interventions that incorporate policy, environmental, and individual components should be evaluated with measurements suited to their settings, goals, and purpose. In this commentary, the authors propose a model (termed the RE-AIM model) for evaluating public health interventions that assesses 5 dimensions: reach, efficacy, adoption, implementation, and maintenance. These dimensions occur at multiple levels (e.g., individual, clinic or organization, community) and interact to determine the public health or population-based impact of a program or policy. The authors discuss issues in evaluating each of these dimensions and combining them to determine overall public health impact. Failure to adequately evaluate programs on all 5 dimensions can lead to a waste of resources, discontinuities between stages of research, and failure to improve public health to the limits of our capacity. The authors summarize strengths and limitations of the RE-AIM model and recommend areas for future research and application.

Interactive computer technology, behavioral science, and family practice.

In this paper we discuss conceptual and practical uses for interactive computer applications (ICAs) for family practice, with an emphasis on implications for patient self-management, physician-patient relationships, primary care research, and health care systems quality improvement. We discuss recent behavioral science advances in patient self-management and the advantages and potential limitations of ICAs for medicine. We describe the benefits and risks of using ICAs for providing information, coping-skills training, and social support for patients and for improving the consistency and quality of care given by physicians. There are currently many effective ICAs, and they will play a central role in future health care. There is also the risk of inappropriate use of ICAs. We provide a summary of the empirical literature examining the use of ICAs to aid patients and providers in behavioral change and guidelines adherence efforts. We advise those people researching and applying ICAs in health care to be bold in what they attempt, but cautious in what they claim. Rigorous scientific evaluation and standardized reporting criteria can help quicken this advance, and there are important policy and ethical issues to consider. We conclude with a list of issues for family practices to consider when selecting and using ICAs.

Diabetes care practices in primary care: results from two samples and three measurement sets.

PURPOSE: There has been substantial recent interest in diabetes disease management interventions, guidelines, and care practices. As the vast majority of diabetes care occurs in primary care settings, it makes sense to evaluate current levels of recommended practices in different primary care settings. METHODS: We report on two separate studies that included a combined total of 389 patients seen by over 30 different providers. Three different sets of recommended practices were assessed: (1) the ADA provider recognition measures, (2) the proposed Diabetes Quality Improvement Project measures, and (3) the state of Oregon Population-Based Guidelines for Diabetes. RESULTS: In general, there was only a moderate level of adherence to recommended practices, and adherence was much lower for behavioral or patient-focused practices as contrasted with laboratory tests. There was considerable variability across providers and across different guidelines activities. CONCLUSIONS: Policy and quality improvement implications and future research issues are discussed, including the need for studying different measurement approaches for evaluating guidelines adherence.

Social support, self-management, and quality of life among participants in an internet-based diabetes support program: a multi-dimensional investigation.

The purpose of this study was to evaluate the relationship of three social support measurement approaches to three criteria: (a) use of an Internet-based disease management system, (b) diabetes self-management, and (c) quality of life. An online survey was conducted among participants on the "D-Net" (Diabetes Network) website, which provided information and support for adults with diabetes mellitus: A total of 221 respondents completed (a) items from the Interpersonal Support Evaluation Checklist, a measure of general support; (b) the Diabetes Support Scale, a new measure of disease-specific informational, advice, and empathic support; and (c) the Chronic Illness Support Survey, a measure based on a social ecologic framework to assess support received for chronic illness management from six different sources (personal, family and friends, health care team, worksites and organizations, neighborhood and community, and media/public policy). Although the three measures were moderately intercorrelated (r = .26-.45), each was related to different aspects of D-Net use, diabetes management, and quality of life. These results remained significant after adjusting for demographic and medical condition factors (partial correlations of.15 to.33). This study illustrates the importance of a multidimensional approach to measuring social support and computer-mediated health outcomes. The advantages and disadvantages of applying these different conceptualizations of support in health promotion programs are discussed, and opportunities for future research are identified.

Smoking-specific weight gain concerns and smoking cessation in a working population.

Smoking cessation rates, progression in stage of change for smoking cessation, and serious quit attempts were examined over 2 years in a cohort of 242 men and women smokers (mean age 39.7 years, mean body mass index [BMI] 26.3) as a function of expressing concern about gaining weight because of quitting smoking. Participants were employees of 25 companies who were in a worksite health promotion program aimed at reducing risk factors for cardiovascular disease. Multivariate odds ratios (controlled for age, education, job class, sex, and BMI) for quitting smoking, attempting to quit smoking, and progressing in stage of change for smoking cessation as a function of weight concern were not significant. Interactions between sex and weight concern, and BMI and weight concern were also not significant. These findings, in a working, predominantly blue-collar population, and those of other studies, suggest that concern about gaining weight is, at best, a weak predictor of change in smoking behavior among most smokers.

Traumatic events and post-traumatic stress disorder in cocaine users entering private treatment.

We investigated traumatic events, post-traumatic stress disorder (PTSD), and psychiatric comorbidity in 450 men and women entering private, hospital-based treatments for cocaine dependence. Overall prevalence of event exposure was the same for women and men; however, women were approximately five times more likely than men to be diagnosed with lifetime and current PTSD. Women experienced more PTSD than men even when exposed to the same type of event. In most subjects with PTSD, onset of the disorder preceded onset of cocaine dependence. Subjects with PTSD were more likely than those without PTSD to have additional co-occurring mental disorders. Findings from this relatively affluent, privately treated sample suggest that PTSD and cocaine dependence are related, independent of patients' resources. They further indicate that the relationship between gender and PTSD is robust across patient populations. More complex examinations of PTSD, cocaine dependence, and gender are needed to better understand these relationships and to design effective interventions.

Take Heart II: replication of a worksite health promotion trial.

The purpose of this study was to evaluate the effects of a revised worksite health promotion program that featured an employee steering committee/menu approach to intervention. The "Take Heart II" program was evaluated using a quasi-experimental matched-pair design with worksite as the unit of analysis. Experimental and control worksites did not differ on baseline organizational or employee demographic variables or on baseline levels of dependent variables. Outcome and process results revealed consistent, but modest effects favoring intervention worksites on most measures. Cross-sectional analyses generally failed to produce statistically significant intervention effects, but cohort analyses revealed significant beneficial effects of the Take Heart II intervention on eating patterns, behavior change attempts, and perceived social support. Neither analysis detected a beneficial effect of intervention on cholesterol levels.

Telephone counseling for smoking cessation: rationales and meta-analytic review of evidence.

We review the various ways in which telephone counseling has been used in smoking cessation programs. Reactive approaches--help lines or crisis lines--attract only a small percentage of eligible smokers but are sensitive to promotional campaigns. While difficult to evaluate, they appear to be efficacious and useful as a public intervention for large populations. Proactive phone counseling has been used in a variety of ways. In 13 randomized trials, most showed significant short-term (3-6 month) effects, and four found substantial long-term differences between intervention and control conditions. A meta-analysis of proactive studies using a best-evidence synthesis confirmed a significant increase in cessation rates compared with control conditions [pooled odds ratios of 1.34 (1.19-1.51) and 1.20 (1.06-1.37) at short- and long-term follow-up, respectively]. Proactive phone counseling appeared most effective when used as the sole intervention modality or when augmenting programs initiated in hospital settings. Suggestions for further research and utilization are offered.

Tobacco policy rating form: a tool for evaluating worksite and tribal smoking control policies.

OBJECTIVE: To report on the development and validation of a rating scale to code the various components of written tobacco policies. DESIGN: A one-page Tobacco Policy Rating Form (TPRF) was developed to apply to written policies in both worksites and American Indian tribes. Fifteen worksite and 24 tribal tobacco policies from a diverse set of companies and tribes of varying size and economic status were rated on the TPRF by two separate sets of experienced and inexperienced raters. Kendall's coefficient of concordance (W) was computed to measure inter-rater agreement. RESULTS: The scale was found to produce a high level of agreement when used by both experienced and inexperienced raters on both tribal and worksite policies. For experienced raters, W = 0.92, P < 0.0001 for tribal policies and W = 0.97, P < 0.0001 for worksite policies; for inexperienced raters, W = 0.89, P < 0.0001 for tribal policies and W = 0.96, P < 0.0001 for worksite policies. CONCLUSIONS: The TPRF seems worthy of future use as a tool to rate the strength and comprehensiveness of written tobacco policies. It may be extended to other settings such as schools and municipalities, or used by investigators studying behavioural or economic consequences of smoking policies. Those interested in policy change may find the TPRF useful as a way of describing existing policies and as a quantitative measure of change.

Take heart: results from the initial phase of a work-site wellness program.

OBJECTIVES: The purpose of this study was to evaluate the short-term effects of a low-intensity work-site heart disease risk reduction program using a matched pair design with work site as the unit of analysis. METHODS: Twenty-six heterogeneous work sites with between 125 and 750 employees were matched on key organization characteristics and then randomly assigned to early or delayed intervention conditions. Early intervention consisted of an 18-month multifaceted program that featured an employee steering committee and a menu approach to conducting key intervention activities tailored to each site. RESULTS: Cross-sectional and cohort analyses produced consistent results. At the conclusion of the intervention, early and delayed intervention conditions did not differ on changes in smoking rates, dietary intake, or cholesterol levels. There was considerable variability in outcomes among work sites within each condition. CONCLUSIONS: Despite documented implementation of key intervention activities and organization-level changes in terms of perceived support for health promotion, this intervention did not produce short-term improvements beyond secular trends observed in control work sites. Research is needed to understand determinants of variability between work sites.

Modifying dietary and tobacco use patterns in the worksite: the Take Heart Project.

This article describes the conceptual basis, design, and intervention approach for a worksite-based heart disease risk reduction project. Baseline characteristics of the 26 moderate size worksites participating in the Take Heart Project are also described. The trial is designed to produce changes at both the organization and employee level on tobacco use, dietary fat intake, and serum cholesterol. A key feature of the intervention is creation of employee steering committees to enhance ownership and involvement. From a menu of brief, low-intensity health education and environmental change activities, these committees select activities best suited to their worksite. The baseline characteristics of organizations randomized to intervention and control conditions were similar, and indicated a relatively high level of worksite activity related to cholesterol and smoking.

Results of a year-long incentives-based worksite smoking-cessation program.

This study evaluated the impact of a year-long incentives-based worksite smoking-cessation program. Nineteen moderate-sized worksites, employing a total of approximately 1100 smokers, were randomized to Incentive or No Incentive conditions. All identified smokers in the worksite were considered as subjects, whether or not they participated in the intervention. Analyses were conducted at both the worksite and individual level, and using both self-reported and biochemically validated cessation as endpoints. The incentive program did not significantly improve cessation rates at either the 1-year or 2-year follow-up assessments. We conclude that more broadly focused interventions that also address worksite smoking policies, skills training, and cessation resources, or programs that target additional risk factors are needed to substantially enhance quit rates.