Associations between Practitioner Personality and Client Quit Rates in Smoking Cessation Behavioural Support Interventions.

Introduction: There is wide variation in the success rates of practitioners employed to help smokers to stop, even once a range of potential confounding factors has been taken into account. Aim: This paper examined whether personality characteristics of practitioners might play a role success rates. Methods: Data from 1,958 stop-smoking treatment episodes in two stop-smoking services (SSS) involving 19 stop-smoking practitioners were used in the analysis. The outcome measure was clients' biochemically verified quit status 4 weeks after the target quit date. The five dimensions of personality, as assessed by the Ten-Item Personality Inventory, were included as predictor variables: openness, conscientiousness, agreeableness, extraversion, and neuroticism. A range of client and other practitioner characteristics were used as covariates. A sensitivity analysis was conducted to determine if managers' ratings of practitioner personality were also associated with clients' quit status. Results: Multi-level random intercept models indicated that clients of practitioners with a higher extraversion score had greater odds of being abstinent at four weeks (self-assessed: OR = 1.10, 95% CI = 1.01-1.19; manager-assessed: OR = 1.32, 95% CI = 1.21-1.44). Conclusions: More extraverted stop smoking practitioners appear to have greater success in advising their clients to quit smoking. Findings need to be confirmed in larger practitioner populations, other SSS, and in different smoking cessation contexts. If confirmed, specific training may be needed to assist more introverted stop smoking practitioners.

Performance of English stop smoking services in first 10 years: analysis of service monitoring data.

OBJECTIVES: To analyse the performance of the English Stop Smoking Services from 2001/02 to 2010/11. DESIGN: Analysis of national service monitoring data. SETTING: England. PARTICIPANTS: Smokers recorded as having been treated by English stop smoking services between April 2001 and March 2011. MAIN OUTCOME MEASURES: Annual figures for the number of quit dates set (throughput), the percentage of these that led to biochemically verified abstinence after four weeks (four week quit rate), and the "impact" in terms of the number of four week quitters beyond those who it is estimated would have stopped with only a prescription for smoking cessation treatment; characteristics of smokers being treated, medication used, and mode of delivery (for example, one to one, group based); variability across local services in throughput, four week quit rates, and impact for 2010/11. RESULTS: Throughput rose from 227,335 in 2001/02 to 787,527 (8% of all smokers) in 2010/11. The percentage of four week quitters declined slightly from 35% to 34%. Impact rose from 22,933 four week quitters created in 2001/02 to 72,411 in 2010/11 (corresponding to an estimated 21,723 12 month quitters). The services were successful in reaching disadvantaged smokers; 54% (n = 425,684) were in receipt of free prescriptions in 2010/11. Substantial variation existed across local services in throughput, success rates, and impact. CONCLUSIONS: The English stop smoking services have had an increasing impact in helping smokers to stop in their first 10 years of operation and have successfully reached disadvantaged groups. However, performance across local services has varied considerably.

Developing the evidence base for addressing inequalities and smoking in the United Kingdom.

AIMS: Smoking is an increasing cause of health inequalities in high-income countries. This supplement describes pilot projects set up in England to develop and test pathways to ensure that disadvantaged groups, where smoking is frequently the norm, are reached, encouraged and supported to stop their tobacco use. Target groups were: smokers attending centres set up for highly deprived parents; smokers with serious and enduring mental illness; pregnant smokers; prisoners/other offenders who smoked; South Asian tobacco chewers; and recent quitters from 'routine and manual' occupational groups. METHODS: Commonalities observed across the six projects are summarized, alongside recommendations for implementation. RESULTS: A significant barrier to implementation was the lack of mandatory identification of tobacco users across primary, secondary and community health-care settings and routine use of expired air carbon monoxide monitoring, particularly for high-risk groups. Appropriate use of financial incentives and national guidance is probably necessary to achieve both this and the adoption of 'joined-up' tobacco dependence treatment pathways for these target groups. Further research is needed on the impact of 'opt out' pathways: while resulting in increased referral rates, success rates were lower. In general, smoking cessation service targets were a barrier to implementation. Flexibility and tailoring of interventions were required and most projects trained those already working in relevant settings, given their greater understanding of target groups. Mandatory training of all frontline health-care staff was deemed desirable. CONCLUSIONS: Implementing the findings of these projects will require resources, for training, incentivizing health-care workers and further research. However, continuing with the status quo may result in sustained tobacco use health inequalities for the foreseeable future.

What makes for an effective stop-smoking service?

BACKGROUND: The English network of stop-smoking services (SSSs) is among the best-value life-preserving clinical intervention in the UK NHS and is internationally renowned. However, success varies considerably across services, making it important to examine the factors that influence their effectiveness. METHODS: Data from 126,890 treatment episodes in 24 SSSs in 2009-10 were used to assess the association between intervention characteristics and success rates, adjusting for key smoker characteristics. Treatment characteristics examined were setting (eg, primary care, specialist clinics, pharmacy), type of support (eg, group, one-to-one) and medication (eg, varenicline, single nicotine replacement therapy (NRT), combination of two or more forms of NRT). The main outcome measure was abstinence from smoking 4 weeks after the target quit date, verified by carbon monoxide concentration in expired air. RESULTS: There was substantial variation in success rates across intervention characteristics after adjusting for smoker characteristics. Single NRT was associated with higher success rates than no medication (OR 1.75, 95% CI 1.39 to 2.22); combination NRT and varenicline were more successful than single NRT (OR 1.42, 95% CI 1.06 to 1.91 and OR 1.78, 95% CI 1.57 to 2.02, respectively); group support was linked to higher success rates than one-to-one support (OR 1.43, 95% CI 1.16 to 1.76); primary care settings were less successful than specialist clinics (OR 0.80, 95% CI 0.66 to 0.99). CONCLUSIONS: Routine clinic data support findings from randomised controlled trials that smokers receiving stop-smoking support from specialist clinics, treatment in groups and varenicline or combination NRT are more likely to succeed than those receiving treatment in primary care, one-to-one and single NRT. All smokers should have access to, and be encouraged to use, the most effective intervention options.

Evaluation of a nationally disseminated self-help intervention for smoking cessation ('Quit Kit').

OBJECTIVE: To assess the extent of uptake and impact of a nationally disseminated self-help intervention for smoking cessation ('Quit Kit'). METHODS: The kit contained practical tools for supporting quit attempts. Of 480,000 individuals receiving the kit, telephone interviews were conducted with 2347 randomly selected individuals. Interviews assessed the impact of the kit on smoking behaviours and on attitudes to the intervention and to health service support. RESULTS: The majority of interviewees reported the kit as being helpful for stopping smoking (61%) and agreed that, having received the kit, they would be more likely to consider the National Health Service for help with quitting (84%). Younger interviewees were significantly more likely to report the kit as helpful, to say they would recommend it to others and to agree that it increased their confidence in quitting (all p≤0.001). As a result of receiving the kit, 29%, 17% and 11% of interviewees, respectively, reported visiting their doctor, pharmacist or stop-smoking service for help with quitting. The kit was reported to have triggered a quit attempt among around half (57%) of those receiving it. When only including those who had received the kit at least 1 month prior to interview, 26.5% (126/475) of those attempting to quit reported remaining completely abstinent from smoking for at least a month. CONCLUSIONS: The findings suggest that distributing a self-help intervention for smoking cessation at a national level may be successful in terms of uptake of the intervention, triggering quit attempts and aiding smoking cessation.

Optimizing on smoke free legislation making the most of the opportunity.

Stop smoking service provision faces significant challenges in optimizing the opportunities raised through the smoke free legislation, which prohibits smoking in a public place. There are a number of innovations in service provision allowing a more tailored and flexible approach to stopping smoking, where the patient requirements are central. Innovations such as cut down then stop (CDTS), combination nicotine replacement therapy (NRT) use, and new drug therapy Champix all provide increased options for the smoker.

A randomized controlled trial of smoking cessation for pregnant women to test the effect of a transtheoretical model-based intervention on movement in stage and interaction with baseline stage.

OBJECTIVES: To examine whether, as predicted by the transtheoretical model (TTM), stage-matched interventions will be more effective than stage-mismatched interventions. DESIGN: Randomized controlled trial of smoking cessation advice to pregnant smokers. METHODS: Pregnant women currently smoking at 12 weeks gestation were enrolled in a pragmatic three-arm trial of TTM-based interventions to help them stop smoking. One arm constituted standard midwifery advice and a self-help leaflet on stopping smoking, which is generally appropriate for women in preparation. Two arms were TTM-based. Differences in positive movement in stage towards quitting from enrolment to 30 weeks gestation and 10 days post-partum were calculated for each arm of the trial. We then examined whether, as predicted from the TTM, the relative benefit of the TTM-based intervention was greater for women in precontemplation and contemplation, for whom the control intervention was stage-mismatched, than for women in preparation, for whom the control intervention was stage-matched. RESULTS: Women in the TTM-based arms were statistically significantly more likely to move forward in stage than were women in the control arm. Contrary to the TTM-derived hypothesis, the greater relative benefit of the TTM-based intervention was seen for women in preparation stage at baseline, rather than women in precontemplation and contemplation. CONCLUSIONS: The TTM-based intervention was more effective in stage movement, but this could be due to its greater intensity. The failure to confirm that stage-matching was important casts doubt on the validity of the TTM in explaining smoking cessation behaviour in pregnancy.

Supporting lifestyle and health-related behaviour change.

This article, the last of eight in the health promotion series, aims to summarise the information presented in the previous articles, and to offer advice and reflective processes to help nurses encourage and support clients through health-related behaviour change.

Supporting vulnerable groups during behaviour change.

This article, the seventh of eight in the health promotion series, aims to inform nurses about the health behaviours and outcomes of vulnerable groups, and to offer strategies for change.

Supporting pregnant women through behaviour change.

This article, the sixth of eight in the health promotion series, aims to offer nurses strategies to help pregnant women identify internal motivators and support them through any behaviour change attempt.

Supporting adolescents through behaviour change.

This article, the fifth of eight in the health promotion series, aims to inform practitioners about potentially harmful health and lifestyle-related behaviours in adolescents, and to provide some strategies for supporting young people to make changes.

Assessing motivation and readiness to alter lifestyle behaviour.

The aim of this article, the second in the health promotion series, is to highlight the importance of assessing clients' motivation and readiness to change, and to offer advice on how to achieve this.

Is advice to stop smoking from a midwife stressful for pregnant women who smoke? Data from a randomized controlled trial.

BACKGROUND: There are no randomized trials examining whether intensive advice to pregnant smokers is more stressful than standard care. METHOD: Nine hundred eighteen U.K. women currently smoking on commencing antenatal care were randomized into three arms. Women in Arm A received one episode of brief advice to stop smoking. Women in Arm B were assessed for stage of change and worked through an exercise in self-help manuals on three occasions. Women in Arm C used a 20-min interactive computer program three times in addition to the intervention women in Arm B received. Stress was assessed by the change in score on the Perceived Stress Scale (PSS) from baseline to 30 weeks gestation, the month before delivery, and 10 days postpartum. RESULTS: There were small and not significant differences in the changes in PSS between the arms at all outcome times. There was no evidence that the importance women attached to pleasing their midwife by stopping, having failed to quit, or nulliparity modified the effect of intensive advice on change in stress levels. CONCLUSIONS.: Intensive advice to stop smoking was not associated with increases in stress. Advice and support for pregnant women to stop smoking should be given without fear of causing stress.

Does stage-based smoking cessation advice in pregnancy result in long-term quitters? 18-month postpartum follow-up of a randomized controlled trial.

AIMS: To evaluate the effect on quitting smoking at 18 months postpartum of smoking cessation interventions based on the Transtheoretical Model (TTM) delivered in pregnancy compared to current standard care. It has been claimed that TTM-based interventions will continue to create quitters after the end of the intervention period. DESIGN: Cluster randomized trial. SETTING: Antenatal clinics in general practices in the West Midlands, UK. PARTICIPANTS: A total of 918 pregnant smokers originally enrolled in the trial, of which 393 women were followed-up at 18 months postpartum. INTERVENTIONS: One hundred general practices were randomized into the three trial arms. Midwives in these practices delivered three interventions: A (standard care), B (TTM-based self-help manuals) and C (TTM-based self-help manuals plus sessions with an interactive computer program giving individualized smoking cessation advice). MEASUREMENTS: Self-reported continuous and point prevalence abstinence since pregnancy. FINDINGS: When combined together, there was a slight and not significant benefit for both TTM arms compared to the control, with an odds ratio (OR) 95% confidence interval (CI) of 1.20 (0.29-4.88) for continuous abstinence. For point prevalence abstinence, the OR (95%CI) was 1.15 (0.66-2.03). Seven of the 54 (13%) women who had quit at the end of pregnancy were still quit 18 months later, and there was no evidence that the TTM-based interventions were superior in preventing relapse. CONCLUSIONS: The TTM-based interventions may have shown some evidence of a short-term benefit for quitting in pregnancy but no benefit relative to standard care when followed-up in the longer-term.

School nurses: policies, working practices, roles and value perceptions.

BACKGROUND: In the UK, school nursing has recently been at the forefront of policy change, with school nurses being considered pivotal to child-centred public health practice. There is very little literature on this topic and, in particular, little that is written from a practitioner perspective. AIM: This paper reports a survey that examines the work of school nurses compared with the expectations of their first line managers and policy-makers in government, in order to discover any potential practical or ideological areas of conflict. METHODS: We first applied a theoretical framework of sensitizing concepts to the historical, political, cultural and contextual background of school nursing. Following this, 46 school nurses in the West Midlands region of the UK were randomly selected and asked to complete a questionnaire about their personal characteristics, experience, training and working practices. The 38 nurses who completed this were then interviewed. Job descriptions for school nurses and governmental job expectations were obtained from various official sources and compared with the self-reported practices of school nurses. FINDINGS: All the nurses met the work criteria of their local employers, except in respect of health needs assessment activities, which two nurses had not yet attempted. All 38 also carried out a range of additional work activities, including providing sexual health services and parental support clinics. They also had a diverse range of skills and qualifications relevant to supporting the needs of their local communities. Qualitative data from interviews provided a useful insight into nurses' feelings of being valued by their clients and by local and national employers, and feelings of professional undervaluing by their peers. They felt positive about role changes in the last few years, and that they supported the child-centred public health role advocated by public policy. CONCLUSIONS: The practice of the school nurses in this study covered what employers and policy-makers required, with the notable exception of health needs assessment, which nurses were uncomfortable and unconfident about. The theoretical framework used provides a useful starting point for examining how school nursing has developed into its current role.

Occupational health and school health: a natural alliance?

BACKGROUND: The United Kingdom National Health Service aims to provide a holistic 'cradle to grave' service. In order to achieve this, systems are in place for effective communication between providers of services for babies and children. However, when children leave school, communication between the school health services and workplace health services to protect and promote the health of the new workforce is rare. Working together is a commonly-stated rhetoric of contemporary nursing theory, but often this is not applied in practice. School health and occupational health have similar aims and objectives and, by working together, may be able to improve the health of large populations for a lifetime. AIM: This paper aims to examine the similarities in principles and practices between school health and occupational health nurses, and to identify areas of overlap in which collaboration could improve care for clients of both services. DISCUSSION: The paper examines the nature of nursing in occupational and school settings, and similarities and differences in policy, law and principles. It also examines these two areas of practice within a public health framework, looking for areas of overlap. A basis is suggested for collaborative working between the two areas, and barriers, facilitators and benefits of this practice are examined. CONCLUSION: We conclude that there does exist a natural alliance between occupational and school health nursing, and that the two should work together to provide continuity of care for clients on leaving school, and to prepare children and young people for the workplace and any special health issues in their chosen careers.

What happens to women's self-reported cigarette consumption and urinary cotinine levels in pregnancy?

AIMS: To describe the pattern of self-reported cigarette consumption and nicotine consumption, measured by urinary cotinine concentration, in a cohort of pregnant women who did not stop smoking. DESIGN: Cohort study. SETTING: Randomly selected general practices from the West Midlands, UK. PARTICIPANTS: Five hundred and fifty-nine pregnant women in a clinical trial who were enrolled at booking for maternity care (about 12 weeks of gestation), who were followed up in mid and late pregnancy and 10 days post-natal and who did not stop smoking during that period. MEASUREMENTS: Retrospectively collected self-reported cigarette consumption prior to pregnancy and contemporaneously collected self-reported cigarette consumption and urinary cotinine concentrations at booking for maternity care, 20 weeks of gestation, 30 weeks of gestation and 10 days post-natal. FINDINGS: Women reported smoking a median of 10-19 cigarettes per day prior to pregnancy and a median of 5-9 cigarettes per day at booking for maternity care. At booking, women reported consuming a mean [95% confidence interval (CI)] of 6.3 (5.6-7.0) cigarettes per day. At 20 weeks of pregnancy this had risen to mean (95% CI) 11.5 (10.9-12.2), and remained at 11 cigarettes per day when measured again at 30 weeks of gestation and 10 days post-natal. Mean (95% CI) urinary cotinine levels at booking were 6.0 (5.4-6.6) microg/mL, and did not change much through pregnancy. There were statistically significant associations between urinary cotinine and reported cigarette consumption at all time points except at booking. CONCLUSIONS: Women smokers report lower cigarette consumption at booking for maternity care than they do prior to pregnancy or from mid pregnancy onwards, but cotinine data imply that their intake of toxins does not change throughout pregnancy. Reports suggesting many women reduce their smoking in pregnancy have probably been over-optimistic.

The problem and management of sickness absence in the NHS: considerations for nurse managers.

AIM: This paper examines the topic of sickness absence management in the context of the healthcare sector. BACKGROUND: National Health Service (NHS) employee absenteeism is an expensive and difficult problem. Nurse managers need to assess the extent and characteristics of absenteeism, be aware of their organization's sickness policies, evaluate the effectiveness of these policies and contribute to the development of related initiatives to ensure prudent management of sickness absence. METHOD: A literature review has been undertaken, providing a broad conceptual context by which the problem of sickness absence in the NHS can be examined. The focus of this paper is to examine the accumulation of research based knowledge to provide a healthcare perspective on the problem of sickness absence management. CONCLUSION: Sickness absence management within the NHS is challenging but provides opportunities to improve the working lives of NHS employees. Sickness absence cannot be eradicated but it can be reduced by a selection of measures that reflect the uniqueness of the NHS. The many and diverse causes of sickness absence need acknowledgement, when devising strategies that can effectively provide solutions to the problems of sickness absence.

A survey of drinking and toilet facilities in local state schools.

The public health role of the school nurse has been formalized recently in several documents. Within that role, they are charged with assessing and responding to health needs of the school-aged population. Children and young people are often accused of making unhealthy choices with regard to their fluid intake, however, there have been informal reports that it is difficult to access water in school. Also, with inclusion for all children high on the agenda, do schools have adequate toileting facilities for children with special needs? This survey used school nurses to assess the access to Midlands schools. It also assessed the cleanliness and facilities available for hand washing and other sanitary processes. It found that many schools are failing to provide the facilities they are expected to. Overcrowding and potentially insanitary conditions were found in a significant proportion of the schools surveyed. Drinking facilities and access was found to be poor. Recommendations are made to begin to address the problems seen here.