Effects of motivational interviewing on smoking cessation in adolescents with psychiatric disorders.

OBJECTIVE: To test the hypothesis that among adolescent smokers hospitalised for psychiatric and substance use disorders, motivational interviewing (MI) would lead to more and longer quit attempts, reduced smoking, and more abstinence from smoking over a 12 month follow up. DESIGN: Randomised control trial of MI versus brief advice (BA) for smoking cessation, with pre- and post-intervention assessment of self efficacy and intentions to change, and smoking outcome variables assessed at one, three, six, nine, and 12 month follow ups. SETTING: A private, university affiliated psychiatric hospital in Providence, Rhode Island, USA. PATIENTS OR OTHER PARTICIPANTS: Consecutive sample (n = 191) of 13-17 year olds, admitted for psychiatric hospitalisation, who smoked at least one cigarette per week for the past four weeks, had access to a telephone, and did not meet DSM-IV criteria for current psychotic disorder. INTERVENTIONS: MI versus BA. MI consisted of two, 45 minute individual sessions, while BA consisted of 5-10 minutes of advice and information on how to quit smoking. Eligible participants in both conditions were offered an eight week regimen of transdermal nicotine patch upon hospital discharge. MAIN OUTCOME MEASURES: Point prevalence abstinence, quit attempts, changes in smoking rate and longest quit attempt. Proximal outcomes included intent to change smoking behaviour (upon hospital discharge), and self efficacy for smoking cessation. RESULTS: MI did not lead to better smoking outcomes compared to BA. MI was more effective than BA for increasing self efficacy regarding ability to quit smoking. A significant interaction of treatment with baseline intention to quit smoking was also found. MI was more effective than BA for adolescents with little or no intention to change their smoking, but was actually less effective for adolescents with pre-existing intention to cut down or quit smoking. However, the effects on these variables were relatively modest and only moderately related to outcome. Adolescents with comorbid substance use disorders smoked more during follow up while those with anxiety disorders smoked less and were more likely to be abstinent. CONCLUSIONS: The positive effect of MI on self efficacy for quitting and the increase in intention to change in those with initially low levels of intentions suggest the benefits of such an intervention. However, the effects on these variables were relatively modest and only moderately related to outcome. The lack of overall effect of MI on smoking cessation outcomes suggests the need to further enhance and intensify this type of treatment approach for adolescent smokers with psychiatric comorbidity.

Nutrition counseling in the promoting cancer prevention in primary care study.

BACKGROUND: Little is known about the influence of personal and practice-level factors on physicians' dietary counseling practices. METHODS: Primary care physicians (n = 130) were surveyed regarding the frequency that they "ask" patients about their diet, "assess" patients' reasons for and against dietary changes, "advise" patients to eat less fat and more fiber, "assist" patients in changing their diet, and "arrange" a follow-up contact to discuss their diet. In addition, physicians were asked their personal dietary practices, counseling confidence, practice demographics, and medical specialty. RESULTS: Physicians who (a) reported consistently avoiding dietary fat, (b) were more confident in their diet counseling abilities, and (c) were sole owners of their practice were more likely to counsel than physicians who were employees or part owners of the practice. For example, physicians who reported consistently avoiding dietary fat (50.7% of physicians) were 3.2 (95% CI: 1.3-7.9) times more likely to "ask" their patients about their diet and 3.5 (95% CI: 1.5-8.6) times likely to "advise" their patients to eat less fat and more fiber. CONCLUSIONS: Given the strong and consistent effects of a physician's dietary pattern on their counseling practices, future studies should examine the impact of modifying a physician's diet on their patients' dietary behavior.

Dissemination of the AHCPR clinical practice guideline in community health centres.

OBJECTIVE: To evaluate dissemination of the Agency for Health Care Policy and Research (AHCPR) Smoking cessation clinical practice guideline in community health centres. DESIGN: Pre- and post-trial. SETTING: Fourteen community health centres in Rhode Island. SUBJECTS: Provider performance was assessed with 1798 and 1591 patient contacts, in pre-post cross sectional consecutive samples, respectively, and 891 contacts at one year follow up. INTERVENTIONS: Three, one hour on-site provider training sessions, on review of effective tobacco interventions, use of office systems, and tobacco counselling skill building. OUTCOME MEASURES: Chart documentation of four A's (Ask, Advise, Assist, and Arrange follow up) at most recent primary care visit. RESULTS: While average performance rates increased for Ask and Advise (from 30% to 44%, and 19% to 26%, pre-post, respectively), significant increases were found only for some visit types, with further differences by patient sex. There were significant increases for Ask for all except obstetric/gynaecological (ob/gyn) visit types. Patients at yearly physicals and first visits were more likely to be asked at all time points, while males were more likely to be asked at acute visits than were females. There were no significant increases for Advise, Assist, and Arrange across time, although female patients showed a differential increase in Advise post-training. Advise was significantly more likely in yearly physicals and first visits, and less likely in ob/gyn visits, at all time points. CONCLUSIONS: This guideline dissemination effort resulted in quite different provider counselling rates across patient sexes, and visit types. Guideline implementation may require more sustained efforts, with multiple strategies, which are reinforced at higher policy levels, to more fully integrate tobacco interventions into routine primary care practice with all patients who smoke.

The development of a decisional balance measure of physician smoking cessation interventions.

BACKGROUND: Decreasing the prevalence of smoking is an important health care goal, and there is evidence that physicians' advice to quit is an important motivator for patients. However, fewer than half of smokers report that they have ever been advised to quit. This study was conducted to develop a decisional balance measure for physician delivery of smoking cessation interventions. METHODS: This study included a convenience sample of 155 primary care physicians. A decisional balance measure was developed using item generation and development, pilot testing, and principal components analyses. Validity was established by relating the decisional balance measure to a previously validated item of counseling behavior and to physician stage of readiness to deliver smoking cessation counseling. RESULTS: Based on principal components analyses and item analyses, the final measure consisted of 10 Pro and 10 Con items with coefficient alpha of 0.83 and 0.86. The Pros and Cons scales were significantly associated with self-reported counseling to patients who smoke and to stage of readiness to deliver smoking cessation counseling. CONCLUSIONS: A decisional balance measure of physician smoking cessation interventions can be used to assist investigators in developing effective interventions to enhance the delivery of smoking cessation interventions in primary care settings.

Cognitive-behavioral treatment for depression in smoking cessation.

Cigarette smokers with past major depressive disorder (MDD) received 8 group sessions of standard, cognitive-behavioral smoking cessation treatment (ST; n = 93) or standard, cognitive-behavioral smokiig cessation treatment plus cognitive-behavioral treatment for depression (CBT-D; n = 86). Although abstinence rates were high in both conditions (ST, 24.7%; CBT-D, 32.5%, at 1 year) for these nonpharmacological treatments, no main effect of treatment was found. However, secondary analyses revealed significant interactions between treatment condition and both recurrent depression history and heavy smoking ( > or =25 cigarettes a day) at baseline. Smokers with recurrent MDD and heavy smokers who received CBT-D were significantly more likely to be abstinent than those receiving ST (odds ratios = 2.3 and 2.6, respectively). Results suggest that CBT-D provides specific benefits for some, but not all, smokers with a history of MDD.

Cognitive avoidance as a method of coping with a provocative smoking cue: the moderating effect of nicotine dependence.

Both nicotine dependence and coping are important determinants of smoking cessation, yet little is understood about mechanisms that link the two. This laboratory study investigated how nicotine dependence moderates execution of an avoidance coping strategy. High and low dependent smokers were exposed to a provocative smoking cue (in vivo) under two instructional sets: cognitive avoidance coping and no coping. Contrary to hypotheses, high dependent smokers reported greater increases in perceived self-efficacy to not smoke and also demonstrated greater facility in processing coping/nonsmoking-related information on a reaction time task, compared with low dependent smokers. These counterintuitive findings are discussed in terms of how nicotine dependence may affect the cognitive process of coping.

The impact of the basic skin cancer triage curriculum on provider's skin cancer control practices.

OBJECTIVE: To evaluate the effect of a 2-hour, multicomponent educational intervention on provider skin cancer control practices. DESIGN: Nonrandomized intervention study. The intervention was a 2-hour curriculum designed to augment provider skin cancer control practices through instruction in basic skin cancer triage (BSCT) and a brief summary of skin cancer epidemiology, prevention, and counseling. SETTING: Five staff-model health maintenance organizations in southeastern New England. PARTICIPANTS: Convenience sample of primary care providers. Providers older than age 75, individuals in practice for less than 1 year, or individuals planning to retire in the next 2 years were excluded from the study. Twenty-two of 28 participants completed the study. RESULTS: Providers completed preintervention and postintervention surveys asking them to rate their attitudes towards skin examination and skin cancer counseling and to rate the frequency of their skin cancer control practices, using 5-point Likert scales. We independently assessed provider behavior through surveys of their patients, eliciting information on provider practices before and after BSCT participation. Following participation in the curriculum, there was significant improvement in provider attitudes towards the total body skin examination but not towards skin cancer prevention counseling. Significant increases in provider self- reported skin cancer control practices during an initial visit with a new patient (2.17 to 3.21, P <.0001) and a routine visit with a patient at high risk for melanoma (2.15 to 3.00, P <.0001) were demonstrated. Analysis of the patient exit interviews independently confirmed these changes in practice patterns. CONCLUSIONS: The study results suggest that the BSCT curriculum may be a useful tool in increasing the practice of skin cancer control measures by primary care providers.

Physician-based activity counseling: intervention effects on mediators of motivational readiness for physical activity.

In theory-based interventions for behavior change, there is a need to examine the effects of interventions on the underlying theoretical constructs and the mediating role of such constructs. These two questions are addressed in the Physically Active for Life study, a randomized trial of physician-based exercise counseling for older adults. Three hundred fifty-five patients participated (intervention n = 181, control n = 174; mean age = 65.6 years). The underlying theories used were the Transtheoretical Model, Social Cognitive Theory and the constructs of decisional balance (benefits and barriers), self-efficacy, and behavioral and cognitive processes of change. Motivational readiness for physical activity and related constructs were assessed at baseline, 6 weeks, and 8 months. Linear or logistic mixed effects models were used to examine intervention effects on the constructs, and logistic mixed effects models were used for mediator analyses. At 6 weeks, the intervention had significant effects on decisional balance, self-efficacy, and behavioral processes, but these effects were not maintained at 8 months. At 6 weeks, only decisional balance and behavioral processes were identified as mediators of motivational readiness outcomes. Results suggest that interventions of greater intensity and duration may be needed for sustained changes in mediators and motivational readiness for physical activity among older adults.

Individual differences in responses to the first cigarette following overnight abstinence in regular smokers.

We utilized cluster analysis to identify individual differences in response to the initial effects of smoking following overnight abstinence among 183 regular smokers. Participants smoked three cigarettes (1 mg nicotine, spaced 30 min apart) in standardized fashion and completed questionnaires about their subjective responses to each cigarette. Heart rate was monitored throughout the procedure. Participants were grouped into two clusters based on their reported subjective effects and heart rate changes to the first cigarette. Clusters differed in terms of greater increases in heart rate, reports of dizziness, sweating, unpleasantness, nausea, and buzzing sensations in one group compared to the other group. The smokers showing increased responses developed greater acute tolerance to the effects of smoking subsequent cigarettes on subjective negative effects and heart rate, and experienced greater negative affect after quitting. These results are partially consistent with a nicotine sensitivity interpretation or a tolerance model of the effects of initial smoking.

Behavioral science research in diabetes: lifestyle changes related to obesity, eating behavior, and physical activity.

Lifestyle factors related to obesity, eating behavior, and physical activity play a major role in the prevention and treatment of type 2 diabetes. In recent years, there has been progress in the development of behavioral strategies to modify these lifestyle behaviors. Further research, however, is clearly needed, because the rates of obesity in our country are escalating, and changing behavior for the long term has proven to be very difficult. This review article, which grew out of a National Institute of Diabetes and Digestive and Kidney Diseases conference on behavioral science research in diabetes, identifies four key topics related to obesity and physical activity that should be given high priority in future research efforts: 1) environmental factors related to obesity, eating, and physical activity; 2) adoption and maintenance of healthful eating, physical activity, and weight; 3) etiology of eating and physical activity; and 4) multiple behavior changes. This review article discusses the significance of each of these four topics, briefly reviews prior research in each area, identifies barriers to progress, and makes specific research recommendations.

Methods to enhance smoking cessation after myocardial infarction.

The evidence linking smoking and coronary artery disease is quite strong, and there is also a positive relationship between smoking cessation and reduction in cardiovascular disease risk. Nicotine replacement therapy and bupropion are effective treatments for smoking cessation and are most effective when combined with behavioral counseling. Intensive multicomponent interventions that include a case-management component have produced the highest smoking cessation rates for patients who suffer a myocardial infarction.

The use of nicotine replacement therapy during hospitalization.

Recent findings suggest that smokers who are hospitalized experience significant craving for cigarettes. Thus, nicotine replacement therapy (NRT) may be a particularly important tool for use during hospitalization. The goal of this study is to evaluate the utilization of the transdermal nicotine patch and/or nicotine gum by hospitalized smokers. The data represented in this article are from 580 smokers who participated in a study of a motivational intervention for smoking cessation that was delivered during hospitalization. The primary outcome for this analysis was use of NRT during hospitalization. The results revealed that, among the entire sample, only 7.1% of the overall sample used NRT during hospitalization; 6% of the hospitalized smokers used the transdermal nicotine patch, and 1.1% used nicotine gum. Use of NRT was significantly greater among patients who reported that they were doing anything to help themselves quit smoking at the time of admission (OR = 4.1), those who were seriously planning to quit smoking within the next 30 days (OR = 2.36), those who were nicotine dependent (OR = 2.81), and those for whom a physician had ever offered to prescribe NRT (OR = 1.9). The finding that there is a very low rate of NRT use during hospitalization provides important information to hospital-based care providers and smoking cessation intervention planners. Barriers to NRT use among hospitalized patients should be identified, and strategies designed to maximize use when appropriate. The AHCPR Guideline on Smoking Cessation recommends routine use of NRT in health care settings. Further research is needed to determine why NRT use was so low. In addition, these data suggest that efforts to increase NRT use during hospitalization are needed.

Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness.

BACKGROUND: Cancer clinicians do not receive routine training in the psychosocial aspects of patient care such as how to communicate bad news or respond to patients who have unrealistic expectations of cure. Postgraduate workshops may be an effective way to increase interpersonal skills in managing these stressful patient encounters. METHODS: The authors conducted 2 half-day workshops for oncology faculty, one on breaking bad news and one on dealing with "problem situations." Participants met in a large group for didactic presentations and then small groups in which they used role-play and discussion to problem-solve difficult cases from their practices. The small groups were assisted in their work by trained physician facilitators. The workshops were evaluated by means of a follow-up satisfaction questionnaire as well as a self-efficacy measure, which was administered before and after the workshops. RESULTS: Twenty-seven faculty and 2 oncology fellows participated in the training programs. Satisfaction questionnaires showed that the programs met the educational objectives and were considered to be useful and relevant by the participants. Self-efficacy questionnaires revealed an increase in confidence in communicating bad news and managing problem situation cases from before to after the workshop. The majority of attendees welcomed the opportunity to discuss their difficult cases with colleagues. A number resolved to implement newly learned approaches to common patient problems they encountered frequently. CONCLUSIONS: Communication skills workshops may be a useful modality to provide training to oncologists in stressful aspects of the physician-patient relationship. Further research is needed to assess whether long term benefits accrue to the participants.

Recent advances in the pharmacotherapy of smoking.

Since the 1996 publication of guidelines on smoking cessation from the Agency for Health Care Policy and Research and the American Psychiatric Association, several new treatments have become available, including nicotine nasal spray, nicotine inhaler, and bupropion hydrochloride. In addition, nicotine gum and patch have become available over-the-counter. This article reviews the published literature and US Food and Drug Administration and pharmaceutical company reports on these therapies. Based on this review, clinical logic, and experience, we conclude that pharmacotherapy should be made available to all smokers. All currently available therapies appear to be equally efficacious, approximately doubling the quit rate compared with placebo. Concomitant behavioral or supportive therapy increases quit rates and should be encouraged but not required. Combining patch with gum or patch with bupropion may increase the quit rate compared with any single treatment. Because patient characteristics predictive of success with a particular therapy are not yet known, the best treatment choice for an individual patient should be guided by the patient's past experience and preference and the product's adverse effect profile.

Thorough skin examination for the early detection of melanoma.

BACKGROUND: Melanoma is a major public health problem for which early detection may reduce mortality. Since melanoma is generally asymptomatic, this requires skin examination. We sought to evaluate the extent to which the general public has their skin examined by themselves, their partners, or health care providers and the frequency of these examinations. METHODS: Random-digit-dial survey of adult Rhode Islanders. RESULTS: Only 9% performed a thorough skin examination (TSE) at least once every few months, although over half of the sample reported conducting skin self-examination "deliberately and systematically." Participants were more likely to perform TSE if they were women and if their health care provider had asked them to examine their skin. Most participants reported that their health care provider never or rarely looked at the areas of their skin in which melanoma is most likely to arise. CONCLUSIONS: The reported frequency of skin self-examination depends critically on the manner of inquiry. TSE by self or a partner is uncommon, and health care providers do not routinely examine the areas of the skin on which melanomas commonly arise.

History and symptoms of depression among smokers during a self-initiated quit attempt.

History of depression in smokers has been associated with an inability to quit smoking and with an increased likelihood of smoking relapse. This study prospectively tracked nicotine withdrawal symptoms, symptoms of depression, and ability to quit smoking between smokers with and without a probable history of major depression who were trying to quit smoking with minimal assistance. Results indicated that prior to quitting, smokers with a history of depression smoked to reduce negative affect, in response to craving, and in social situations. Additionally, positive history smokers scored higher on the Center for Epidemiological Studies Depression Scale (CES-D) than did smokers without such a history. Following a quit attempt, positive history smokers were somewhat more likely to experience greater symptoms of nicotine withdrawal than negative history smokers. However, among the positive history smokers, depressive symptoms as measured by the CES-D increased significantly 4 weeks after trying to quit, compared to a decline among negative history smokers. Positive and negative history smokers did not significantly differ on ability to quit smoking within the 30-day follow-up period. History of depression appears to be associated with a delayed increase in symptoms of depression following a quit attempt. However, it remains to be demonstrated whether such an increase in depressive symptoms may influence later probability of relapse.

Physician-based physical activity counseling for middle-aged and older adults: a randomized trial.

Sedentary behavior among older adults increases risk for chronic diseases. Physicians in a primary care setting can play an important role in promoting physical activity adoption among their older patients. The Physically Active for Life (PAL) project was a randomized, controlled trial comparing the efficacy of brief physician-delivered physical activity counseling to usual care on self-reported physical activity levels. The physical activity counseling was based on the Transtheoretical Model of Change and social learning theory. Twenty-four community-based primary care medical practices were recruited into the study; 12 were randomized to the Intervention condition and 12 to the Control condition. Physicians in the Intervention practices received training in the delivery of brief physical activity counseling. Subjects in the Intervention practices (n=181) received brief activity counseling matched to their stage of motivational readiness for physical activity, a patient manual, a follow-up appointment with their physician to discuss activity counseling, and newsletter mailings. Subjects in the Control practices (n=174) received standard care. Measures of motivational readiness for physical activity and the Physical Activity Scale for the Elderly (PASE) were administered to subjects in both conditions at baseline, 6 weeks following their initial appointment, and at 8 months. Results showed that at the 6-week follow-up, subjects in the Intervention condition were more likely to be in more advanced stages of motivational readiness for physical activity than subjects in the Control condition. This effect was not maintained at the 8 month follow-up and the intervention did not produce significant changes in PASE scores. Results suggest that more intensive, sustained interventions may be necessary to promote the adoption of physical activity among sedentary, middle-aged, and older adults in primary care medical practices.

A population-based survey of physician smoking cessation counseling practices.

BACKGROUND: To be most effective, physicians' smoking cessation interventions must go beyond advice, to include counseling and follow-up. A full profile of physician performance on the recommended activities to promote smoking cessation has not been provided previously. METHODS: We surveyed a representative sample of 246 community-based primary care physicians who had agreed to participate in a 3-year study to evaluate a strategy for disseminating smoking cessation interventions, based on the National Cancer Institute 4-A model and on the Transtheoretical Model of Change. RESULTS: A majority reported they Ask (67%) and Advise (74%) their patients about smoking, while few go beyond to Assist (35%) or Arrange follow-up (8%) with patients who smoke. The criteria for "thorough" counseling was met by only 27% of physicians. More than half were not intending to increase counseling activity in the next 6 months. After controlling for other variables, physicians in private offices were more likely than physicians in HMO or other settings to be active with smoking cessation counseling. General Internal Medicine physicians were most active, and Ob/Gyn physicians were least active, with smoking cessation counseling among primary care specialty groups. CONCLUSIONS: Innovative approaches are needed to motivate, support, and reward physicians to counsel their patients who smoke, especially when considering the movement toward managed health care. PRECIS: A survey of primary care physicians focusing on national guidelines for smoking cessation counseling showed a majority Ask (67%) and Advise (74%) patients about smoking, but few Assist (35%) or Arrange follow-up (8%).