Tobacco cessation interventions for young people.

BACKGROUND: Teenage smoking prevalence is around 15% in developing countries (with wide variation from country to country), and around 26% in the UK and USA. Although most tobacco control programmes for adolescents are based around prevention of uptake, there are also a number of initiatives to help those who want to quit. Since those who do not smoke before the age of 20 are significantly less likely to start as adults, there is a strong case for programmes for young people that address both prevention and treatment. OBJECTIVES: To evaluate the effectiveness of strategies that help young people to stop smoking tobacco. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, and the bibliographies of identified trials. We also searched the 'grey' literature (unpublished materials), and contacted authors and experts in the field where necessary. SELECTION CRITERIA: Types of studies: Randomized controlled trials, cluster-randomized controlled trials and controlled trials. TYPES OF PARTICIPANTS: Young people, aged less than 20, who are regular tobacco smokers. Types of interventions: The interventions ranged from simple ones such as pharmacotherapy, targeting individual young people, through complex programmes targeting people or organizations associated with young people (for example, their families or schools), or the community in which young people live. We included cessation programmes but excluded programmes primarily aimed at prevention of uptake. Types of outcome measures: The primary outcome was smoking status at six months follow up, among those who smoked at baseline. We report the definition of cessation used in each trial (e.g seven- or thirty-day point prevalence abstinence, or sustained or prolonged abstinence), and we preferred biochemically verified cessation when that measure was available. DATA COLLECTION AND ANALYSIS: Both authors independently assessed the eligibility of candidate trials identified by the searches, and extracted data from them. We categorized included trials as being at low, medium or high risk of bias, based on concealment of allocation, blinding (where applicable) and the handling of attrition and losses to follow up. We conducted limited meta-analyses of some of the trials, provided that it was appropriate to group them and provided that there was minimal heterogeneity between them. We estimated pooled odds ratios using the Mantel-Haenszel method, based on the quit rates at longest follow up for trials with at least six months follow up from the start of the intervention. MAIN RESULTS: We found 15 trials, covering 3605 young people, which met our inclusion criteria (seven cluster-randomized controlled trials, six randomized controlled trials and two controlled trials). Three trials used or tested the transtheoretical model (stages of change) approach, two tested pharmacological aids to quitting (nicotine replacement and bupropion), and the remaining trials used various psycho-social interventions, such as motivational enhancement or behavioural management. The trials evaluating TTM interventions achieved moderate long-term success, with a pooled odds ratio (OR) at one year of 1.70 ( 95% confidence interval (CI) 1.25 to 2.33) persisting at two-year follow up with an OR of 1.38 (95% CI 0.99 to 1.92). Neither of the pharmacological intervention trials achieved statistically significant results (data not pooled), but both were small-scale, with low power to detect an effect. The three interventions (5 trials) which used cognitive behavioural therapy interventions did not individually achieve statistically significant results, although when the three Not on Tobacco trials were pooled the OR 1.87; (95% CI 1.00 to 3.50) suggested some measure of effectiveness. Although the three trials that incorporated motivational interviewing as a component of the intervention achieved a pooled OR of 2.05 (95% CI 1.10 to 3.80), the impossibility of isolating the effect of the motivational interviewing in these trials meant that we could not draw meaningful inferences from that analysis. AUTHORS' CONCLUSIONS: Complex approaches show promise, with some persistence of abstinence (30 days point prevalence abstinence at six months), especially those incorporating elements sensitive to stage of change. There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers. Psycho-social interventions have not so far demonstrated effectiveness, although pooled results for the Not on Tobacco trials suggest that that this approach may yet prove to be effective; however, their definition of cessation (one or more smoke-free days) may not adequately account for the episodic nature of much adolescent smoking. There is a need for well-designed adequately powered randomized controlled trials for this population of smokers, with a minimum of six months follow up and rigorous definitions of cessation (sustained and biochemically verified). Attrition and losses to follow up are particularly problematic in trials for young smokers, and need to be kept to a minimum, so that management and interpretation of missing data need not compromise the findings.

Are audits wasting resources by measuring the wrong things? A survey of methods used to select audit review criteria.

OBJECTIVES: This study measured the extent to which a systematic approach was used to select criteria for audit, and identified problems in using such an approach with potential solutions. DESIGN: A questionnaire survey using the Audit Criteria Questionnaire (ACQ), created, piloted, and validated for the purpose. Possible ACQ scores ranged from 0 to 1, indicating how systematically the criteria had been selected and how usable they were. SETTING: A stratified random sample of 10 audit leads in each of 83 randomly selected NHS trusts and all practices in each of 11 randomly selected primary care audit group areas in England and Wales. PARTICIPANTS: Audit leads of ongoing audits in each organisation in which a first data collection had started less than 12 months earlier and a second data collection was not completed. MAIN OUTCOME MEASURES: ACQ scores, problems identified in the audit criteria selection process, and solutions found. RESULTS: The mean ACQ score from all 83 NHS trusts and the 11 primary care audit groups was 0.52 (range 0.0-0.98). There was no difference between mean ACQ scores for criteria used in audits on clinical (0.51) and non-clinical (0.52) topics. The mean ACQ scores from nationally organised audits (0.59, n=33) was higher than for regional (0.51, n=21), local (0.53, n=77), or individual organisation (0.52, n=335) audits. The mean ACQ score for published audit protocols (0.56) was higher than for locally developed audits (0.49). There was no difference in ACQ scores for audits reported by general practices (0.49, n=83) or NHS trusts (0.53, n=383). Problems in criteria selection included difficulties in coordination of staff to undertake the task, lack of evidence, poor access to literature, poor access to high quality data, lack of time, and lack of motivation. Potential solutions include investment in training, protected time, improved access to literature, support staff and availability of published protocols. CONCLUSIONS: Methods of selecting review criteria were often less systematic than is desirable. Published usable audit protocols providing evidence based review criteria with information on their provenance enable appropriate review criteria to be selected, so that changes in practice based on these criteria lead to real improvement in quality rather than merely change. The availability and use of high quality audit protocols would be a valuable contribution to the evolution of clinical governance. The ACQ should be developed into a tool to help in selecting appropriate criteria to increase the effectiveness of audit.

Handedness in boys with gender identity disorder.

Handedness preference was assessed in 205 boys with gender identity disorder and 205 clinical control boys referred for other reasons. Boys with gender identity disorder were significantly more likely to be left-handed than the clinical control boys (19.5% vs. 8.3%, respectively). The boys with gender identity disorder, but not the clinical control boys, also had a significantly higher rate of left-handedness compared to three independent, general population studies of nonreferred boys (11.8%; N = 14,253) by Hardyck, Goldman, and Petrinovich (1975), Calnan and Richardson (1976), and Eaton, Chipperfield, Ritchot, and Kostiuk (1996). Left-handedness appears to be a behavioral marker of an underlying neurobiological process associated with gender identity disorder in boys.

Expert consensus on the desirable characteristics of review criteria for improvement of health care quality.

OBJECTIVES: To identify the desirable characteristics of review criteria for quality improvement and to determine how they should be selected. BACKGROUND: Review criteria are the elements against which quality of care is assessed in quality improvement. Use of inappropriate criteria may impair the effectiveness of quality improvement activities and resources may be wasted in activities that fail to facilitate improved care. METHODS: A two round modified Delphi process was used to generate consensus amongst an international panel of 38 experts. A list of 40 characteristics of review criteria, identified from literature searches, was distributed to the experts who were asked to rate the importance and feasibility of each characteristic. Comments and suggestions for characteristics not included in the list were also invited. RESULTS: The Delphi process refined a comprehensive literature based list of 40 desirable characteristics of review criteria into a more precise list of 26 items. The expert consensus view is that review criteria should be developed through a well documented process involving consideration of valid research evidence, possibly combined with expert opinion, prioritisation according to health outcomes and strength of evidence, and pilot testing. Review criteria should also be accompanied by full clear information on how they might be used and how data might be collected and interpreted. CONCLUSION: The desirable characteristics for review criteria have been identified and will be of use in the development, evaluation, and selection of review criteria, thus improving the cost effectiveness of quality improvement activities in healthcare settings.

Diagnosis of heart failure in primary care: an assessment of international guidelines.

An appraisal of published, peer-reviewed guidelines, in terms of their development methodologies and clinical effectiveness, was undertaken using a published and validated appraisal tool. Electronic databases revealed 13 guidelines on heart failure but only seven of these referred to diagnosis. The quality of the published guidelines was variable but there was consensus over the main symptoms and diagnostic tests, although only two symptoms were mentioned in all guidelines. Only two guidelines scored greater than 50% for rigour of development.

First-language acquisition in adolescence: evidence for a critical period for verbal language development.

It has been hypothesized that there is a critical period for first-language acquisition that extends into late childhood and possibly until puberty. The hypothesis is difficult to test directly because cases of linguistic deprivation during childhood are fortunately rare. We present here the case of E.M., a young man who has been profoundly deaf since birth and grew up in a rural area where he received no formal education and had no contact with the deaf community. At the age of 15, E.M. was fitted with hearing aids that corrected his hearing loss to 35 dB, and he began to learn verbal Spanish. We describe his language development over the 4-year period since his acquisition of hearing aids and conclude that the demonstrates severe deficits in verbal comprehension and production that support the critical period hypothesis.

Integration and interference in the cerebral hemispheres: relations with hemispheric specialization.

The two hemispheres of the brain often perform complementary computations and make unique contributions to task performance. This study examines the interaction of linguistic (left hemisphere) and prosodic (right hemisphere) information in speech processing. An individual differences approach is used in which interference between linguistic and prosodic processes in a Stroop-like task is compared between individuals who process the two dimensions in opposite hemispheres (complementary specialization) vs. those who process both dimensions in the same hemisphere (noncomplementary specialization). Complementarity was not related to interference in any way. This finding is consistent with the hypothesis of Chiarello and Maxfield (1996) that interference is equivalent between and within hemispheres when it arises in a response selection stage.

Changes in diameter of the abdominal aorta with age: an epidemiological study.

Rupture of abdominal aortic aneurysms is a major cause of death for men who are over 60 years old. This study invited 13,000 men aged 60 to 75 years, within the Birmingham conurbation, to have an ultrasound scan of the abdominal aorta. The scan was performed at the patients' own General Practitioner's surgery; 10,061 men were scanned. Only 3% of this population were found to have large aneurysms. An analysis of the distribution of aortic diameters in this population shows that for diameters less than 40 mm, changes in the diameter with age (previously attributed to the growth of small aneurysms) occurs for up to 25% of the population although the median diameter for each year group, 21 mm, does not increase with age. This analysis suggests that the threshold diameter at which the aorta is categorized as abnormal should be related to age, especially by those undertaking mass screening.

Mental rotation at 7 years: relations with prenatal testosterone levels and spatial play experiences.

Biological and social-experiential factors appear to play a role in the male advantage in spatial abilities. In the present study, relations among prenatal testosterone levels, spatial play experiences, and mental rotation task performance were explored in 7-year-old boys and girls. A positive correlation was observed between prenatal testosterone levels and rate of rotation in girls. The findings were less clear for boys, but suggested the opposite pattern of results. Relations between spatial play preferences and mental rotation task performance were not observed in children of either sex. These findings are consistent with the hypothesis that testosterone acts on the fetal brain to influence the development of spatial ability.

The abnormal aorta: a statistical definition and strategy for monitoring change.

OBJECTIVES: This study defines a protocol for monitoring the growth of small abdominal aortic aneurysms based on age-related abnormality thresholds, observed aortic growth patterns and the limits of precision of the measurement technique. DESIGN: 13000 men aged 60 - 75 years were invited to their GP's surgery for measurement of the maximum diameter of the infrarenal aorta. Seventy-six percent responded and measurement was possible in 97.1% of the respondents. The AP diameter of the aorta was measured according to a strict protocol, with a portable ultrasound scanner. SETTING: Cases were recruited from the conurbation of Birmingham and Solihull, U.K. CHIEF OUTCOME MEASURE: A statistical description of the differences in distributions of aortic diameters of four age groups of males. MAIN RESULT: The aorta expands in diameter during the seventh and eighth decade for up to 25% of all those screened. The order of magnitude of this change is similar to that previously attributed to the growth of small aneurysms. Age-related thresholds for abnormality should range from 24 mm for a 60 year old to 37 mm for a 75 year old. CONCLUSIONS: Using data on the expected maximum rate of change of the dilated aorta and statistically derived thresholds from this analysis a monitoring strategy is suggested for those with an abnormal aorta.

A statistical analysis of the growth of small abdominal aortic aneurysms.

Screening for abdominal aortic aneurysm has been offered to 13,000 patients. An overall compliance of 76% (range 51-99%) has been achieved. For those with an initial aortic diameter between 29 mm and 45 mm serial ultrasound scans are offered to monitor aortic change. Of the 302 cases followed up by repeated scans, 93 have had more than 5 scans (mean of 7 scans) over a mean time period of 32.1 months (range 15-63 months). The rate of change of all these aneurysms has been calculated using all data points and robust linear regression. It has been possible to postulate an algorithm for aortic growth. The influence of measurement precision and ultrasound quality assurance on the rescan interval is demonstrated and it is suggested that 2 years is a suitable rescan interval for aortas with diameter less than 40 mm.

Prevalence of abdominal aortic aneurysm associated with hypertension in an urban population.

SETTING AND METHOD: Since 1989 13,000 invitations to screening for abdominal aortic aneurysm have been offered to men aged 60 to 75 living within the Birmingham conurbation. RESULTS: The overall attendance was 76.1% (52-99%). The prevalence of aneurysms greater than 29 mm in the whole male population aged 60 to 75 was 7.2%. For those aged 60 to 64 the prevalence was 3.8%. For those aged between 60 and 64 with hypertension, however, the prevalence of abdominal aortic aneurysm was 7.7%. The relative risk of hypertension associated with aneurysm disease is 2.7. CONCLUSIONS: This paper suggests that all men over 65 should be screened for aortic aneurysm, but that those men over 60 with hypertension should be added to the screened cohort.

Ultrasonographic screening for abdominal aortic aneurysm in an urban community.

As part of the Birmingham Community Aneurysm Screening Project, 3500 men aged 65-75 years from 20 urban general practices were invited for aortic ultrasonographic screening at their own general practitioner's surgery; 2669 (76.3 per cent) attended. Compliance rates varied between catchment areas, from 52.1 per cent for inner-city areas to 89.6 per cent for suburbs. Successful aortic imaging was achieved in 97.3 per cent of scans. Aortic diameter > 29 mm occurred in 219 patients (8.4 per cent) and 79 (3.0 per cent) with a diameter > 40 mm were referred for vascular surgical assessment; 140 patients with an aortic diameter of 29-40 mm are currently undergoing follow-up by serial ultrasonographic examinations at intervals of 3 months at their doctor's surgery. Risk factor analysis revealed ischaemic heart disease in 21.9 per cent of men with aneurysm, compared with 11.6 per cent in those without (P < 0.001); 18.3 per cent of men with aneurysm had had a previous myocardial infarction and 13.2 per cent had peripheral vascular disease, compared with 7.4 per cent (P < 0.001) and 8.0 per cent (P < 0.01) respectively of those without. No association was found between aneurysm and hypertension or diabetes. Community-based aortic screening is an inexpensive, effective method of diagnosis of aneurysm, with high compliance from the at-risk cohort of an urban population. Such screening programmes may help to reduce the mortality rate from aortic aneurysm rupture.

Accurate screening for abdominal aortic aneurysm.

In Birmingham a screening programme has been set up to detect abdominal aortic aneurysm in the male population between the ages of 65 and 75 years. The men to be screened are invited to their own general practitioners surgery and offered an abdominal ultrasound. The accuracy with which abnormalities can be detected is of crucial importance to a screening programme. Repeatability has been assessed for the single operator involved and is found to be +/- 1.3 mm. The accuracy of a single scan has been calculated by comparison with the measured diameter from a CT scan of the patient, taken subsequently. This comparison indicates that 95% of the differences between the two measurements can be expected to be less than 3.5 mm.

Measurement of the focal spot size of diagnostic x-ray tubes--a comparison of pinhole and resolution methods.

The pinhole camera technique has been compared with resolution and other methods for measuring the focal spot dimensions fo diagnostic X-ray tubes. These comparisons show that the resolution method offers an accurate estimation of the focal spot dimensions without the difficulties normally encountered in pinhole camera techniques. Accuracy and reproducibility of the "star-test" resolution method is examined. The current standard specifications for pinhole camera measurements are also discussed, and in the light of results obtained, changes in these specifications are suggested, particulary with regard to correction factors for non-uniformity of the intensity distribution and manufacturing tolerances.