Multiple in-hospital counseling increases six-month smoking abstinence among individuals participating in a hospital-initiated smoking cessation program.

BACKGROUND: A cessation program for hospitalized smokers is an effective strategy to achieve smoking abstinence. The effects of multiple in-hospital counseling sessions on 6-month smoking abstinence require further investigation. METHODS: We retrospectively analyzed the data of smokers who participated in hospital-initiated cessation programs at a medical center between 2017 and 2019. Data on age, sex, comorbidities, daily number of cigarettes, cessation motivation, nicotine dependence, cessation medications, discharge diagnosis, length of hospitalization, and intensive care unit admission were collected. We conducted multiple logistic regression analysis to investigate the effect of multiple in-hospital counseling sessions on 6-month sustained smoking abstinence. Sensitivity analyses were carried out excluding participants who underwent post-discharge cessation programs and assuming that the loss to follow-up participants had failure in 6-month smoking abstinence. RESULTS: A total of 1943 participants aged ≥ 20 years were analyzed. Compared with single in-hospital counseling session, the adjusted odds ratios (ORs) for 2 and ≥ 3 counseling sessions were 1.44 (95% confidence interval [CI] 1.05 to 1.98) and 2.02 (95% CI 1.27 to 3.22), respectively, with a significant trend for increasing the number of counseling sessions (P < 0.001). The results remained significant after excluding participants who underwent a post-discharge cessation program or when assuming that lost to follow-up participants had failure in smoking abstinence. CONCLUSION: Multiple in-hospital counseling sessions were associated with a higher 6-month sustained smoking abstinence rate. This strategy could be used to reduce the prevalence of smoking.

Shared Decision-Making Model for Adolescent Smoking Cessation: Pilot Cohort Study.

The control of tobacco use in adolescents is a critical public health issue that has long been studied, yet has received less attention than adult smoking cessation. Shared decision making (SDM) is a method that highlights a patient's preference-based medical decision. This study aimed to investigate the effects of a novel SDM-integrated cessation model and early intervention on the control of tobacco use in adolescents. The SDM-integrated model provides psychological support and motivational enhancement by involving the participants in making decisions and plans through the three-talk model of the SDM principle. The primary outcome shows positive effects by both increasing the cessation rate (a 25% point abstinence rate at 3 month follow up) and decreasing the number of cigarettes smoked per day (60% of the participants at 3 month follow up) among 20 senior high school participants (mean age, 17.5 years; 95% male). The results also show that the model can achieve the goal of SDM and optimal informed decision making, based on the positive SURE test and the satisfaction survey regarding the cessation model. The SDM cessation model can be further applied to different fields of adolescent substance cessation, yielding beneficial effects regarding reducing potential health hazards. The dissemination of the model may help more adolescent smokers to cease smoking worldwide.

Incorporating Post-Cessation Weight-Control Coaching into Smoking Cessation Therapy to Reduce Type 2 Diabetes Risk.

Post-cessation weight gain (PCWG) facilitates short-term type 2 diabetes (T2D) risk in prediabetic smokers in the absence of complementary measures. In this shared decision-making-based non-randomized controlled trial, prediabetic smokers joined the Fight Tobacco and Stay Fit (FIT2) program or received usual care. The 16-week FIT2 program combined smoking cessation therapy with individualized coaching in diet and physical activity strategies for PCWG restriction (NCT01926041 at ClinicalTrials.gov). During a mean follow-up period of 1316 days, 217 participants (36.8%) developed T2D, and 68 (11.5%) regressed to normoglycemia. In the intention-to-treat analysis (n = 589), the FIT2 program was associated with a reduced T2D risk (HR, 0.58; 95% CI, 0.40-0.84) and a higher probability of regression to normoglycemia (HR, 1.91; 95% CI, 1.04-3.53) compared with usual care. The post-program quitters were at lower T2D risk (HR, 0.63; 95% CI, 0.44-0.92) and were more likely to regress to normoglycemia (HR, 1.83; 95% CI, 1.01-3.30) compared with the controls in the time-varying analysis (n = 532). We demonstrated that the FIT2 program was negatively associated with long-term T2D risk and positively associated with the probability of regression to normoglycemia compared with usual care. To prevent T2D development, we recommend simultaneously promoting smoking abstinence and lifestyle coaching for PCWG restriction.

The Expression of Toll-Like Receptor 4 mRNA in PBMCs Is Upregulated in Smokers and Decreases Upon Smoking Cessation.

Background: Studies have shown in vitro that cigarette smoke condensate stimulates monocytes to express toll-like receptor 4 (TLR4), tumor necrosis factor-α (TNF-α), and intercellular adhesion molecule 1 (ICAM-1), and enhances their adhesion to the endothelium. However, the same effects of cigarette smoking have not been explored in vivo. This study is to investigate the effect of cigarette smoking and smoking cessation on their mRNA expression in human peripheral blood mononuclear cells (PBMCs). Methods: A group of 97 smokers and 62 nonsmokers were enrolled. The RNA from PBMCs was assessed with real-time polymerase chain reaction (PCR) to determine the levels of ICAM-1, TNF-α, and TLR4. The same markers in PBMCs of 87 quitters were examined before and at one week, one month, and two months after smoking cessation. Results: Of the 97 smokers, 85 (87.6%) were males, and 30 (48.4%) of the nonsmokers were males (p < 0.0001). The mean (SD) age of the smokers was 43.24 (10.89) years, which was younger than 43.45 (11.41) years of nonsmokers (p < 0.0001). The incidence of cardiovascular diseases was 13.4% in smokers, which was higher than 1.6% in nonsmokers (p < 0.05). Both ICAM-1 and TNF-α mRNA levels in PBMCs were higher among the smokers (p < 0.0001). In addition, TLR4 mRNA levels in PBMCs were statistically elevated in the smokers (p < 0.0001) comparing with those in the nonsmokers. The mRNA levels of TLR4 and TNF-α in PBMCs decreased in those who had quit smoking for 2 months (p < 0.0001). Conclusions: ICAM-1, TNF-α, and TLR4 mRNA expression levels in PBMCs increased in smokers and decreased after being on a smoking cessation program for 2 months. This finding suggested that TLR4 expression may mediate the atherogenic inflammatory process induced by smoking.

Doses of hepatitis B revaccination needed for the seronegative youths to be seropositive to antibody against hepatitis B surface antigen.

OBJECTIVES: To determine the required hepatitis B vaccine doses for subjects who were seronegative for three hepatitis B seromarkers during their youth who wish to have seroprotective antibodies against the hepatitis B surface antigen (anti-HBs). METHODS: We conducted a retrospective cohort study. From 2012 to 2015, graduate school students born after 1986 who were seronegative for three hepatitis B virus seromarkers at college entrance (n = 1037) were recruited. Four groups of subjects received zero to three doses of a hepatitis B vaccine booster at their free willingness, and their anti-HBs titre were measured at their graduate school entrance. Very low and extremely low antibody titres against the hepatitis B surface antigen were elucidated by graphic inference to determine the required booster dose cut-off value for seropositivity after revaccination. RESULTS: The anti-HBs seropositive rates in the four groups of subjects receiving the hepatitis B booster vaccine(s) were 17.7%, 52.1%, 78.6% and 90.9% for those receiving zero, one, two and three doses, respectively. In subjects with very low antibody titres against the hepatitis B surface antigen after one dose of the vaccine booster and subjects with an extremely low titre after two doses of the booster, the seropositive rates reached 95% at the cut-off value of 3 mIU/ml. CONCLUSION: A seropositive rate of at least 95% can be reached by the administration of two hepatitis B booster doses to youths with extremely low antibody titres against the hepatitis B surface antigen (<3 mIU/ml) and administering one dose to those with very low titres (3-10 mIU/ml) at college.

Addition of one session with a specialist counselor did not increase efficacy of a family physician-led smoking cessation program.

Objective Higher-intensity counseling sessions increase the smoking abstinence rate. However, counselors are limited in Taiwan. This study was performed to determine whether the addition of one session with a specialist counselor increases the efficacy of a family physician-led smoking cessation program. Methods Participants opted to either visit a family physician for brief counseling and pharmacotherapy (Po) or visit a specialist counselor for an initial session followed by a family physician for brief counseling sessions with pharmacotherapy (P+). The 7-day point prevalence (PP) rate was evaluated at weeks 12 and 24. Results In total, 356 patients were enrolled. In the intention-to-treat analysis, the PP rate at week 12 was higher in the Po than P+ group, but there was no significant difference at week 24. In the per-protocol analysis, the PP rates at weeks 12 and 24 were not significantly different between the Po and P+ groups. The adjusted odds ratios also revealed no significant differences in either the intention-to-treat analysis or the per-protocol analysis between the two groups. Conclusion The addition of one session with a specialist counselor had no benefit over the provision of counseling through a family physician at either 12 or 24 weeks of follow-up.

A 10-year review of health care reform on Family Practice Integrated Care Project-Taiwan experience.

Objective: Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness of this nationwide demonstration programme over a 10-year period. Methods: Papers and reports related to the FPICP published both in English and in Chinese from 2003 to 2015 were collected systematically based on keywords including 'family doctor', 'primary care', 'integrated care' and 'Taiwan'. Also collected and reviewed were national health insurance administration annual reports and related publications from Taiwan Association of Family Medicine. Quality care indicators including structure, process and outcome for programme monitoring were reported. Results: Up to June 2015, the project had enrolled a total of 10.5% of Taiwan's population. Approximately 24.9% of primary care physicians and 29.7% of community clinics joined the project to serve the members of 426 community health care groups (CHCGs). Compared to non-members, CHCG members received more preventive care services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (43% versus 31%) (P < 0.01). Members showed a markedly high level of satisfaction (>95%), especially in overall satisfaction, provision of health consultation and information, and improvement in understanding personal health condition. Conclusions: In the future, through the support of family physicians and CHCGs, a person-centred integrated health care delivery system can be an effective solution to the current barriers in the medical care system.

Combine body mass index and body fat percentage measures to improve the accuracy of obesity screening in young adults.

INTRODUCTION: Obesity screening among young adult groups is meaningful. Body mass index (BMI) is limited to discriminate between fat and lean mass. Asian young adult group tends to have lower BMI and higher body fat percentage (BFP) than other ethnic groups. Accuracy of obesity screening by commonly used BMI criteria is unclear in young Taiwanese population. MATERIAL AND METHODS: A total of 894 young adults (447 males and 447 females) aged 20-26 were recruited. BMI, regional fat percentage and BFP determined by bioelectrical impedance analysis (BIA) were measured. BMI cutoff points were based on the criteria adopted by the Ministry of Health and Welfare in Taiwan. Cutoff points of low or high BFP were defined as 24% in men and 31.4% in women. RESULTS: Prevalence of BFP defining obesity was 14.8% in young men and 27.3% in young women. 23.2% of young men and only 8.3% of young women were classified to overweight or obesity categories according to the BMI criteria. Disagreement was noticed mainly among overweight males and normal weight females. 68.7% of BMI defining overweight young men had low BFP; however, 29.7% of young women of BMI defining normal group had high BFP. Up to 69.7% of young women with high BFP would be missed by BMI category only. CONCLUSION: Disagreement between BMI and BFP was significant among young adults, especially young women. We suggest combining BMI and BIA for obesity and overweight screening in Asian young adults.

Change of government's subsidization policy improves smoking cessation services: a cross-sectional study from the perspectives of physicians.

BACKGROUND: The Taiwanese government increased financial subsidies for smoking cessation services in 2012. We aimed to evaluate the effects of this new policy on smoking cessation services from the physician's perspective. METHODS: This was a cross-sectional nationwide survey. Physicians who provided smoking cessation services for more than ten patient encounters in the preceding year of the new policy (February 2011 to March 2012) were recruited. The questionnaire was developed by two experts and was validated by a committee consisting of 11 delegates. RESULTS: We sent a total of 1,319 questionnaires. The response rate was 45.9 %. The majority of respondents were male (88.4 %), middle-aged (65.3 %), and worked as family physicians (56.1 %). Most physicians agreed that the new policy had increased the number of patients seeking smoking cessation, increased patients' willingness to adopt pharmacotherapy, helped physicians to prescribe medications, improved patients' adherence to medications, and improved quality of care. These changes were most prominent in medical centers. Changes in the practice of the 5As (ask, advise, assess, assist, arrange) were moderate. Among different medical settings, the most significant change was an increase in the expenditure on smoking cessation medications. CONCLUSIONS: The new subsidization policy in Taiwan has improved smoking cessation services. Overall, physicians reported positive effects of the new policy. Further study is warranted to evaluate the long-term influence of the policy.

Combination therapy of varenicline with nicotine replacement therapy is better than varenicline alone: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Smoking is a major preventable cause of morbidity and premature death worldwide. Both varenicline and nicotine replacement therapy (NRT) help achieve smoking cessation. However, limited evidence exists regarding whether combination of varenicline and NRT is more effective than either alone. The aim of this research was to investigate the efficacy and safety of varenicline combined with NRT. METHODS: A systematic search of MEDLINE, EMBASE, ClinicalTrial.gov, and Cochrane Library was conducted in November 2014. Two authors independently reviewed and selected randomized controlled trials. The quality of the studies was evaluated by the Jadad score. We carried out meta-analysis of both early (abstinence rate assessed before or at the end of treatment) and late (assessed after the end of the treatment) outcomes. RESULTS: Three randomized controlled trials with 904 participants were included in this meta-analysis. All three were comparing combination therapy with varenicline therapy alone. The late outcomes were assessed in 2 of the 3 trials. Both the early and late outcomes were favorable for combination therapy (OR = 1.50, 95 % CI 1.14 to 1.97; OR = 1.62, 95 % CI 1.18 to 2.23, respectively). However, this significance diminished after eliminating a study with pre-cessation treatment using nicotine patch. The most common adverse events were nausea, insomnia, abnormal dreams, and headache. One study reported more skin reactions (14.4 % vs 7.8 %; p = 0.03) associated with combination therapy. CONCLUSIONS: Combination therapy is more effective than varenicline alone, especially if pre-cessation treatment of nicotine patch is administrated. Adverse events of combination therapy are similar to mono-therapy except for skin reactions.

Plasma zinc α2-glycoprotein levels are elevated in smokers and correlated with metabolic syndrome.

BACKGROUND: Smoking is a strong risk factor of metabolic syndrome. Zinc α2-glycoprotein (ZAG) is a protein involved in metabolic syndrome. This study aims to investigate the effect of smoking on plasma ZAG levels and its relations to metabolic syndrome. MATERIALS AND METHODS: A group of 41 cigarette smokers and 47 non-smokers were enrolled. ZAG levels were measured to correlate to participants' demographic and metabolic parameters. RESULTS: Plasma ZAG levels of smokers were higher than those of controls (P < 0.0001). Plasma ZAG levels were positively correlated with male gender (P = 0.0002), number of cigarettes smoked per day (P < 0.0001), smoking duration in years (P < 0.0001), smoking index (P < 0.0001) and nicotine dependence score (P < 0.0001). In the multiple regression analysis, smoking was a strong independent factor affecting plasma ZAG levels (P = 0.0034). Plasma ZAG levels elevated progressively with the number of metabolic syndrome components (P = 0.0143). In the multiple regression analysis, plasma ZAG was an independent factor for metabolic syndrome. CONCLUSIONS: Plasma ZAG levels are high in smokers and correlate with metabolic syndrome. Our results indicate ZAG is an independent risk factor, but also interacted with smoking, for the metabolic syndrome.

Changes of serum adiponectin and soluble intercellular adhesion molecule-1 concentrations after smoking cessation.

BACKGROUND: This study aims to investigate the effect of increased serum adiponectin concentration during smoking cessation on soluble intercellular adhesion molecule-1 (sICAM-1) concentration. METHODS: One hundred and sixty-six eligible smokers were assessed at baseline and were followed up at the 1st, 5th, and 9th weeks after smoking cessation. Demographic data, body weight and blood pressure of these participants were obtained; serum glucose biochemical data, sICAM-1 and adiponectin concentrations were measured. Repeated measures analysis paired t-tests and generalized estimating equations for balanced repeated measures were used for statistical analyses. RESULTS: Forty-one individuals completed the 2-month smoking cessation program. The mean cigarette consumption dramatically decreased (p<0.0001) and the cotinine concentration also decreased significantly (p<0.0001) among the quitters. Serum adiponectin concentration significantly increased (p=0.0186) and sICAM-1 significantly decreased (p<0.0001) in quitters after smoking cessation. The elevation of serum adiponectin concentration significantly correlated with lowering of sICAM-1 (p=0.0001) concentration. Body weight changes at the end of 2-month smoking cessation was inversely correlated with adiponectin increment from baseline (p=0.0003). CONCLUSIONS: An increase in serum adiponectin concentration is an independent factor correlated with lowering of sICAM-1 concentration during smoking cessation.

Two strategies to intensify evidence-based medicine education of undergraduate students: a randomised controlled trial.

INTRODUCTION: Undergraduate evidence-based practice (EBP) is usually taught through standalone courses and workshops away from clinical practice. This study compared the effects of 2 clinically integrated educational strategies on final year medical students. MATERIALS AND METHODS: Final year medical students rotating to the general medicine service for a 2-week internship were randomly assigned to participate in a weekly EBP-structured case conference focusing on students' primary care patients (Group A, n = 47), or to receive a weekly didactic lecture about EBP (Group B, n = 47). The teaching effects of these 2 interventions were evaluated by a validated instrument for assessment of EBP related knowledge (EBP-K), attitude (EBP-A), personal application (EBP-P), and anticipated future use (EBP-F) on the first and last days of rotation. RESULTS: All scores improved significantly after the 2-week EBM-teaching for both groups. When compared to Group B, students in Group A had significantly higher post-intervention scores of EBP-K (21.2 ± 3.5 vs 19.0 ± 4.6; ie. 57.8 ± 72.9% vs 29.1 ± 39.1%; P <0.01) and EBP-P (18.7 ± 4.3 vs 15.3 ± 3.9; ie. 28.5 ± 25.5 % vs 14.1 ± 18.7 %; P <0.001). In contrast, the scores of EBP-A and EBP-F were similar between the 2 groups. CONCLUSION: Structured case conference, when compared to the didactic lectures, significantly improved EBP-K and EBP-P for final year medical students.

Smokers show reduced circulating adiponectin levels and adiponectin mRNA expression in peripheral blood mononuclear cells.

OBJECTIVES: Circulating adiponectin levels in cigarette smokers are lower than those in nonsmokers. We have previously shown that adiponectin is expressed in human monocytes. The aim of this study was to further investigate the effect of smoking on adiponectin expression in peripheral blood mononuclear cells (PBMCs). METHODS: A group of 77 cigarette smokers and 51 nonsmokers were consecutively enrolled in this study. The participants' body weight, blood pressure, and metabolic parameters, including plasma glucose and plasma adiponectin levels, were recorded. The RNA from the PBMCs was assessed with real-time polymerase chain reaction (PCR) to determine the levels of adiponectin mRNA. RESULTS: Of the 77 smokers, 67 (87.0%) were male. Their mean (standard deviation) age was 43.17 (11.47) years, and they smoked 24.56 (12.53) cigarettes/day. The duration of smoking was 23.73 (11.69) years. Both circulating adiponectin levels (p=0.0262) and adiponectin mRNA levels in PBMCs (p<0.0001) of smokers were significantly lower than those in nonsmokers. Both circulating adiponectin levels and adiponectin mRNA levels were negatively correlated with the number of cigarettes smoked per day (p<0.01). In multiple linear regression analysis, smoking was an independent factor affecting adiponectin mRNA expression in PBMCs (p<0.0001). CONCLUSIONS: Circulating adiponectin levels and adiponectin expression in PBMCs were lower in smokers; this finding suggested that attenuation of both systemic and local actions of adiponectin might contribute to the atherosclerotic process in cigarette smokers.

The evaluation of a Taiwanese training program in smoking cessation and the trainees' adherence to a practice guideline.

BACKGROUND: The Taiwanese government began reimbursement for smoking cessation in 2002. Certification from a training program was required for physicians who wanted reimbursement. The program certified 6,009 physicians till 2007. The objective of this study is to evaluate the short- and long term efficacy of the training program. METHODS: For short term evaluation, all trainees in 2007 were recruited. For long term evaluation, computer randomly selected 2,000 trainees who received training from 2002 to 2006 were recruited. Course satisfaction, knowledge, confidence in providing smoking cessation services and the adherence to a practice guideline were evaluated by questionnaires. RESULTS: Trainees reported high satisfaction with the training program. There was significant difference between pre- and post-test scores in knowledge. Confidence in providing services was lower in the long term evaluation compared to short term evaluation. For adherence to a practice guideline, 86% asked the status of smoking, 88% advised the smokers to quit, 76% assessed the smoker's willingness to quit, 59% assisted the smokers to quit, and 60% arranged follow-up visits for smokers. The incentive of reimbursement was the most significant factor affecting confidence and adherence. CONCLUSIONS: The training program was satisfactory and effective. Adherence to a practice guideline in our study was better than studies without physician training in other countries.