Cost-effectiveness analysis of a family physician delivered smoking cessation program.

OBJECTIVES: The objectives were to present a cost-effectiveness analysis of a smoking cessation program delivered by physicians and compare results to other smoking cessation interventions. METHODS: Retrospective effectiveness figures from a previous evaluation of the smoking cessation program were supplemented with estimates based on researched assumptions. Net abstinence rates were determined for smokers, depending on their stage of readiness to quit, that is, "prepared," "contemplative," and "precontemplative," leading to an assessment of the number of smokers achieving abstinence as a result of the Smokescreen intervention. Costs were calculated from the perspectives of smokers, family physicians, organizers, trainers, and all parties combined. Assumptions were varied with a sensitivity analysis. RESULTS: Baseline costs per additional abstainer were $183 based on physicians' intervention costs at 1995 prices. This is the figure most comparable to previously conducted economic evaluations of smoking cessation interventions. Sensitivity analysis varying the perspective and under optimistic and pessimistic assumptions about effectiveness produced a wide variety of estimates. The decision to include or exclude training costs had a particularly important bearing on the estimates. However, under reasonable assumptions the cost per additional quitter compares favorably to smoking and other medical and health care interventions worldwide. CONCLUSIONS: The program appears cost-effective when compared to other smoking cessation and health promotion interventions and illustrates the potential for retrospective cost-effectiveness analysis of interventions.

Physicians can make a difference with smokers: evidence-based clinical approaches. Presentation given during the Symposium on Smoking Cessation at the 29th World Conference of the IUATLD/UICTMR and Global Congress on Lung Health, Bangkok, Thailand, 23-26 November 1998. International Union Against Tuberculosis and Lung Disease.

Tobacco use poses one of the greatest public health challenges globally. This paper reviews the role of the physician as a key figure in promoting tobacco control and prevention. The physician is in a prime position to assist patients to stop smoking because of the high rate of contact with the general public. His/her efforts can contribute towards stemming the projected increase in smoking prevalence and resulting mortality and morbidity from cigarette-related diseases. However, the doctor is not taking full advantage of this window of opportunity to identify smokers and provide stop smoking advice. Evidence of physicians' and general practitioners' success in advising patients to stop smoking is presented. In general, clinical trials have reported abstinence rates of 5% to 10% for brief advice, and 20% to 36% for more physician involvement in providing advice and counselling. Nicotine replacement therapies (gum and patch) and other pharmacological treatments are useful adjuncts to physicians' advice to quit. Three evidence-based approaches available for the physician to use are described: 'Smokescreen for the 1990s in Australia', 'Smoking Cessation Clinical Practice Guideline' in the USA, and 'Guidelines on Smoking Cessation for General Practitioners and Other Health Professionals' in Europe. The information and resources that we have produced in industrialised countries must be translated, made culturally appropriate and distributed to physicians around the world, particularly in low income countries, so that they can fulfil their vital function of assisting patients to stop smoking.

Stage distributions for five health behaviors in the United States and Australia.

BACKGROUND: A key variable for the design of individual and public health interventions is the Stage of Change. The five stages of readiness to change are Precontemplation, Contemplation, Preparation, Action, and Maintenance. The distribution of individuals across the stages of change can provide a valuable tool for designing health interventions. METHODS: The pattern of distribution across the stages of change for five behavioral risk factors is presented from five independent surveys, two from the United States and three from Australia. The five risk factors are smoking, low fat diet, regular exercise, reducing stress, and losing weight. Identical single-item questionnaire items for staging health behaviors were used in all surveys. RESULTS: The stage distributions for the five risk factors were similar across the five independent samples. In general, the pattern of stage distributions was stable across health risk factors, gender, country, and sample. CONCLUSIONS: Single-item survey measures of stage of change that are readily applicable to population studies appear to provide important information about the population characteristics of readiness to change behavioral risk factors. The stability of these distributions suggests that interventions matched by stage may have broad applicability.

Quantitative and qualitative evaluations of brief interventions to change excessive drinking, smoking and stress in the police force.

AIMS: To evaluate the effects of a brief intervention to reduce excessive drinking, smoking and stress among police. DESIGN: (1) Controlled intervention trial with pre and post-intervention assessment approximately 8 months apart; (2) focus group identification of relevant factors). SETTING, PARTICIPANTS: Assessment was carried out of 954 NSW (Australia) police at 19 stations within two matched districts in the Sydney metropolitan area. Five focus groups were carried out with 43 randomly selected police from the matched districts. MEASUREMENTS: Weekly alcohol consumption and binge drinking, smoking and symptoms of stress were measured by a self-administered Health and Fitness Questionnaire. Recorded responses to set questions provided qualitative data. RESULTS: Participation was high (89%) at both quantitative assessments. Alcohol consumptions, particularly among men, was high at both baseline and follow-up assessments, although comparisons between groups across occasions showed no significant intervention effects. Excessive drinkers and those reporting moderate to severe stress levels reported more sick leave days (p < 0.05, p < 0.05). A significant increase in awareness of alcohol policies in the work-place showed in both experimental and control groups over time (p < 0.01). The percentage of smokers declined significantly in both intervention and control groups. Overall, women had significantly more symptoms of stress than men. Only 20% of police thought they would seek advice from work-place staff about alcohol consumption, 14% for smoking and 61% for stress. In the qualitative study, employees generally distrusted their organization's involvement in health unless work performance was affected. Seeking professional assistance for life-style issues was viewed as a sign of weakness. Alcohol use was seen as a way of obtaining information or group membership, self-medication and socializing. CONCLUSIONS: The brief interventions did not produce significant improvements in three life-style factors beyond positive trends in alcohol consumption among women and general reductions in smoking among both study groups. Combining quantitative and qualitative approaches helped identify interactive individual and organizational factors which influence behavioural and cultural norms.

Are higher doses of nicotine replacement more effective for smoking cessation?

This study determined whether higher dose nicotine patches are more efficacious than lower dose patches among heavy smokers. A randomized double-blind study compared 0, 21, 35, and 42 mg/day of a 24-h patch in 1039 smokers (> or = 30 cigarettes/day) at 12 clinical sites in the USA and one in Australia. Daily patches were used for 6 weeks followed by tapering over the next 10 weeks. Weekly group therapy occurred. Biochemically validated self-reported quit rates at 6, 12, 26, and 52 weeks post-cessation were measured. Quit rates were dose-related at all follow-ups (p < 0.01). Continuous, biochemically verified abstinence rates for the 0, 21, 35, and 42 mg doses at the end of treatment (12 weeks) were 16, 24, 30, and 39%. At 6 months, the rates were 13, 20, 20, and 26%. Among the 11 sites with 12 month follow-up (n = 879), the quit rates were 7, 13, 9, and 19%. In post-hoc tests, none of the active doses were significantly different from each other at any follow-up. The rates of dropouts due to adverse events for 0, 21, 35, and 42 mg were 3, 1, 3, and 6% (p = n.s.). Our results are similar to most prior smaller studies; i.e., in heavy smokers higher doses increase quit rates slightly. Longer durations of treatment may be necessary to show greater advantages from higher doses.

Worldwide survey of education on tobacco in medical schools.

OBJECTIVES: To determine the extent of teaching about tobacco, tobacco-related diseases, and smoking cessation techniques in medical schools around the world; and to ascertain the problems of getting the teaching about tobacco onto the medical curriculum. DESIGN: Cross-sectional survey. Questionnaires were sent to the 1353 medical schools in 143 countries around the world using the World Health Organization's Directory of Medical Schools. The questionnaire was translated from English into French, Russian, Mandarin, and Japanese. SUBJECTS: Deans of medical schools worldwide, or their nominees. MAIN OUTCOME MEASURES: Extent and format of teaching about tobacco in the medical curriculum, objectives and content of the courses on tobacco, and problems encountered in introducing the topic of tobacco. RESULTS: 493 medical schools responded, representing 64% of countries and 36% of schools. Only 12% of medical schools did not cover the topic of tobacco in the medical curriculum. 58% of medical schools taught about tobacco during the teaching of other subjects. 40% taught tobacco by systematically integrating teaching with other modules. 11% had a specific module on tobacco. The medical schools reported on the objectives and content of their courses on tobacco, which commonly included knowledge about tobacco-related diseases and pharmacological issues. Only a third taught about smoking cessation techniques. 22% had encountered problems in introducing the topic of tobacco, and respondents offered solutions to overcome these problems. CONCLUSIONS: Medical schools need continued encouragement to include tobacco issues in their curricula, with particular emphasis on teaching about smoking cessation techniques.

Effect of training on general practitioners' use of a brief intervention for excessive drinkers.

OBJECTIVE: To determine among general practitioners (GPs) the effect of three different types of training on utilisation of a brief, controlled drinking intervention. DESIGN: A non-randomised intervention study. Setting, participants: 96 GPs (64%) within the South Eastern Sydney Division of General Practice participated; 35 chose workshop training, 39 one-to-one training and 22 received a special kit by mail. MAIN OUTCOME MEASURES: Identification by GPs of excessive drinkers by practice audits; use of the program determined by the number of patients recruited in 3 months and by GPs' use of the intervention 6 months after training. RESULTS: 41 (43%) GPs conducted practice audits, identifying 15.1% of males and 6.6% of females as excessive drinkers (regular excessive weekly consumption and/or binge). 179 patients were recruited by 36 GPs over 3 months, and 32% of these patients reported a reduction of alcohol consumption. 63% who attended workshop training, 57% who received one-to-one training, and 36% who received the kit by mail reported they were current users of the program at 6 months. Significantly fewer GPs who received the kit by mail reported ever using the program (59%) compared to the other groups (p < 0.01). CONCLUSION: This naturalistic study found that workshops and one-to-one training sessions in doctors' surgeries achieved greater uptake of a brief intervention for problem drinkers than distribution of a special kit by mail.

How healthy are the police? A survey of life-style factors.

AIMS: To examine the prevalence of five life-style behaviours among New South Wales police. DESIGN: A cross-sectional survey using a self-administered questionnaire. SETTING AND PARTICIPANTS: A total of 852 police were recruited from metropolitan Sydney. MEASUREMENTS: Prevalence related to age and sex of self-reported alcohol consumption, cigarette smoking, inadequate exercise, perception of overweight and stress symptoms. RESULTS: A high level (89%) of participation was achieved in the survey. Almost half (48%) of males and more than two-fifths (40%) of females consumed alcohol excessively including continuous hazardous or harmful consumption and binge drinking. Excessive drinking was more prevalent among younger police. There were 8% of male and 15% of female police who reported that they did not drink alcohol. Over one-quarter (27%) of male and one-third (32%) of female respondents reported smoking. Almost half (46%) of men and women (47%) believed that they were overweight. More than one-fifth (21%) of men and less than one-quarter (24%) of women reported that they did not exercise. Finally, 12% of men and 15% of women reported feeling moderate to severe symptoms of stress. CONCLUSIONS: The police work-force offers an opportunity to screen for a large number of healthy, young and high risk individuals (particularly men) who are hard to reach in other settings and who rarely visit their general practitioner. A sizeable majority (83%) of NSW police had at least one unhealthy life-style behaviour with 19% reporting 3-5 unhealthy factors. The high prevalence of excessive alcohol consumption among police is of particular concern. More active health promotion and provision of brief interventions among police may reduce morbidity and mortality associated with unhealthy life-styles.

How women and youth are targeted by the tobacco industry.

Women and youth are fast becoming casualties of the cigarette epidemic. Although global male smoking rates are almost four times higher than female rates (47 versus 12%), male rates are declining, while female smoking rates are increasing. With the significant decline in tobacco consumption over the past two decades in Western countries, the tobacco industry has responded by developing new markets. The main targets of the tobacco industry are women and youth: in developing countries, in lower socioeconomic groups, and those with independent careers. The tobacco industry recognizes that women and youth represent a major untapped market and are targeting them with aggressive advertising, marketing and promotional campaigns, sponsorship, and employment in the growing tobacco industry. In addition, they are applying political and commercial pressure to open new markets in developing countries. These initiatives of the tobacco industry have resulted in an increase in tobacco use among women and youth. The economic arguments put forward by the tobacco industry of providing employment for many people have to be balanced against the social and financial drain that tobacco costs the economy in the health area, and the human suffering from preventable diseases resulting from smoking.

Smoking behaviour and attitudes among Australian medical students.

Teaching about tobacco and related diseases is essential in the undergraduate medical course in order for students to gain knowledge about smoking and how to intervene with patients who smoke. The objective of the study was to assess students' smoking-related behaviour, knowledge and attitudes towards tobacco, and perceptions of their future role as doctors. Data were collected from two consecutive years of year 1 and year 5 medical students at the University of New South Wales, Sydney. A total of 594 (79%) of students across the 2 years completed the survey: 90% of year 1 students, and 69% of year 5 students. The daily smoking rate among the total medical students was 2.9%: 11.8% in year 1 (2.3% daily, 9.5% occasional) and 13.7% in year 5 (3.3% daily, 10.4% occasional). There were significantly more male than female smokers in year 5 (P < 0.05). The overall smoking rates for males in years 1 and 5 were 12.4% and 19.3%, and the smoking rates for females were 11.2% and 8%. Knowledge about the causal role of tobacco in the development of specific diseases improved significantly from year 1 to year 5 (P < 0.001). Nevertheless, in year 5 there remained a lack of knowledge about the relationship of smoking and some diseases. Fifty-seven per cent of students thought that their current knowledge was sufficient to counsel smokers, with year 5 students (89%) being far more positive than year 1 students (34%) (P < 0.001). Teaching medical students about smoking-related diseases and a patient-centred smoking cessation intervention results in an increase in knowledge, as well as positive perceptions about their future role in intervening with smokers.

Effectiveness of a 24-hour transdermal nicotine patch in conjunction with a cognitive behavioural programme: one year outcome.

Hospital-based outpatients participating in a cognitive-behavioural group programme (2 hours/week over 5 weeks) were studied to evaluate the effectiveness of a 24-hour transdermal nicotine patch in assisting smokers to stop smoking when used as an adjunct to a cognitive-behavioural group programme, and to assess weight gain following cessation, using a randomized, double-blind, placebo-controlled trial with 12 months' follow-up. The main outcome measure was a comparison between point prevalence abstinence, continuous abstinence and 12-months sustained, biochemically validated abstinence. The validated abstinence rates at 12 months for point prevalence, sustained and continuous abstinence for subjects in the active and placebo groups were all statistically significant: 28 vs. 12%; 24 vs. 11%; and 19 vs. 9%, respectively. Moderately dependent smokers using the nicotine patch were more successful than highly dependent smokers at 3 and 6 months (p < 0.05). Weight gain was greater among sustained abstainers at 12 months compared to continuing smokers (p < 0.001). When the active nicotine patch was used in combination with cognitive-behavioural therapy in an outpatient hospital clinic, 12-months sustained abstinence rates were more than double those of a placebo patch.

Three year continuous abstinence in a smoking cessation study using the nicotine transdermal patch.

A total of 305 subjects from Sydney were randomly allocated to receive either an active (24 hour transdermal nicotine patch over a 10 week course) or placebo nicotine patch. All subjects participated in a multicomponent cognitive-behavioural smoking cessation programme over five weeks in two-hour group sessions. The continuous abstinence rates at three years (validated by expired carbon monoxide) were 13.8% for the active group and 5.2% for placebo group (p = 0.011). The active nicotine patch with behavioural therapy achieved more than double the abstinence rates early in treatment compared with placebo and this difference was maintained throughout the three year follow up.

A comparison of measures used to assess effectiveness of the transdermal nicotine patch at 1 year.

This study examines outcome measures of abstinence among studies reporting 12-month outcomes of the nicotine transdermal patch using different measures of effectiveness. This was achieved by reviewing published randomized controlled studies reporting 1-year abstinence rates of the nicotine transdermal patch. Comparisons are made across studies of three outcome measures used to report abstinence: point prevalence, continuous, and prolonged abstinence. Studies that measured outcome in terms of continuous and prolonged abstinence at 1 year showed double the effect for the active patch compared to placebo; however, this difference was not always apparent in those studies using point prevalence as the outcome measure.

Retracing the steps of Marco Polo: from clinical trials to diffusion of interventions for smokers.

We report the results from a series of four controlled trials which evaluate efficacy, effectiveness, and implementation of interventions for smokers, and then discuss diffusion of our program in feasibility studies both nationally in Australia and internationally. In our first study we reported that when general practitioners delivered moderately brief advice to smokers, they have a 36% abstinence rate at three years. In the second study we found that doctors achieve a 12% abstinence at one year after giving minimal advice to patients, and when using a more involved intervention, quit rates of just less than 20% at one year. In the third and fourth studies of utilization of the smoking cessation program we report that reinforcement contact following a 2-hour training workshop increased doctors' use of a smoking cessation program at 6 months compared to no contact. The challenge of translating research findings into practice for the benefit of doctors in Australia as well as in a low-income country such as China, is described in two feasibility studies. Over the past 11 years we have disseminated the program nationally in Australia, and over 4500 doctors have been trained. Diffusion theory provides a useful model which has guided us in our implementation efforts in Australia and is being used to allow us to introduce the smoking cessation intervention for Chinese doctors to use.

Screening for smokers in four Sydney teaching hospitals.

BACKGROUND: Cardiovascular disease is a major cause of death and a reason for hospital admissions. The hospital stay is a window of opportunity to assist smokers to quit. METHODS: Patients from selected wards in four teaching hospitals in Sydney, Australia were screened using a self-completed general health questionnaire. The questionnaire included questions on demographic variables, tobacco and alcohol consumption, attitudes towards tobacco and alcohol use, and a measure of readiness to charge high-risk lifestyle behaviors, based on that proposed by Prochaska and DiClemente [1]. RESULTS: The total number of screening questionnaires completed was 2,815: 78% men and 22% women. The average age of the sample was 44 years, 48% were married or living in a de facto relationship whilst 35% never married, with the rest widowed, separated or divorced. A total of 877 (31%) patients reported smoking: 33% of men and 24% of women screened. Predictors of smoking were sex, age, marital status, education level and socio-economic status. A significant association was found between excessive drinking and smoking. Among the smoking patients, 157 (18%) planned no change in smoking (precontemplation), 379 (43%) were ambivalent about smoking (contemplation), and 334 (38%) were serious about quitting. CONCLUSION: As about one third of patients in hospital are smokers, the hospital is an ideal setting for the delivery of brief interventions by a range of health personnel at the patients bedside. The use of a detection instrument measuring levels of intake and readiness to change tobacco use is described, as a practical method for targeting patients in hospital who are at risk or have already developed cigarette-related diseases, such as cardiovascular disease.

The transdermal nicotine patch: results of a randomised placebo-controlled trial.

OBJECTIVES: To evaluate the efficacy of the transdermal nicotine patch as an aid to smoking cessation when used as an adjunct to a cognitive-behavioural group intervention and to assess the effectiveness of the patch in ameliorating withdrawal symptoms. DESIGN AND SETTING: Double-blind placebo-controlled randomised trial with six months' follow-up of those who returned to the hospital-based outpatients smoking cessation clinic. SUBJECTS: Three hundred and thirteen smokers recruited from the local community. Mean age was 42 years, 48% were male, mean cigarette consumption was 29 per day and mean duration of smoking was 24 years. INTERVENTION: Cognitive-behavioural intervention delivered in a group context, two hours once a week over five weeks, self-help manual, and 24-hour daily nicotine patch treatment for 10 weeks. MAIN OUTCOME MEASURES: Point prevalence abstinence at three and six months, and sustained cessation from end of treatment to six months, with biochemical validation (expired carbon monoxide). We examined the effectiveness of the nicotine patch in ameliorating specific withdrawal symptoms by self-report of degree of severity. RESULTS: The active nicotine patch resulted in significantly higher biochemically confirmed abstinence rates when compared with placebo at three months (48% v. 21%) and at six months (33% v. 14%). Six-months' continuous abstinence rates were also significantly higher among the active nicotine group (25%) compared with placebo (12%). The most common adverse events among active patch users were sleep disturbance and local skin irritation. The nicotine patch reduced the severity of some withdrawal symptoms. A low level of dependence was the strongest predictor of three and six months' abstinence. CONCLUSIONS: The transdermal nicotine patch is effective when used as an adjunct to a group cognitive-behavioural intervention and it provides relief from withdrawal symptoms associated with nicotine dependence.

Smokescreen for the 1990s. A new approach to smoking cessation.

Smokescreen for the 1990s is a brief program designed specifically for general practitioners to help patients to stop smoking and is based on the latest research in smoking cessation. This article looks at the major principles on which the revised program is based and outlines the key steps taken to assist smokers according to their readiness to quit.

Research in general practice for smokers and excessive drinkers in Australia and the UK. I. Interpretation of results.

This review examines the role of the general practitioner in assisting patients to stop smoking and in reducing levels of excessive drinking. After over a decade of clinical trials, we discuss what interventions work in general practice and interpret the results of clinical trials conducted predominantly in Australia and the UK. Studies have generally found a superiority of GPs' brief advice over non-intervention groups. Very brief GP advice results in smoking abstinence rates from 5% to 10%, reduction in alcohol consumption of around 25-35% and reduction in proportions of excessive drinkers of around 45%. The greater investment of GPs' time and the more comprehensive interventions which include follow up usually resulted in higher abstinence rates among smokers from between 20% to 36%, and reduction in proportions of excessive drinkers of up to 60-70%. The contributions of the adjuncts nicotine chewing gum, follow up visits and the personalization of health effects are discussed. It is difficult to make comparisons between studies and we examine some of the reasons. The predictors of successful outcome are presented as they are of particular interest to GPs in terms of targeting health promotion activities.

Research in general practice for smokers and excessive drinkers in Australia and the UK. II. Representativeness of the results.

This paper reviews some of the issues related to the appropriateness of generalizing the results from clinical trials which have been conducted in general practice for smokers and excessive drinkers. We discuss the representativeness of the results related to the method of recruitment of general practices and patients to the study populations. We examine methodological issues and reasons associated with general practitioners' and patients' non-compliance with maintaining the research protocols and intervention requirements which relate to the practiceworthiness and the future uptake of interventions. When assessing the applicability of interventions to general practice, there are three basic research questions which should be looked at quite separately that relate to: efficacy, effectiveness and implementation.