Short-term change in self-reported COPD symptoms after smoking cessation in an internet sample.

Smoking is the first risk factor for chronic obstructive pulmonary disease (COPD). Some recent reports suggest that, unexpectedly, some respiratory symptoms may increase transiently after smoking cessation, but there is a dearth of short-term data to test this hypothesis. The aim of the present study was to assess the validity of an online screening tool and to describe short-term associations between smoking behaviour and self-reported respiratory symptoms, in cross-sectional and longitudinal data. An internet survey was conducted in 2003-2009, on a smoking cessation website, with a follow-up survey after 30 days. There were 15,916 participants at baseline and 1,831 at follow-up. In the 252 baseline smokers who had quit smoking at 30-day follow-up, there was a substantial decrease in the proportion of participants who declared that they often coughed even without a cold (from 51.6% at baseline to 15.5% at follow-up), expectorated when they coughed in the morning (from 47.6% to 19.4%), were out of breath after climbing stairs or after a quick walk (from 75.0% to 48.4%), and who had a wheezing respiration (from 33.7% to 10.3%) (p<0.001 for all before/after comparisons). In participants who did not change their smoking behaviour between assessments, the test-retest reliability was r = 0.87 for a score summing these four symptoms. Smoking cessation was followed by a rapid and substantial improvement in self-reported respiratory symptoms. COPD is largely underdiagnosed and undertreated. Internet screening is reliable and may allow for the early detection of COPD symptoms at a large scale, in patients who may otherwise have no access to COPD case-finding efforts.

[Are graphic warnings on cigarette packs useful?]. / Les mises en garde illustrées sur les paquets de cigarettes sont-elttes utites?

Based on the WHO Framework Convention on Tobacco Control recommendations, health warnings and messages should be printed on cigarettes packages. Scientific data show that such messages are effective by delivering important information directly to smokers, who believe these messages more and remember better than they do public education campaigns. These warnings also increase the chance of quitting. This narrative review summarizes the data at the time Switzerland requires such pictures on tobacco products.

Effectiveness of a computer-tailored smoking cessation program: a randomized trial.

BACKGROUND: From a public health perspective, prevention of cancer and cardiovascular diseases requires effective smoking cessation programs that can be used on a large scale. OBJECTIVE: To test the effectiveness of a new computer-tailored smoking cessation program vs no intervention. METHODS: Randomized controlled trial, in the French-speaking part of Switzerland, September 20, 1998, to December 31, 1999. Potential participants were randomly selected from a general population register and recruited by mail. Daily cigarette smokers who wished to participate (N = 2934) were randomized to either the program or no intervention. A mean of 1.5 times per 6 months, participants in the active arm received by mail a computer-tailored counseling letter based on their answers to a questionnaire and stage-matched booklets. The counseling letters were tailored to the participants' stage of change (categorized as precontemplation [no intention of quitting smoking in the next 6 months], contemplation [seriously considers quitting in the next 6 months], or preparation [has decided to quit in the next 30 days]), level of tobacco dependence, self-efficacy, and personal characteristics. The outcome measure was self-reported abstinence (no puff of tobacco smoke in the past 4 weeks) 7 months after entry into the program. RESULTS: Abstinence was 2.6 times greater in the intervention group than in the control group (5.8% vs 2.2%, P<.001). The program was effective in "precontemplators" who were not motivated to quit smoking at baseline (intervention vs control, 3.8% vs 0.8%; P =.001) and was effective regardless of perceived difficulty in quitting smoking at baseline. CONCLUSIONS: The program was effective in increasing smoking cessation rates. Because it can reach a large number of smokers, this program can substantially contribute to disease prevention at a population level.

Measurement of self reported active exposure to cigarette smoke.

STUDY OBJECTIVE: The number of cigarettes smoked per day is an imprecise indicator of exposure to cigarette smoke, and biochemical assessment of exposure is not always feasible. The aim of this study was to develop more accurate measures of self reported active exposure to cigarette smoke. DESIGN: Mail survey in 386 smokers, retest at one month in 94 participants (24%), analysis of saliva cotinine in 98 participants (25%), collection of empty cigarette packs in 214 participants (55%), collection of cigarette butts in 107 participants (28%). Ten questions and items intended to assess active exposure to cigarette smoke were tested and compared with saliva cotinine, the Fagerström test for nicotine dependence, and self rated dependence. SETTING: A population sample in Geneva, Switzerland, in 1999. PARTICIPANTS: 323 daily smokers and 63 occasional smokers. MAIN RESULTS: Measures that were associated with saliva cotinine included the number of cigarettes smoked per day (r(2)=0.36), smoking intensity (r(2)=0.40), the type of cigarettes smoked (regular versus light) (r(2)=0.04), smoking when ill (r(2)=0.15) and a single item rating of the total quantity of smoke inhaled (r(2)=0.27). A multivariate model combining the first four items explained the largest proportion of the variance in cotinine (r(2)=0.63), substantially more than was explained by the number of cigarettes per day alone, by 75% in all smokers and by 110% in daily smokers. CONCLUSIONS: The study identified measures of exposure to smoke that reflect saliva cotinine better than the number of cigarettes per day. These measures can be used in studies of the dose related risk of smoking and in smoking reduction studies.

A comparison of cigarette smokers recruited through the Internet or by mail.

OBJECTIVES: To compare smokers recruited by mail or through the Internet. METHODS: A questionnaire was mailed to 19,352 inhabitants of Switzerland in 1998, in an effort to enroll them in a smoking cessation trial. The same questionnaire was also available on the Internet. Furthermore, we mailed a survey to a representative sample (n = 1000) of the population of Geneva, Switzerland, in 1996. In this study, we compare three groups: 1027 smokers recruited through the Internet, 2961 volunteer trial participants recruited by mail (response rate 16%), and 211 smokers in the representative sample also recruited by mail (response rate 75%). RESULTS: Smokers self-recruited through the Internet were younger, more educated, more motivated to quit smoking and smoked more cigarettes per day than smokers in the other samples. Compared to trial participants, Internet participants had more negative attitudes towards smoking, higher self-efficacy scores, and were more addicted to tobacco. The strength of associations between smoking-related variables was similar in Internet and trial participants. CONCLUSION: As expected, the three groups of smokers differed on several characteristics. However, bias in distributions of variables did not imply bias in associations between variables. Thus, Internet recruitment is a potentially useful method for analytical studies that focus on associations between variables.

Attitudes toward nicotine replacement therapy in smokers and ex-smokers in the general public.

OBJECTIVE: Nicotine replacement therapy (NRT) doubles the chances that a smoker will quit smoking, but most smokers who attempt to quit do not use it at all or only use it inconsistently. We aimed to identify attitudes of smokers and ex-smokers toward NRT and to develop and assess the validity of a brief scale used to measure these attitudes. METHODS: We conducted a first mail survey of 256 smokers and ex-smokers to collect qualitative data and to develop survey items and a second mail survey of 494 smokers and ex-smokers to finalize the scale and assess its validity. The study was conducted in Geneva, Switzerland, in 1998 to 1999. RESULTS: The study resulted in a 2-dimensional, 12-item scale: the Attitudes Toward Nicotine Replacement Therapy scale (ANRT-12). The 2 subscales measure perception of the advantages of NRT (8 items) and the drawbacks of NRT (4 items). Internal consistency coefficients (alpha = 0.84 and 0.75, respectively) and test-retest correlations (0.79 for both scales) were high. The scales respected criteria of content and construct validity. Scores were associated with intention to use NRT, and among those who had ever used NRT, with the number of days of use. A disturbing result was that only 1 (16%) of 6 participants agreed that "NRT helps people quit smoking," and only 1 (24%) of 4 ex-smokers had ever used NRT. CONCLUSIONS: Many smokers and ex-smokers have inadequate knowledge of and negative attitudes toward NRT. ANRT-12 is a valid and reliable measure of these attitudes; it can be used by clinicians, researchers, and educators to improve use of and compliance with NRT.

Assessment of the COOP charts with and without pictures in a Swiss population.

OBJECTIVES: This study aimed to assess the validity of COOP charts in a general population sample, to examine whether illustrations contribute to instrument validity, and to establish general population norms. METHODS: A general population mail survey was conducted among 20-79 years old residents of the Swiss canton of Vaud. Participants were invited to complete COOP charts, the SF-36 Health Survey; they also provided data on health service use in the previous month. Two thirds of the respondents received standard COOP charts, the rest received charts without illustrations. RESULTS: Overall 1250 persons responded (54%). The presence of illustrations did not affect score distributions, except that the illustrated 'physical fitness' chart drew greater non-response (10 vs. 3%, p < 0.001). Validity tests were similar for illustrated and picture-less charts. Factor analysis yielded two principal components, corresponding to physical and mental health. Six COOP charts showed strong and nearly linear relationships with corresponding SF36 scores (all p < 0.001), demonstrating concurrent validity. Similarly, most COOP charts were associated with the use of medical services in the past month. Only the chart on 'social support' partly deviated from construct validity hypotheses. Population norms revealed a generally lower health status in women and an age-related decline in physical health. CONCLUSIONS: COOP charts can be used to assess the health status of a general population. Their validity is good, with the possible exception of the 'social support' chart. The illustrations do not affect the properties of this instrument.

On quitting smoking: development of two scales measuring the use of self-change strategies in current and former smokers (SCS-CS and SCS-FS).

Smoking-cessation advice may be more effective and acceptable if it is based on strategies used by people who quit smoking on their own. The objective of this study was to identify these self-change strategies and to develop and validate questionnaires measuring the frequency of their use in current and former smokers. Development of questionnaire items was based on qualitative data provided by 120 current and former smokers, and the validation study was conducted by mail in 638 smokers and ex-smokers in Geneva, Switzerland, from 1996 to 1998. We identified 5 distinct and interpretable self-change strategies in current smokers and 5 strategies in former smokers, and measured their frequency of use with a 19-item questionnaire in current smoker (SCS-CS) and with a 17 item questionnaire in former smokers (SCS-FS). Eight items and 2 strategies were common to both current and former smokers. the scales fulfilled criteria of test-retest reliability, and content, construct, and predictive validity. Participants who quit smoking between the baseline survey and the 1-month follow-up had higher baseline scores for all self-change strategies (+0.65 to +1.16 standard deviation units) than participants who remained smokers at follow-up. These scales may be used to describe and understand the processes of smoking cessation and relapse, as well as to produce input data for computer systems which produce individually-tailored smoking cessation advice.

Development and validation of a scale measuring self-efficacy of current and former smokers.

AIMS: To develop and test the validity of a questionnaire measuring the confidence of current and former smokers in their ability to abstain from smoking in high-risk situations. DESIGN AND PARTICIPANTS: We collected qualitative data in a first mail survey in 115 smokers and ex-smokers, and used these data to develop survey items. We collected quantitative data in a second mail survey in 529 smokers and ex-smokers to finalize the instrument. SETTING: General population in Geneva, Switzerland, 1995, 1997 and 1998. FINDINGS: The study resulted in a two-dimensional 12-item scale: the "Smoking Self-Efficacy Questionnaire" (SEQ-12). The two six-item subscales measure confidence in ability to refrain from smoking when facing internal stimuli (e.g. feeling depressed) and external stimuli (e.g. being with smokers). Internal consistency coefficients were high ("internal stimuli": alpha = 0.95; "external stimuli": alpha = 0.94). Test-retest intraclass correlation coefficients were high (0.95 and 0.93 for the two scales, respectively). In smokers, baseline self-efficacy scores predicted smoking cessation at 16-month follow-up. Finally, the scale respected criteria of content- and construct validity. CONCLUSION: SEQ-12 is a valid and reliable scale, which has applications in both research and clinical settings. It can also produce input data for computer systems that generate counselling reports tailored to the characteristics of each individual smoker.

Labeling smokers' charts with a "smoker" sticker: results of a randomized controlled trial among private practitioners.

We randomly assigned private practitioners (n = 393) to receiving, by mail, a box of "Smoker" stickers and a recommendation to label smokers' charts with these stickers, or to no intervention. Twenty percent of the physicians reported using the stickers and applying them on 43% of their smoking patients' charts. The intervention had no impact on physician reports of the proportion of smokers advised to quit smoking, but physicians who reported using the stickers stated that they advised more smokers to quit after the intervention (89%) than before (80%, P =.02). Thus, self-reports by physicians indicated that use of the stickers was associated with an increased proportion of smokers advised to quit. However, overall, the intervention did not modify physicians' behavior.

Development and validation of the Attitudes Towards Smoking Scale (ATS-18).

AIM: To develop and test the validity of a scale measuring attitudes towards smoking in current and former cigarette smokers. DESIGN AND PARTICIPANTS: In a first mail survey, we collected qualitative data from 616 smokers. In a second mail survey, we collected quantitative data from 529 smokers and ex-smokers. We conducted a 16-month follow-up survey among 93 participants in the second survey. SETTING: Geneva, Switzerland, 1995-98. FINDINGS: The study resulted in a three-dimensional, 18-item scale: the "Attitudes Towards Smoking Scale" (ATS-18). The scale was validated with reference to criteria of content-, construct- and predictive validity. The three subscales measure perceptions of adverse effects of smoking (10 items), psychoactive benefits (four items) and pleasure of smoking (four items). Internal consistency coefficients (0.85, 0.88 and 0.81) and test-retest correlations were high (0.90, 0.75, 0.89, respectively). Differences in attitude scores between smokers in the pre-contemplation and preparation stages of change were -0.83, 0.71 and 1.23 standard deviation units, respectively. A differential score (advantages minus disadvantages of smoking) predicted smoking cessation in baseline smokers and relapse in baseline ex-smokers. CONCLUSION: ATS-18 is a valid and reliable instrument which can be used in both research and clinical settings.

Snowball sampling by mail: application to a survey of smokers in the general population.

BACKGROUND: In a series of surveys intended for current and former smokers but sent to a random sample of the general population, we asked never smokers and smokers who did not wish to participate to transmit the questionnaire to any ever smoker they knew. We compared participants who received the questionnaire directly from us (original participants) to participants who received it from an addressee (secondary participants). METHODS: Questionnaires on smoking were mailed to 3300 residents of Geneva (Switzerland) in 1997, and returned by 1167 people (35%). RESULTS: The final sample consisted of similar numbers of original participants (n = 578, primary response rate = 18% of total sample, or about 46% of ever smokers) and secondary participants (n = 566). Original participants were 1.7 years older than secondary participants (P = 0.03) and were more likely to be men (50% versus 43%, P = 0.009). Proportions of current smokers, stages of change, confidence in ability to quit smoking, cigarettes per day and attempts to quit smoking were similar in the two groups. Secondary participants had lower self-efficacy scores (-0.30 standard deviation (SD) units, P < 0.03), and they derived more pleasure from smoking (+0.25 SD units, P = 0.04). Among ex-smokers, direct participants were less active than secondary participants in coping with the temptation to smoke (-0.58 SD units, P = 0.002). Associations between smoking-related variables were similar in original and secondary participants. CONCLUSION: Allowing non-eligible addressees to transmit the questionnaire to someone else doubled the response rate, produced moderate bias on some variables only and had no detectable impact on associations between smoking-related variables.

Saliva cotinine levels in smokers and nonsmokers.

The authors collected by mail self-reported data on smoking habits and saliva samples that were analyzed for cotinine concentration in 222 smokers and 97 nonsmokers. Participants were members of the University of Geneva (Switzerland) in 1995. The 207 cigarette-only smokers smoked on average 10.7 cigarettes/day and had a median concentration of cotinine of 113 ng/ml. The cotinine concentration was moderately associated with the number of cigarettes smoked per day (+14 ng/ml per additional cigarette, p < 0.001, R2 = 0.45) and was 54 ng/ml higher in men than in women after adjustment for cigarettes per day and for the Fagerström Test for Nicotine Dependence. The cotinine level was not associated with the nicotine yield of cigarettes (r= 0.08). In nonsmokers, the median concentration of cotinine was 2.4 ng/ml. The cotinine concentration was 1.5 times higher in nonsmokers whose close friends/spouses were smokers than in nonsmokers whose close friends/spouses were nonsmokers (p = 0.05). A cutoff of 7 ng/ml of cotinine distinguished smokers from nonsmokers with a sensitivity of 92.3% and a specificity of 89.7%; a cutoff of 13 ng/ml provided equally satisfactory results (sensitivity, 86.5%; specificity, 95.9%). This study provides evidence for the construct validity of both questionnaires and saliva cotinine for the assessment of active and passive exposure to tobacco smoke.

Cross-cultural adaptation of a psychometric instrument: two methods compared.

Cross-cultural adaptations of questionnaires are needed in multilingual research, but little is known about the effectiveness of specific translation methods. We compared properties of two French-language adaptations of the SF36 health survey: (a) a rapid translation developed over 3 months in Geneva in 1992 (Geneva version), based on three initial translations, one synthesis, and two pretests, and (b) a comprehensive adaptation developed by the International Quality of Life Assessment Project between 1991 and 1994 (IQOLA version), which involved back-translations, focus groups, development of equidistant response options, item difficulty and quality ratings, and multiple pretests. Wordings of 34 of 36 items differed. These two instruments were administered 1 year apart to the same sample of 946 young adults. Ceiling effects were somewhat lower for the IQOLA than for the Geneva version (means 30.4% and 35.5%), and missing scores slightly less frequent (IQOLA: mean 0.5%; Geneva: 1.2%). Floor effects (means 2.7% and 2.4%), proportions of consistent respondents (93.4% and 94.0%), and internal consistency coefficients (IQOLA: 0.78-0.89, Geneva: 0.80-0.92) were similar. Factor analysis supported the existence of two main aspects of health (physical and mental) for both versions. A majority of known-group comparisons were compatible with theory, for both versions. In conclusion, the two French-language versions of the SF36 had similar psychometric properties, despite extensive differences in the development process. This suggests that a moderately resource-intensive translation may produce adequate results. More empirical research is needed to understand what translation methods yield the best results.

Validity of the Fagerström test for nicotine dependence and of the Heaviness of Smoking Index among relatively light smokers.

AIMS: To assess the validity of the Fagerström test for nicotine dependence (FTND, six items) and of a short-form of this questionnaire, the Heaviness of Smoking Index (HSI, two items), in a population of relatively light smokers. DESIGN: Comparison of item content with published definitions of addiction. Test-retest reliability and multiple tests of construct validity, based on a secondary analysis of a cohort study conducted between November 1995 and June 1996. SETTING: University of Geneva, Switzerland. PARTICIPANTS: Students (82%), academic (12%) and administrative staff (6%): 643 smokers at baseline and 482 smokers at follow-up. MEASUREMENTS: French-language versions of the FTND and HSI, smoking status, saliva cotinine level, self-efficacy for quitting smoking and other variables related to addiction with cigarettes. FINDINGS: A literature review showed that both composite scales fail to assess several recognised aspects of tobacco dependence. In this population of relatively light smokers (average: 12 cigarettes per day), both tests had important floor effects with, respectively, 55% and 63% of participants with scores equal to 0 or 1 on these scales. In addition, two of the FTND items (Difficult-to-refrain and Hate-most-to-give-up) had poor psychometric properties. Even though FTND and HSI correlated about as expected with criterion variables, the number of cigarettes smoked per day performed better than either composite scale on most validation criteria. CONCLUSION: In a population of relatively light smokers, FTND and HSI seem to measure little more than the number of cigarettes per day. Designing a new and more broadly applicable test of addiction to cigarettes is a research priority.

Associations between the stages of change and the pros and cons of smoking in a longitudinal study of Swiss smokers.

To develop effective smoking prevention interventions, we need to identify modifiable variables, such as the "pros and cons" of smoking, that predict self-initiated smoking cessation. Our objective was to assess associations between the pros and cons of smoking and the stages of change, both cross-sectionally and longitudinally, in a cohort of smokers. In cross-sectional comparisons, the pros of smoking were 0.19-0.31 standard deviation (SD) higher and the cons 0.79-0.87 SD lower in the precontemplation than in the preparation stage. In follow-up data, progressing from precontemplation to contemplation and from contemplation to preparation was associated with substantial and significant increases in the cons (+0.71 SD and +0.50 SD, respectively). No longitudinal associations were found between changes in pros of smoking and progress through stages. Thus this study added evidence from longitudinal data to published evidence from cross-sectional data about the association between the cons of smoking and the stages of change. Intervention studies are necessary to establish whether this association is causal.

Short-term impact of a university based smoke free campaign.

STUDY OBJECTIVE: The aim of this study was to evaluate the impact of a smoke free programme implemented at the University of Geneva, Switzerland, in 1996. This programme included a prohibition to smoke in university buildings everywhere except in limited areas, and a smoking cessation counselling service. METHODS: Surveys were conducted before and four months after the programme was implemented, in representative samples of programme participants (n = 833) and university members not exposed to the programme (n = 1023). RESULTS: In retrospective assessments, participants reported being less bothered by environmental tobacco smoke after programme implementation, but no between group difference was detected in prospective assessments. Relationships between smokers and non-smokers improved moderately in the intervention group and remained unchanged in the comparison group (between group p = 0.001). Proportions of smokers who attempted to quit smoking in the past four months increased from 2.0% to 3.8% in the intervention group and remained unchanged at 3.5% in the comparison group (between group difference: p = 0.048). No impact on smoking prevalence (25%) was detected. The programme was appreciated by university members, although some of its modalities were criticised. CONCLUSION: A regulation prohibiting smoking everywhere but in limited areas of university buildings was acceptable and reduced the perception of bother by environmental tobacco smoke. It did not, however, influence smoking habits or attitudes toward smoking.

A comparison of two measures of stage of change for smoking cessation.

AIMS: To compare two questionnaires used to identify the stages of change of current and former smokers: a conventional five-item questionnaire and an alternative one-item questionnaire. DESIGN AND SETTING: Mail surveys of 1167 ever smokers in Geneva (Switzerland), conducted in 1997. Participants were classified into five stages: precontemplation, contemplation, preparation, action and maintenance. Other questions covered smoking-related behaviours, attitudes and self-efficacy. FINDINGS: Only 62% of participants were classified as being in the same stage by the two questionnaires (weighted kappa = 0.69). The five-item questionnaire produced more missing data (8%) than the one-item questionnaire (2%, p < 0.001). Using the conventional questionnaire, the precontemplation stage included a group of smokers who had absolutely no intention of stopping smoking and a group more prone to change, and the preparation stage included only 43% of people who had made a "firm decision" to quit smoking in the next 30 days. Using the alternative questionnaire, the contemplation stage was also quite heterogeneous. The action stage included over 35% of people who were still smoking occasionally, whichever questionnaire was used. CONCLUSIONS: The single-item questionnaire was better at avoiding missing responses. However, both staging questionnaires classified smokers in heterogeneous groups, and both misclassified many occasional smokers and ex-smokers, which suggests that a discrete five-stage model does not fit reality well. This may reflect underlying conceptual issues, notably that the classic definition of stages incorporates separate dimensions, albeit incompletely (current behaviour, quit attempts, intention to change, time). Both theoretical and methodological developments are needed to overcome these problems.