Tobacco is still widely consumed in a variety of different ways, mainly as smokeless tobacco and cigarette smoking. Facts about the harmful effects of tobacco have existed for nearly 200 years (Doll, 1998). At the end of the fifteenth century, Tobacco was introduced into Europe from America (Corti, 1931). At the beginning, it was used for medicinal proposes to be burnt in pipes for pleasure on a large extent for about 100 years later in Europe and all over the world. Tobacco used first through pipe smoking as snuff and, in turn, to cigar and cigarettes at different times in different countries until cigarettes became the main type in the most developed nations between the two world wars (Doll, 1998). Throughout all these years, there were medical evidences of the harm done by smoking, most of these related to the lip and mouth cancers (Lombard and Doering, 1928; Potter and Tully, 1945) and then to vascular disease and lung cancer (English et al., 1940; Tylecote, 1927; Lickint, 1930; Proctor, 1997; Adler, 1912; Hoffman, 1931). All The previous evidences were generally ignored until 1950 when five studies relating smoking to lung cancer were published (four in the USA and one in Britain) (Doll and Hill, 1950; Wynder and Graham, 1950; Levin et al., 1950; Schrek et al., 1950; Mills and Porter, 1950). These case-control studies showed a close association with smoking and the analysis of one of them conclude "excessive and prolonged use of tobacco, especially of cigarettes, seems to be an important factor in the induction of bronchogenic cancer" (Wynder and Graham, 1950). It was the beginning to show that smoking was related to the development of many other diseases. The understanding that smoking caused these diseases was vigorously debated for some years but it was generally accepted by the late of 1950s. During the period of 1957 to 1959, many health institutes and councils in Europe and US reported that cigarette smoking was a cause of lung cancer (The Medical Research Council, 1957; The US National Cancer and National Heart Institutes and The American Cancer Society, 1957; Swedish Medical Research Council, 1958; Burney, 1958 ) which accepted by an expert committee of the WHO one year later (World Health Organization, 1960).
Despite of that, the previous reports did not have long-lasting impact on the social community and the condition remain until the Royal College of Physicians of London and the advisory Committee of the US Surgeon General publicised their reports (Royal College of Physicians of London, 1962; U.S. Deptartment of Health Education and Welfare, 1964). Both of these reports agreed that tobacco use was a most important cause of lung cancer and was either a most important cause or an essential conditioning factor for chronic bronchitis (Doll, 1998). Furthermore, they conclude that smoking had an adverse effect on the healing of the peptic ulcers, it might promote the development and progression of peripheral vascular disease, it increased the risk of dying from coronary heart disease and contribute to the production of cancers of the mouth, pharynx, oesophagus and bladder. In 1985, the American Thoracic Society released a position statement which reviewed the health effects of smoking, taking into account scientific data and consensus opinion (Mason et al., 1985).
Since then the knowledge of smoking effects has markedly expanded and significant scientific facts has been published reporting the implications not only of tobacco use but also of tobacco exposure for morbidity and mortality.
Health consequences of tobacco use
Extensive evidences have been published about the harmful effects of tobacco use on health. These evidences include laboratory investigations of smoke characteristics and biological activity, short-term clinical investigations, and epidemiological studies that assess the prevalence of diseases in relation to tobacco use in certain populations (Mason et al., 1985; U.S. Department of Health and Human Services, 2004). Since the publication of the first Surgeon General's report in 1964 that confirmed the smoking to be the cause of lung cancer, the list of diseases and other adverse effects caused by tobacco use continues to expand. According to the latest report of the Surgeon General, the active smoking affects nearly every organ in the body, causing a wide range of diseases and reducing quality of life and life expectancy (U.S. Department of Health and Human Services, 2004) (as presented in Table 2.1).
When compared with non-smokers, It has been estimated that smoking increase the risk of coronary heart disease and stroke by two to four times, the smoker men have the ability to develop cancer by 23 times more than the non-smokers, while the smoker women developing lung cancer by 13 times, and dying from chronic obstructive lung diseases (such as chronic bronchitis and emphysema) by 12 to 13 times (U.S. Department of Health and Human Services, 2004; U.S. Department of Health and Human Services, 1989; Ockene and Miller, 1997). These risks are not similar overall smokers. They were varied according to the duration and amount of tobacco smoked, with those who are heavy smokers at greater risk. There is no safe level of smoking, even occasionally smoking cause harm (Centers for Disease Control and Prevention, 2011a).
Table 2.1 The effects of smoking on human health (U.S. Department of Health and Human Services, 2004)
Cancer
Acute myeloid leukaemia
Bladder
Cervical
Oesophageal
Gastric
Kidney
Laryngeal
Lung
Oral cavity and pharyngeal
Pancreatic
Cardiovascular
disease
Abdominal aortic aneurysm
Coronary heart disease (angina pectoris, ischaemic heart disease, myocardial infarction)
Cerebrovascular disease (transient ischaemic attacks, stroke)
Peripheral arterial disease
Pulmonary disease
Acute respiratory illnesses
Upper respiratory tract (rhinitis, sinusitis, laryngitis, pharyngitis)
Lower respiratory tract (bronchitis, pneumonia)
Chronic respiratory illnesses
Chronic obstructive pulmonary disease
Respiratory symptoms
Poor asthma control
Reduced lung function
Reproductive effects
Reduced fertility in women
Pregnancy and pregnancy outcomes
Preterm, premature rupture of membranes
Placenta previa
Placental abruption
Table 2.1 Continued
Reproductive effects
Preterm delivery
Low infant birth weight
Infant mortality
Sudden infant death syndrome
Other effects
Cataract
Osteoporosis (reduced bone density in postmenopausal women, increased risk of hip fracture)
Periodontitis
Peptic ulcer disease (in patients who are infected with Helicobacter pylori)
Surgical outcomes
Poor wound healing
Respiratory complications
Moreover, the smoke from tobacco products (which called second-hand smoke, environmental tobacco smoke, involuntary smoke, and passive smoke) has also adverse effects on those exposed to it. It is defined as a known human carcinogen (cancer-causing agent) (National Toxicology Program, 2005; International Agency for Research on Cancer (IARC), 2002; U.S. Department of Health and Human Services, 2010). It has been concluded that environmental tobacco smoke can cause lung cancer in non-smoking people (U.S. Department of Health and Human Services, 2006; U.S. Department of Health and Human Services, 2010). It is estimated that living with tobacco user increases the chances of the non-smoker of developing lung cancer by 20% to 30% (U.S. Department of Health and Human Services, 2006). There is an association between the passive smoking and the development of the cardiovascular disease and premature death, for instance, the relationship between the exposure to second-hand smoke and the risk of stroke and hardening of the arteries. Furthermore, there is an increased risk of sudden infant death syndrome, ear infection and slow in the growth of the lung any child who expose to second-hand smoke (U.S. Department of Health and Human Services, 2006; U.S. Department of Health and Human Services, 2010).
Tobacco use has been causally associated with substantially increased risk of mortality from several diseases (U.S. Department of Health and Human Services, 1989; Zaridze and Peto, 1986; International Agency for Research on Cancer (IARC), 2002). It is the leading preventable cause of death in the world and up to half of its regular users will die of a tobacco-related disease (World Health Organization, 2006). Globally, it is estimated that tobacco kills up to 6 million people annually or approximately one person every six seconds and this accounts for one in 10 adult deaths. Of six million, more than 5 million are either current smokers or ex-smokers. Additionally, about 600,000 people die every year from exposure to second-hand smoke. The current death toll is projected to increase to up to 8 million by 2030 if serious action is not taken, and that accounted for 10 percent of all deaths. The current death toll could rise to double by 2030 if urgent action is not taken (World Health Organization, 2012). Most of those deaths will be in low- and middle-income countries. In Malaysia, It is estimated that approximately ten thousand people died every year due to smoking related illness making it the main cause of death since the 1980s (Disease Control Division, 2003). Generally, the list of the diseases and harmful effects associated with tobacco use continues to expand, the medical staff and health care professionals in every medical setting should play a role in the prevention and treatment of tobacco smoking.
Tobacco dependence and nicotine addiction
Tobacco use is a learned habit that is difficult to stop once established. Most of smokers relapse due to tobacco dependence which represented by withdrawal symptoms and other clinical characteristics (Fiore et al., 2008; U.S. Department of Health and Human Services, 2010; U.S. Department of Health and Human Services, 2000). This explains the strength of tobacco addiction. Tobacco addiction is typified as a chronic disease that requiring repeated interventions until achieving permanent abstinence.
Despite the majority of the toxicity and adverse event of smoking is related to several components other than nicotine, the pharmacological effects of nicotine lead to tobacco addiction which in turn consider the proximate reason aiding to cause smoking related-disease (Eriksen et al., 2012; Benowitz, 2008). Generally, nicotine is not categorized among "harder" addictive drugs with continued usage of tobacco, it often becomes more difficult to abandon. As anyone who has always struggled with repeated attempts to quit smoking can attest to, nicotine is exceptionally intractable to abandoning interventions (Benowitz, 1996). This addiction remains a global health epidemic. Globally, more than three million people due to smoking-related disease are reported annually (Peto et al., 1996). Several tools have been developed for the evaluation of the degree of nicotine dependence among smokers. The Fagerstrom Test for Nicotine Dependence (FTND) (Heatherton et al., 1991), which has become the most widely used for the nicotine dependence evaluation tool in epidemiological surveys, clinical trials, and laboratory studies.
A lot of studies have been undertaken to understand how nicotine produces addiction and its influences smoking behaviour in order to give an important basis for ideal smoking cessation intervention (Benowitz, 1996). Like all drug addictions, addiction to tobacco includes the role of pharmacology, genetics, and social and environmental factors (Carpenter et al., 2007). Structurally, nicotine a tertiary amine consisting of a pyridine and a pyrrolidine ring (Benowitz, 2009). When any person inhales smoke from tobacco products, nicotine will be distilled from the tobacco and carried in the smoke particles into the lungs. In the lung, the nicotine will be absorbed into the pulmonary venous circulation. Nicotine rapidly then enters the arterial circulation and quickly crosses the blood brain barrier and diffuses into brain tissue and binds to nicotinic acetylcholine receptors (nAChRs) (ligand-gated ion channels that normally bind acetylcholine) (Dani and Heinemann, 1996; Benowitz, 2008; Benowitz, 2010). In the brain of mammalian, there are as many as nine α-subunits and three β-subunits. The most abundant receptor subtypes in the brains of humans are α4β2, α3β4, and α7 (homomeric) (Benowitz, 2009). Moreover, it is believed that the α4β2 receptor subtype (which is predominant in the human brain) is the main receptor mediating nicotine dependence (Benowitz, 2009). The activation of this nicotinic receptors by nicotine stimulates the transmission of a number of the neurotransmitters in the brain including acetylcholine, nor-epinephrine, serotonin, glutamate, endorphin, γ-aminobutyric acid (GABA) which mediating various behaviours of nicotine (Benowitz, 2010), and most importantly dopamine release because of its critical role in the in drug-induced reward of the nicotine and signals a pleasurable experience (Benowitz, 1999; Dani and De Biasi, 2001; Nestler, 2005) (as demonstrated in Figure 2.1).
C:\Users\Ali\Desktop\Figure 2.1.png
Figure 2.1 Neurochemical effects of nicotine. GABA = γ-aminobutyric acid. [Adapted with permission (Benowitz, 1999)]
Recurrent exposure to nicotine, may lead to develop neuroadaptation (smoking dependence) and may suffer from withdrawal symptoms upon cessation due to the effects of the nicotine which causes lasting modifications in dopaminergic function (Wang and Sun, 2005). There is a relationship between the withdrawal symptoms and dependence; tobacco users who appear signs of nicotine dependence are more susceptible to experience withdrawal symptoms when they stop smoking. Moreover, these symptoms may also be related to the level of the dependence, and may encourage smoking and alleviate the withdrawal (World Health Organization, 2010). There are two complementary theories that could demonstrate this phenomenon: firstly, tobacco users keep smoking throughout the day to maintain plasma nicotine levels to avoid the occurrence of the withdrawal symptoms. Another theory is that tobacco users drive some rewarding effects from conditioned smoking such as the taste and feel of smoke (Brody et al., 2006; Balfour, 2004; Donny et al., 2003). Thus, tobacco use is an ideal delivery system for an addictive drug because its role in increasing the potential for causing dependence (Lauro and Paxeras, 2004). Additionally to physiological basis for the addiction of nicotine demonstrated previously, there are behavioural and psychological factors such as environmental stimuli (smoking cues or situational cues) that have also contributed to the addiction.
The withdrawal syndrome and craving of smoking
It is concluded that the failure of smokers who try to stop smoking and their relapse after a period of abstinence is attributable to nicotine dependence represented by the emergence of craving and nicotine withdrawal symptoms because they cause substantial distress. (Allen et al., 2008; Doherty et al., 1995; Ferguson et al., 2006; Killen and Fortmann, 1997; Killen et al., 1991; Niaura et al., 1988; Orleans et al., 1991; Shiffman et al., 1997; Shiffman and Jarvik, 1976; Swan et al., 1996). This makes them worthy of clinical consideration. The onset of these symptoms begins within 2 - 3 hours after the last dose of nicotine. The duration of nicotine withdrawal symptoms can persist for a couple of weeks and the acute physical syndrome is worst in the first month after abstinence (Burke et al., 2008; Hays et al., 2009). In 1994, American Psychiatric Association comprises in their DSM-IV the withdrawal symptoms that are routinely assessed. They define them as "a syndrome of behavioural, affective, cognitive, and physiological symptoms, typically transient, emerging upon cessation or reduction of tobacco use, and causing distress or impairment" (American Psychiatric Association, 1994). Since the publication of this manual other symptoms has been suggested (upper respiratory tract infection, mouth ulcers and constipation). Furthermore, there are preliminary studies suggested to include the craving for cigarettes item in the DSM-IV criteria. These studies indicated that the craving is a vital symptom of nicotine withdrawal (Etter and Hughes, 2006; Jorenby et al., 1996; Shiffman et al., 2004).
Subsequently, craving for cigarettes and nicotine withdrawal symptoms are the most important clinical phenomena related to smoking cessation. Based on evidence that they are important in the relapse process (Fiore et al., 2008), the assessment for them is very important for several issues: it can be consider as markers or proxies for treatment effects. Additionally, it can be helped for clinical monitoring to guide ongoing treatment. Moreover, it helps to present and understand why some intervention more effective than others in the abstinence process (West et al., 2006; Shiffman et al., 2004).
Assessment instruments
Over the past three decades, a number of measurement scales have been developed for the assessment of the withdrawal symptoms and cravings for smoking. These scales have difference if several points: vary in their coverage of symptoms, the number and wording of labels used to assess the symptoms, the response options and the systems for aggregating responses to derive quantitative indices of withdrawal (West et al., 2006). For instance, they vary by method of assessment for symptoms from visual analogue scales, fixed-point rating scales, check-boxes noting just the presence or absence of symptoms (Tonnesen et al., 1991; Shiffman and Jarvik, 1976; Jorenby et al., 1999). There is an explanation for these variations, it is uneasy to assess the true validity of subjective measures. For this reason, there is no gold standard exists against which to compare between them.
Withdrawal syndrome scales
In the beginning of the assessment of nicotine withdrawal symptoms, the researchers assess them by a single, face-valid item or sometimes develop their own questionnaires on specific studies with unknown or unproven reliability and validity (Kozlowski and Wilkinson, 1987; West, 1992; Covey et al., 1990; Gunn, 1986; Persico, 1992; Wei and Young, 1988). There are several questionnaires which commonly used in tobacco withdrawal studies, and each one of them has undergone to at an initial evaluation of its psychometric properties. In 1976, Shiffman and Jarvik developed their own scale (Shiffman-Jarvik Withdrawal Scale) which probably consider the oldest withdrawal scale have been developed (Shiffman and Jarvik, 1976). This scale was developed before a clearer definition for nicotine withdrawal symptoms was appearing, because of that it involves few items that is not considered and related to the withdrawal symptoms formal definition (Shiffman et al., 2004).
Other measurement tools were also developed for this purpose: Schneider's Smoker Compliant Scale which was developed in 1984 and involved 14 items. The response for items were obtained using 7-point scale (very definitely not to very definitely). Hughes and Hatsukami developed the MNWS which focusing on the following items using 5-point scale (none, slight, mild, moderate, and severe): angry or irritability; restless, impatient; depressed mood; increased appetite, weight gain; difficulty concentrating; sleep problems; anxious, nervous; and desire to smoke (Hughes and Hatsukami, 1986). After more than a decade, Welsch and his colleagues reported the development their validated Wisconsin Smoking Withdrawal Scale which included 28 items and assesses seven symptoms using five-point scale (strongly disagree, disagree, neutral, agree, and strongly agree) (Welsch et al., 1999). It developed from items designed to meet DSM-IV criteria. One year later, Shiffman developed his own self-reported assessment tool (Shiffman Scale) that included fourteen items assessed four content areas: craving, withdrawal symptoms, negative mood and self-efficacy, using 10-scale point (from 0 = "not at all" to 10 = "strongest feeling possible") (Shiffman et al., 2000). In 2004, Mood and Physical Symptoms Scale has been developed by West and Hajek. It contained nine items that are assessed by using 5-point response scale (not at all, slightly, somewhat, very, and extremely). Finally, Etter reported the development of the Cigarette Withdrawal Scale which included twenty one items with six subscales using 5-point scale (totally disagree, mostly disagree, more or less agree, mostly agree, totally agree) (Etter, 2005).
As mentioned previously, several scales developed for the measurement of nicotine withdrawal symptoms. The MNWS has been one of the most widely used self-reported measures of the nicotine withdrawal scales (Shiffman et al., 2004), and demonstrated good reliability and validity in multiple studies (Hughes, 1992; Hughes et al., 1991; Hughes and Hatsukami, 1986; Etter and Hughes, 2006; Piasecki et al., 2003). It is brief, self-administered scale for the assessment of withdrawal symptoms (West et al., 2006; Etter and Hughes, 2006). People, who use this scale, rate the degree to which they experience every symptom on a 5-Likert scale. The scale originally includes seven nicotine criteria with additional one item measuring craving for a cigarette (Hughes and Hatsukami, 1986). Later, the content of the scale modified slightly over the years to reflect the criteria that specified in the DSM-IV text version (American Psychiatric Association, 2000).
There are discrepant findings and suggestions regarding the factor structure of the MNWS and how to score this instrument (Toll et al., 2007). Several studies tobacco withdrawal studies have used the scale with large sample size and reported that the factor analyses for it yielding a single factor and the total score for it is a unitary construct (Piasecki et al., 2003; Etter and Hughes, 2006). However, other studies findings showed multiple-factor solutions (Hughes, 1992; Hughes et al., 1991).
MNWS is translated to several languages such as Korean and Chinese (Kim et al., 2007; Yu et al., 2010). In the Korean version, the authors translated and assessed the psychometric validity (construct validity) with reliability (internal consistency reliability and stability) for the translated scale among Korean American male individuals (Kim et al., 2007). The study showed that the Korean version of the MNWS had the satisfactory internal consistency along with the validity findings through the construct validity and factor analysis suggest the translated scale can be used with Korean American population.
Furthermore, the Chinese study which included 10 steps for translation into Chinese version of MNWS (Yu et al., 2010). The assessment of reliability (Cronbach's alpha coefficient) and validity (construct validity with factor analysis) of translated scale were evaluated based on the data collected from 354 subjects. The findings of the study presented the scale had satisfactory validity and reliability and suggest that the Chinese version can be used in further research and clinical evaluation in Chinese smoking population.
Craving on smoking scales
Craving which is defined by The United Nations International Drug Control Programme (UNDCP) and World Health Organization (WHO) as "the desire to experience the effect(s) of a previously experienced psychoactive substance" (WHO, 1992). Craving for smoking can be provoked by several factors: smoking cues, thoughts associated with smoking, affective states, and smoking deprivation (Drobes and Tiffany, 1997; Drobes et al., 1994; Cepeda-Benito and Tiffany, 1996; Tiffany and Drobes, 1991). Thus, the evaluation of craving is fundamental to understand about the relapse process and, consequently, to develop interventions that will help tobacco users to cope with a strong urge on smoking (Sayette et al., 2000).
Until recently, the assessment for smoking craving was done by the instruments having questionable psychometric properties (Cox et al., 2001). Many studies used limited single-item scales to measure craving (Abelin et al., 1989; Daughton et al., 1991; Doherty et al., 1995; Hughes et al., 1984; Glassman et al., 1984). Such kind of evaluation is limited because it presents a one-dimensional picture of craving. Additionally, it cannot determine the reliability of a single-item measure (Tiffany, 1992). Other studies add an extra item either to assess how often a tobacco user experiences craving throughout the day or how distressing craving is to tobacco user (West et al., 1989; West et al., 1987; Killen et al., 1991). Furthermore, there are some questionnaires which have multiple items in craving measure have been developed but they have limitation on their usage due to validation with small sample size, lack of information about the psychometric properties of the questionnaires (West et al., 1984; Shiffman and Jarvik, 1976).
In 1991, Questionnaire on Smoking Urges was developed in order to reliably measure and to evaluate the potential multidimensional nature of smoking urge (Tiffany and Drobes, 1991). This 32-item self-report instrument intend to capture several features of craving ranging from anticipation of the positive outcomes of smoking, the desire to smoke to more general intention to smoke. Exploratory factor analysis of this questionnaire distributed to two hundred thirty current smokers indicated that it consists of a two-factor item structure, which can be described as "the desire and intention to smoke with an anticipation of pleasure from smoking' and 'the relief from nicotine withdrawal or negative affect with an urgent and overwhelming desire to smoke" (Tiffany and Drobes, 1991). These two factors showed strong reliability and internal consistency (Cronbach's alpha was more 0.9 for each factor). The first factor was represented the quality of desire to smoke, in contrast to the second factor, it represented a pressing and urgent state of desire.
Questionnaire on Smoking Urges was impractical for use in research settings especially when several craving assessments are required or for clinical settings when additional measures are combined with craving assessment because of the questionnaire length. Accordingly, Cox and his colleagues developed an abbreviated questionnaire to represent the two factors found in the original questionnaire (Cox et al., 2001). The resulting abbreviated questionnaire that contains only ten items that can be completed in less than two minutes. People who used this shortened instrument are instructed to reply to statement using 100-point scale ranging from strongly disagree to strongly agree. The brief questionnaire on smoking urges (QSU-Brief) has good reliability and factor analysis of its items presented also a two-factor structure that is well with what selected from the longer scale. However, there were two items not assigned to any subscale because their loading on both factors. Consequently, Factor one in the 10-item QSU-Brief consists of 5 items and factor two involved 3 items (Cox et al., 2001). The psychometric properties for QSU-Brief have been confirmed in several studies (Cepeda-Benito and Reig-Ferrer, 2004; Cappelleri et al., 2007). The QSU-Brief has been widely used in many studies (Cepeda-Benito and Tiffany, 1996; Drobes et al., 1994; Drobes and Tiffany, 1997; Attwood et al., 2008; Bradley et al., 2008; LaRowe et al., 2007).
The QSU-Brief was translated into numerous languages such as Chinese, Dutch, and Brazilian. The Chinese version study showed a strong reliability (Cronbach's alpha was 0.92) and the validity which done by using construct validity (factor analysis) that showed resemble structure to the original one. In addition, criterion validity displayed that there is significant correlation between QSU-Brief Scores and patient-evaluated craving scores (P Ë‚ 0.001) (Yu et al., 2010). The authors conclude that Chinese version can be used in further research and clinical evaluation in Chinese smoking population. Araujo and his colleagues reported translation and validation of the Brazilian version of the QSU-Brief (Araujo et al., 2006). The findings of their study showed the reliability of the scale was good (Cronbach's alpha values from QSU-Brief was above 0.7). Furthermore, there was a significant correlation between total score of QSU-brief and the Visual Analogic Scale (P Ë‚ 0.001), with two questions of FTND (P = 0.004 for question 1; P Ë‚ 0.001 for question 2). It is concluded that Brazilian version was an adequate psychometric questionnaire for the use (Araujo et al., 2006). In 2011, QSU-Brief was translated into the Dutch language among 208 Dutch smokers (Littel et al., 2011). The questionnaire displayed good internal consistency (Cronbach's alpha more than 0.83). There were significant correlation coefficients between the QSU-Brief total score and other questionnaires/rating scales. However, the factor structure deviates a little bit from the original which might be explained by the differences in languages, but it seems to be suitable for use in a general Dutch population.
Documenting of smoking status
As mentioned previously, tobacco smoking has been cited as the main preventable cause of illness and death in our society. Health care providers play a vital role in encouraging smoking cessation based on evidence that the majority of smokers visit physicians at least once per year (Centers for Disease Control and Prevention, 1993b). Physicians can take a chance from these visits to intervene with their patients who smoke (Ahluwalia et al., 1999). Assessment or identification of tobacco use is considered as a first step in treating tobacco use and dependence (Fiore et al., 2008). Tobacco users mentioned that a physician's advice to stop smoking as an important motivator to quit (Ockene, 1987; Owen and Davies, 1990). For instance, several studies found that physician advice to stop smoking increase patients cessation rates (U.S. Department of Health and Human Services, 1996; Russell et al., 1979; Rose et al., 1982; Kottke Te, 1988). Even with this evidence, it is reported that health care professionals frequently failed to ask patients about smoking status or advise them to stop (Frank et al., 1991; Centers for Disease Control and Prevention, 1993a).
Fiore proposed an essential change in the way of assessment, documenting, and intervention with smoker patients (Fiore M. C., 1991). He recommended adding smoking status as a new vital sign, along with blood pressure, temperature, pulse, and respiratory rate (Figure 2.2). He explained that by adding the assessment of smoking status, an activity usually done by a nurse or medical assistant prior to the physician's encounter, will ensure the identification of all smokers (Fiore M. C., 1991). After five years, the US Department of Health and human services published official guidelines recommending the clinicians to adopt office-wide systems. For instance, to adopt vital sin intervention in order to determine smoking status systematically (Fiore M.c. et al., 1996). It was updated and repeated in 2000 (Fiore M.C. et al., 2000). In 2000, it was found that forty three percent of health plans need to document smoking status as part of vital signs for the patients (Manley et al., 2003).
Blood pressure: ___________________________________________________
Pulse: Weight: ___________________________________________________
Temperature: ___________________________________________________
Respiratory rate: ___________________________________________________
Smoking: Current Former Never
(Circle one)
Figure 2.2 Vital sign stamp
There was a limitation of scientific evidence to support this recommendation. The US Department of Health and human services guideline's recommendation was based on three studies (Fiore et al., 1995; Robinson et al., 1995; Ahluwalia et al., 1999) which reported an increase of counselling at clinical settings that adopted the vital sing intervention. In addition, these studies dependent on before-and-after designs, were either subject to confounding and limited generalizability, or both. However, after the publication of this guideline, other studies showed that the vital sign intervention did not increase subsequent counselling (Piper et al., 2003; Boyle and Solberg, 2004; Milch et al., 2004; Maizlish et al., 2006).
In summary, effective smoking status identification not only lead to successful interventions, but also guide the health professionals to choose appropriate interventions based on patients' smoking status and their willingness to quit (Fiore et al., 2008).
Smoking cessation
Previously, there was a lack of effective treatment which leads to a failure to intervene with tobacco users. However, in the last three decades, there was a fundamental change in the research regarding tobacco use (Anonymous, 2000). For instance, it was clarified the tobacco dependence nature as chronic disease, nicotine addictive nature, and the availability of numerous, effective pharmacotherapy and counselling strategies for tobacco dependence (Anonymous, 2000). After the approval of the nicotine products by the Food and Drug administration (FDA), pharmacotherapy has been the fundamental treatment of the physical aspects of the tobacco dependence and withdrawal (Nides et al., 2007). However, pharmacotherapy alone can increase the quit rates for longer term, but the results are modest (Fiore M.C. et al., 2000; Hughes et al., 2003). Smoking cessation treatment needs a combination of motivation and skill efforts. For some tobacco users, it could be sufficient for them to use brief intervention (simple advice and/or motivational enhancement strategies) to address the motivation issue (World Health Organization, 2010). However, others may require further intensive interventions and significant support to be successful in their quitting attempt due to several individual and environmental factors. Consequently, the control of tobacco use efforts require to be multidimensional (World Health Organization, 2005).
The recent release of clinical practice guideline updates by US public health service (Fiore et al., 2008) recommended that health care professionals can intervene with the patients by a common approach known As "5 A's". The 5 A's strategy includes (Figure 2.3):
Ask about tobacco use - Identify and document all tobacco users at every visit.
Advise to quit - Clearly urge every tobacco user to quit.
Assess willingness to make a quit attempt - Assess the willingness of the tobacco user to make a quit attempt.
Assist in quit attempt - Help the patient to stop smoking (provide counselling and treatment).
Arrange follow-up - Arrange for follow-up contact via phone or face-to-face.
Every patient should be regularly asked if he or she uses tobacco and tobacco use should be documented. All smokers should be advised to quit smoking in a clear and strong manner. Following this, the health care provider should evaluate patient's willingness to make a cessation attempt at this time. In addition, tobacco user who willing to quit, behavioural counselling and pharmacotherapy should be provided to him or her by a clinician. Lastly, a follow-up schedule should be arranged.
Ask patient whether he or she smokes
If "Yes"
Provide personalized and clear advice about stopping smoking
Determine whether the patient is interested in quitting at this time
If "NO"
If "Yes, in the next 30 days"
If "Yes, but not now"
Use motivational approaches (5 R's).
Discuss the risks of passive smoking for family and friends.
Offer support to the smoker if he/she ready to quit.
Identify and address barriers to quitting.
Identify reasons to stop smoking (health-related and others).
Ask patient to set a quitting date.
Assist in quit attempt through:
Asking to set a quit date.
Assess prior efforts if any.
Making a plan.
Arrange for a follow-up visits, soon after the quit date.
Follow up with the patient
at the next visit
Follow up with the patient
at the next visit
Figure 2.3 Smoking-Cessation Strategy for clinical health providers
In addition to the steps that are necessary to effectively identify smokers; it is also important to motivate individuals who did not think or not willing to quit smoking by using motivational counselling intervention which also known as "5 R's" (Fiore et al., 2008). Studies found that "5 R's" enhance future attempts of stop smoking (Carpenter et al., 2004; Carpenter et al., 2003). The 5 R's includes:
Relevance - Encourage the patient to indicate why quitting is personally relevant.
Risks - Emphasize negative consequences and risks of tobacco use and highlight the most relevant to the patient.
Rewards - Emphasize the benefits from stop smoking and highlight the most relevant to the patient.
Roadblocks - Highlight the barriers or impediments to quitting and provide treatment.
Repetition - Ensure to repeat the motivational intervention for unmotivated patient.
There are two vital strategies for ceasing the use of tobacco products: pharmacotherapy agents and behavioural counselling support. Providing these two strategies for individuals who willing to quit at present follows the principles of Tanstheoretical Model (TTM) of behaviour change (DiClemente et al., 1991), which uses stages of change to integrate processes and principles the stagesnge across major theories of intervention (Glanz et al., 2008). These stages consist of:
Precontemplation stage (no serious consideration to quit smoking within the next 6 months).
Contemplation stage (intends to stop smoking within the next 6 months).
Preparation stage (intends to quit smoking within the next 30 days and has taken some behavioural steps in this direction).
Action stage (changed overt behaviour for less than 6 months).
Maintenance stage (changed overt behaviour for more than 6 months).
Termination stage (No temptation to relapse and totally confident).
The pharmacotherapy and behavioural counselling have strong evidence for their effectiveness in the treatment of tobacco use and dependence (Anonymous, 2000; Fiore M.C. et al., 2000; Lancaster et al., 2000). Each approach is effective by itself, but it can double the long term rate of abstinence that achieved by tobacco user with the association of both strategies (Zierler-Brown and Kyle, 2007; Rigotti, 2002; World Health Organization, 2006). It is believed that the combination of these two approaches has the complementary type of action (Cofta-Woerpel et al., 2007; Hughes, 1995). In a recent review article which included 41 studies done by Stead and Lancaster (2012), they concluded that the combination of the pharmacotherapy with behavioural support increase the smoking abstinence success compared to minimal intervention or usual care (Stead and Lancaster, 2012b).
Pharmacological therapy for smoking cessation
The treatment for tobacco dependence needs the use of multiple clinical modalities which consider the most effective approach. The pharmacologic therapy is considered as a vital element of a multi-component approach (Anonymous, 2000). As reported in the previous chapter, the health care professionals must motivate and encourage all tobacco users to initiate a quit attempt with using one or a combination of effective pharmacotherapies in the absence of contraindications (e.g., tobacco users with medical conditions, pregnant or breastfeeding women, adolescent, and tobacco users who smoke less than 10 cigarettes per day) (Fiore M.C. et al., 2000; Fiore et al., 2008).
There are two medication lines which have been considered the most effective pharmacotherapy in tobacco dependence treatment. The first-line include: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline, which approved by the FDA, while the second-line, which not approved by the FDA, include: clonidine and nortriptyline (FDA Consumer Health Information, 2012). There is evidence, which has published by a standard guideline, pointed to the effectiveness and safety of each particular medication or combinations of medications in the treatment of tobacco use and dependence (Fiore et al., 2008). Many randomized clinical trials as presented in multiple reviews demonstrated the efficacy of these medications (Glover and Rath, 2007; Zierler-Brown and Kyle, 2007; Wilkes, 2008). Recently, in Malaysia, varenicline has been approved as of the medications for smoking cessations.
The choice of the particular agent from first-line pharmacotherapy guided by several factors such as contraindications for selected patients, clinician's familiarity with the medications, patient preference and his positive or negative experience with a specific medication (Henningfield, 1995; Hughes et al., 1999; Disease Control Division, 2003). NRT products are considered the mainstay pharmacotherapy for tobacco users to quit smoking. It is defined as "NRT is defined as the administration of nicotine by a means of delivery other than the inhalation of tobacco smoke, in quantities sufficient to alleviate withdrawal symptoms but not large enough to cause dependence" (Lauro and Paxeras, 2004). NRT aimed to, thereby maintaining some of its effects, suppress smoking motivation and the physiological and psychomotor withdrawal symptoms often experienced during an attempt to stop smoking, which leading to increase the probability of remaining abstinent and preventing relapse (West and Shiffman, 2001). However, published meta-analysis which included 83 studies, showed that varenicline had the highest estimated odd ratios and estimated abstinence versus placebo among others mono-therapies (Estimated OR 3.1, 95% CI 2.5 - 3.8); (Estimated abstinence rate 33.2, 95% CI 28.9 - 37.8) at 6 months post-quit smoking. Furthermore, the meta-analysis showed that the combination of nicotine patch (˃ 14 weeks) with ad lib NRT (gum or spray) had the greatest values in the estimated odd ratio (estimated OR 3.6, 95% CI 2.5 - 5.2) and estimated abstinence rate (estimated abstinence rate 36.5, 95% CI 28.6 - 45.3) compared to placebo at 6 months after quitting smoking (Fiore et al., 2008).
Non-pharmacological therapy for smoking cessation
Numerous psychological and behavioural techniques have been developed, based on the fact that tobacco use is associated with nicotine addiction. This type of addiction is associated with psycho-behavioural and physical dependence (Benowitz, 2009; Lauro and Paxeras, 2004). Giving up smoking still is difficult for people who wanted, but providing high levels of non-pharmacological support with effective pharmacotherapies may increase success abstinence rates further. The non-pharmacologic techniques are intended to enhance the efficacy of tobacco cessation therapies (Rigotti, 2002; Nides et al., 2007). In addition, it considers helpful in planning a quit attempt and preventing relapse during the initial period of quitting (Brandon et al., 2000). However, most of the tobacco users quit smoking without using evidence-based cessation therapies (Centers for Disease Control and Prevention, 2011b). Even though, there are several treatments are proven effective for smoking cessation (Fiore et al., 2008) such as:
Self-help materials (e.g., written materials containing advice on stopping smoking and the benefits of quitting).
Brief intervention (e.g., taking an advice from a doctor for about 10 minutes or less regarding quitting of smoking) (Stead et al., 2008).
Counselling and behavioural cessation techniques: programs teach smokers problem-solving skills through individual, group, or telephone counselling (Lancaster and Stead Lindsay, 2005; Stead and Lancaster, 2005; Stead et al., 2006).
Intensive treatments (e.g., more than one intervention used and/or more contact time with counsellors).
Although effective evidences to behavioural face-to-face support, but there is a limitation in these programs that they are not widely available (Nides et al., 2007). Furthermore, it is recognised that many people will not attend multiple sessions (Stead and Lancaster, 2012a). Telephone counselling (quit line or call-back counselling) can target a larger number of smokers, and these services are readily available in many countries.
The purpose of this part of the literature review is to explore the different types of non-pharmacologic approaches and their effectiveness in smoking cessation therapy. In the next few sections, telephone counselling, the intensity of behavioural support and front loading counselling technique will be discussed as consider the most non-pharmacologic methods related to our research study.
Telephone counselling
Telephone counselling is considered to be more accessible and convenient approach in smoking cessation treatment, particularly for people living in distant areas. Telephone counselling by a trained health care provider is a type of adjunctive support that shows promise (Reid et al., 1999). It assists in planning a quit attempt and in preventing relapse during the initial period of abstinence (Brandon et al., 2000). However, the face-to-face counselling increases the abstinence rates, but there are obstacles in delivering it to large numbers of people (Stead et al., 2006).
There are two approaches of telephone counselling: proactive and reactive counselling. In the proactive counselling a trained counsellor makes one or more phone calls offer his or her support in making an attempt to stop smoking or in preventing relapse. On the contrary, reactive counselling which provides assistance for tobacco users who making calls to specific services such as hotlines or quit-lines (Lichtenstein et al., 1996; Zhu et al., 1996; Centers for Disease Control and Prevention, 2004). In another way, the contact which initiated by a smoker, the counselling procedure during that phone call is reactive. Smoking cessation interventions alongside with telephone counselling achieved various but consistent abstinence rates ranging from 10% to 45%, especially the proactive approach (MıÌguez et al., 2002; Zhu et al., 1996; Curry et al., 1995; Fiore M.C. et al., 2000; Westman Ec, 1993).
A recent Cochrane review indicated that proactive telephone counselling is more efficient than the reactive counselling (Stead et al., 2006). In addition, there are evidences to support using the proactive telephone counselling as an adjunct treatment with minimal intervention, could be a single or combination interventions, (e.g., self-help materials, physician advice, pharmacotherapy, internet-based program and reactive telephone hotlines or quit-lines), as it is potentially more effective than the using of telephone counselling or minimal intervention alone (MıÌguez et al., 2002; Fiore M.C. et al., 2000; Fiore et al., 2008; Stead et al., 2006; Macleod et al., 2003; Pan, 2006). However, further research needed to investigate the ways and timing to combine face-to-face counselling alongside with telephone counselling to increase successful quit attempt rate and prevent relapse (Stead et al., 2006).
The accompanying tables summarize the main studies that reported the different ways of using the telephone counselling approach in smoking cessation treatment procedure (Table 2.2, 2.3 and 2.4).
Table 2.2 Randomised control trials explored telephone counselling as the main component of a cessation intervention
First author
Setting
Objectives
Methodology
Main findings
Comments
Abu Saleh M. Abdullah (Abdullah et al., 2005)
Hong Kong Special Administrative Region, China
To investigate the efficacy of using telephone counselling with self-help materials for motivating smoking parents of young children to stop smoking.
952 current smoker parents were invited by mail. They randomised either to receive:
Single mailing self-help materials.
As 1, plus three sessions telephone-based counselling by trained counsellors.
Measured outcomes: The primary outcome was self-reported 7-day point prevalence quit rate at 6 months. Secondary outcomes were: self-reported 24-hour point prevalence, self-reported continues abstinence and biochemical validated (CO level <9 ppm or urinary cotinine level <10 mmol/mol) quit rate at 6-month follow-up point.
903 participants were included in the intention-to-treat analysis. The findings showed that the intervention group was significantly higher than the control group in the self-reported 7 day point prevalence of abstinence (7.4% vs. 15.3%, P<0.001). In the same manner, all secondary outcomes in the proactive telephone counselling group were significantly more than the control group.
The conclusion of this study was proactive telephone counselling assists in promoting smoking cessation among mothers and fathers of young children.
Lawrence C. An (An Lc and et al., 2006)
Five Veterans
Affairs medical centres, USA
To test the using of telephone counselling could enhance the proportion of the abstinence compared with minimal intervention as part of usual health care.
837 tobacco users randomized either:
Mailed self-help materials with routine usual care; all participants have chances for intervention during the standard health care and referral to smoking cessation programme, NRT and bupropion available on formulary.
As above, plus proactive phone counselling using adapted protocol (7 calls over two months).
The outcomes: sustained for 6 months or more at 12 months and 7-day point prevalence at 3 and 12 month without validation.
At 3 months, there was a significance difference between the control and intervention groups in the quit rate (7-day PP) (10.1% vs. 39.6%, P<0.001).
At 12 months, the telephone group had a higher proportion of non-smoking people in two outcomes (7-day point prevalence, P=0. 01 and sustained abstinence for 6 months or more, P<0.001).
The study explored the enhancement in the smoking cessation due to addition of telephone counselling to the pharmacological and behavioural treatments.
Table 2.2: Continued
First author
Setting
Objectives
Methodology
Main findings
Comments
Angela L. Stotts (Stotts et al., 2002)
Antenatal clinics, USA
To examine the efficacy of a brief telephone counselling approach using staged-based personalized feedback and Motivational Interviewing strategies compared with minimal intervention among late pregnancy resistant smokers.
269 pregnant smokers at 28 weeks.
All participants received brief counselling (3 to 5 minutes) plus 7 mailed self-help materials in early pregnancy then:
No further intervention.
Personalized feedback letter and two phone calls (20-30 minutes) using Motivational interviewing (MI) strategies.
At 6 weeks postpartum, there was a significant difference between the between women who classified as non-smoker or light smoker and the control group (27.1% vs. 14.6%). The findings demonstrated there was no difference in the proportion of non-smoking pregnant at 3 and 6 months postpartum.
At 34th week, the cotinine analyses demonstrated that the proportion of non-smoking women receiving the full intervention were higher than control group (42.6% vs. 33.7%, respectively). However, they failed to reach to the statistical significance.
This study refers that telephone counselling has only short-term benefit (at 6 weeks) on smoking cessation.
Jane M Young (Young et al., 2008)
30 general practices, South Western Sydney, Australia
To investigate the efficacy of opportunistic referral of the tobacco users by their doctors for telephone counselling by a trained nurse.
318 adult smoker patients who attending for routine consultations. Randomised either to:
General practitioners refer to a telephone counselling comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse.
Usual care (general practitioners distributed quit kits to patients).
Point prevalence abstinence at 6 and 12 months without validation.
There was no significant differences between the groups in point prevalence abstinence at 6 months (intervention group 9% vs. control group 8%, P=0.7) and at 12 months (intervention group 8% vs. control group 6%, P=0.6).
There was no difference in the efficacy of intervention by patient sex (P=0.5) or by stage of change (P=0.6).
This study did not show improved cessation rates following the intervention. The authors suggested to focus support for tobacco users who are motivated to stop smoking.
Table 2.2: Continued
First author
Setting
Objectives
Methodology
Main findings
Comments
James O. Prochaska (Prochaska et al., 2001)
Four offices of managed care organization, USA
To enhance the expert system by adding proactive telephone counselling or a stimulus controlled computer designed to produce better smoking cessation outcomes.
1447 tobacco users randomised to:
Assessment only (completed questionnaires on 0,6,12 and 18 months.
Expert system self-help tailored 2-3 page report at 0, 3 and 6 months and a set of stage-matched self-help manuals.
As 2, plus proactive telephone counselling, short calls at 0, 3, and 6 months.
As 3, plus computer scheduled cigarettes reduction.
Measurements: point prevalence abstinence (7 days) at 12 and 18 months.
The results demonstrated that the 7-day point prevalence abstinence was the greatest among the smokers who receive expert system intervention with telephone counselling compared to the assessment only, expert system intervention, and expert system plus stimulus control computer at 6 months (16.7% vs. 11.8% vs. 15.1% vs. 10.3%, respectively), at 12 months (24.7% vs. 13.5 vs. 19.4 vs. 13.4%, respectively) and at 18 months (23.2% vs. 17.1% vs. 22.9% vs. 13.9%, respectively).
In addition, the study showed that using computerized-based intervention did not have impact on the quit rate, it made the proportion of quit rates 20% less than assessment alone condition.
The study showed there was no significant difference in using telephone counselling in combination with their expert system intervention than the intervention alone.
Karen M. Emmons (Emmons et al., 2005)
Childhood Cancer Survivors Study cohort, USA
To report the outcomes of smoking cessation intervention for tobacco users in the Childhood Cancer Survivors Study (CCSS).
Participants (n = 796) were randomly assigned to either:
Self-Help control. Mailed manual (Clearing the Air) & letter from study physician.
Peer counselling intervention included for up to 6 calls in 7 months period by trained cancer survivor plus tailored and targeted materials plus free NRT.
Measurements: Abstinence at 12m (7-day point prevalence)
The cessation rate was significantly greater in the intervention group compared to control group at 8 months (16.8% vs. 8.5%; P < 0.01) and 12 months (15% vs. 9%; P ≤ 0.01).
The findings showed that abstinence rate improved with an increase in counselling call's number
The study suggested increase the number the intense of the phone counselling calls to improve the outcomes of the quit rate.
Table 2.2: Continued
First author
Setting
Objectives
Methodology
Main findings
Comments
Edward Lichtenstein (Lichtenstein et al., 2000)
Community, USA
To change smoking behaviour in households where a smoker is present and there are low but detectable concentrations of radon.
1006 participants in 714 households assigned either to:
Standard Environmental Protection Agency leaflet on risks of radon
A specially developed pamphlet highlighting risk of smoking in low concentrations of radon with advices for quitting.
Pamphlet as 2 in combination with proactive telephone counselling (up to 2 brief calls).
Measurements: Abstinence at 12m (sustained at 3m, 12m) without validation.
The group who receiving developed pamphlet plus phone calls had the highest quit rate compared to standard environmental protection agency leaflet and developed pamphlet only at 3 month (11% vs. 6.3% vs. 7.4%) and 12 month (12.1% vs. 11% vs. 8.6%) but it did not reach to statistical significance.
Edward Lichtenstein (Lichtenstein et al., 2008)
To assess the main effects of the telephone counseling and targeted video on quitting smoking and
the establishment
of new household smoking bans
1821 smokers in 1364 households randomized within a 2 Ã- 2 factorial design with/without brief phone calls and 15 minutes video self-help materials. All participants received A Citizens Guide to Radon, they assigned either:
Phone calls (up to 2 calls) after the radon test results. The phone counseling included clarification for the risk of smoking and encouraged quitting or no smoking in house. Second call scheduled if interest
No further intervention
Measurements: 7-day point-prevalence abstinence rate at 3 and 12 months.
The study demonstrated that both of phone calls and targeted video did not have impact on the quit rates at either 12 months.
Jennifer B. McClure (McClure et al., 2005)
Health Maintenance Organization, USA
To assess the impact and the acceptability of proactive tailored phone counselling program among smoker women with high risk for cervical cancer.
275 female smokers invited and randomized, regardless of their interest in quitting smoking, either to:
Usual care (self-help material + contact details for free and clear program + a covered benefit.
As 1, plus brief phone calls (up to 4 calls around 15 minutes each) in 6 months periods.
Measurements: 7-day point-prevalence abstinence rate at 6 and 12 months.
The results demonstrated that the intervention group have higher and significant quit rate compared to usual care group at 6-month follow up (19.6% vs. 12.4%; P < 0.05), but the abstinence enhanced in the usual care group at 12 months (19.7% vs. 18.1%, P = NS).
The trial showed the feasibility of delivering a proactive phone intervention to female smokers increased risk of cervical cancer. In addition, the intervention had a good impact on cessation in the short term.
Table 2.2: Continued
First author
Setting
Objectives
Methodology
Main findings
Comments
Sonia A. Duffy (Duffy et al., 2006)
ENT clinics at 4 hospitals, USA
To investigate a developed tailored smoking, depression and alcohol intervention among cancer patients.
89 current smoker patients, out of total sample (n = 184) included in the study, received a 45-minute fully assessment for these disorders by nurse and followed by brief counselling related to them. They randomly assigned either to:
Proactive telephone counselling: received 9 to 11 phone call sessions of cognitive behavioural therapy plus workbook of cognitive behavioural therapy and pharmacologic management as needed.
Enhanced usual care with assessment and referral
Measurements: sustained abstinence at 6 months.
The intervention had positive effect on the smoker patients, specifically those who stop in the last month and those who quit in the last 6 months. However, they failed to reach statistical significance due to small sample size.
The authors suggest improving smoking cessation among cancer patients by clinic-based, nurse-administered interventions.
Table 2.3 Randomised control trials explored the using of phone counselling as adjunct to brief intervention
First author
Setting
Objectives
Methodology
Main findings
Comments
Jon O. Ebbert (Ebbert et al., 2007)
Eight dental practices, USA
To investigate whether providing brief smoking cessation counselling or brief counselling in combination with referrals to quit-line for dental patients.
Eighty two smoker patients assigned either to:
Brief counselling by hygienist, reinforced by dentist.
As 1, plus refer to quit-line proactive counselling (3 calls at baseline, 1 week and 2 weeks, if requested.
Measurements: 7-day point prevalence abstinence rate at 6 months without validation.
The findings showed that the self-reported 7-day point prevalence abstinence rate were 25% in the intervention group and 27.3% in the control group (P ≈ 1.0) at 6 months.
The study concludes that the quit rates among the tobacco users in the quit-line group were higher if they completed more phone call consultations.
Chouinard MC (Chouinard and Robichaud-Ekstrand, 2005)
Inpatients hospital, Canada
To test if inpatient smokers receiving quit smoking program based on trans-theoretical model with or without telephone follow ups will improve the sustained abstinence rates.
Smokers (n = 168) assigned either to:
Counselling by trained nurse (one baseline depth counselling based on trans-theoretical model, 23% used pharmacotherapy).
As 1, plus follow-up phone calls (6 calls over 2 months after discharge, 29% used pharmacotherapy).
Usual care advice on stop smoking.
Measurements: sustained abstinence at 6 months with biochemical validation (urine cotinine or CO reading level).
The results showed that the abstinence rates in the inpatient counselling with phone call follow-up group is significantly higher than in the inpatient counselling and usual care groups (41.5% vs. 30.2% vs. 20%; P = 0.05).
The trial conclude that this tailored program for smoking cessation which using phone calls follow-up have positive impact on quit rate at 6 months.
Robert D. Reid (Reid et al., 2007)
Tertiary care cardiac hospital, Canada
To test the efficacy and feasibility of receiving an interactive voice response (IVR) follow-up (automated telephone
follow-up calls) system
for recently hospitalized smokers with coronary heart disease.
All participants (n = 100) received in the hospital brief counselling, access to NRT and self-help materials and assigned either to:
Usual care.
IVR system: received phone calls at 3, 14 & 30 days after discharge inquiring about their smoking status and confidence in remaining smoke-free.
Measurements: 7-day point prevalence abstinence at 1 year without validation.
At one year follow-up point, the point prevalence rate in the intervention group was higher than in the usual care group (46% vs. 34.7%) but it did not reach to statistical significance.
The authors conclude that automated phone calls system is a promising technology for following coronary heart disease patients who try to stop smoking after the hospital discharge.
Table 2.3: Continued
First author
Setting
Objectives
Methodology
Main findings
