Reasons for non-adherence to nicotine patch therapy during the first month of a quit attempt.

INTRODUCTION: Prior research has shown that the transdermal nicotine patch is a safe and effective aid to smoking cessation, but adherence to the directed use of the nicotine patch is often low. Few studies have examined participant-reported reasons for non-adherence to nicotine patch therapy during a quit attempt. AIMS: The aim of this study was to evaluate adherence to nicotine patch therapy and to identify participant-reported reasons for non-adherence. METHODS: Participants were 201 current daily smokers who were offered 6-weekly group treatment sessions and were asked to report nicotine patch use and barriers to use. RESULTS: Seventy-one (35.3%) participants were adherent for the first 28 days of treatment and 130 (64.7%) participants were non-adherent. Commonly reported reasons for non-adherence were forgetting to put the patch on (30%), not liking the experienced side effects (15%), resuming smoking (10%) and difficulty affording the cost of the patches (7%). CONCLUSIONS: Participant- reported barriers to adherence of nicotine patch therapy can be mitigated with advice from healthcare providers. Some examples of advice to patients could include carrying an extra patch, using community resources to obtain free or reduced cost nicotine patches, reviewing the effectiveness of nicotine replacement, and explaining side effects associated with the use of the nicotine patch.

Once bitten, twice shy: concern about gaining weight after smoking cessation and its association with seeking treatment.

BACKGROUND: Concern about weight gain after quitting smoking is often cited as a barrier to smokers making a quit attempt or seeking treatment. AIM: To identify whether smokers who are non-treatment seekers (NTS) are more concerned about weight gain and have lower confidence to maintain weight after quitting smoking as compared with treatment-seeking smokers (TS). METHODS: Participants were smokers recruited from Penn State Hershey Medical Center and family practice outpatient clinics. A total of 102 NTS and 186 TS, who participated in a smoking cessation trial, completed a survey regarding tobacco use, weight concern and diet. Stepwise logistic regression was used to identify variables associated with treatment seeking, overall and stratified by those who gained and did not gain weight on a previous quit attempt. RESULTS: Fifty three per cent of the overall sample (47.1% NTS vs. 56.5% TS, p = 0.127) had gained weight on a prior quit attempt. Among smokers who had gained weight, higher weight gain concern (WGC) and lower confidence in ability to maintain weight were significantly associated with being a NTS after adjusting for other factors. CONCLUSION: Among smokers who gained weight on a previous quit attempt, NTS had greater concern about gaining weight and less confidence in their ability to maintain their weight after quitting than treatment seekers. Clinicians can identify smokers for whom WGC may be a barrier to seeking treatment by asking if they gained weight on a previous quit attempt. These smokers should be assured that this issue will be addressed in treatment.

The epidemiology of weight counseling for adults in the United States: a case of positive deviance.

Weight counseling for adults is uncommonly performed by primary-care providers (PCPs), despite recommendations. In order to design effective primary-care interventions, a full understanding of the epidemiology of weight counseling in primary care is needed. Our objective was to measure the frequency of weight counseling at the level of the PCP. We performed a cross-sectional study of 21 220 US adult outpatient primary-care visits with 954 PCPs in 2007-2008, using data from the National Ambulatory Medical Care Survey (NAMCS). Most (58%) PCPs performed no weight counseling during any patient visits. A total of 85 (8.9%) PCPs provided 52% of all weight counseling and were categorized as 'positive deviant' (PD) physicians. Patients seeing PD physicians were older, less likely to be female and more likely to have hypertension, diabetes and obesity. Adjusting for patient characteristics strengthened the association between PD status and receipt of weight counseling during visits (adjusted odds ratio=13.2 (95% confidence interval 11.5-15.7)). In conclusion, a minority of PCPs provide the majority of primary-care weight counseling in the United States. Studies of these PCPs may help to identify practical methods to increase weight counseling in primary-care settings.

Long-term weight loss maintenance in the United States.

CONTEXT: Although the rise in overweight and obesity in the United States is well documented, long-term weight loss maintenance (LTWLM) has been minimally explored. OBJECTIVE: The aim of this study is to estimate the prevalence and correlates of LTWLM among US adults. DESIGN, SETTING AND PARTICIPANTS: We examined weight data from 14 306 participants (age 20-84 years) in the 1999-2006 National Health and Nutrition Examination Survey (NHANES). We defined LTWLM as weight loss maintained for at least 1 year. We excluded individuals who were not overweight or obese at their maximum weight. RESULTS: Among US adults who had ever been overweight or obese, 36.6, 17.3, 8.5 and 4.4% reported LTWLM of at least 5, 10, 15 and 20%, respectively. Among the 17.3% of individuals who reported an LTWLM of at least 10%, the average and median weight loss maintained was 19.1 kg (42.1 pounds) and 15.5 kg (34.1 pounds), respectively. LTWLM of at least 10% was higher among adults of ages 75-84 years (vs ages 20-34, adjusted odds ratio (OR): 1.5; 95% confidence interval (CI): 1.2, 1.8), among those who were non-Hispanic white (vs Hispanic, adjusted OR: 1.6; 95% CI: 1.3, 2.0) and among those who were female (vs male, adjusted OR: 1.2; 95% CI: 1.1, 1.3). CONCLUSIONS: More than one out of every six US adults who has ever been overweight or obese has accomplished LTWLM of at least 10%. This rate is significantly higher than those reported in clinical trials and many other observational studies, suggesting that US adults may be more successful at sustaining weight loss than previously thought.

Using electronic/computer interventions to promote physical activity.

The internet has been used as a method to deliver various health interventions (eg, weight management, smoking cessation, increasing physical activity). An electronic search (ie, PubMed, PsycInfo, Web of Science) for internet-based physical activity interventions among adults yields fewer than 25 studies. Although many have considered physical activity as one element of a multifactorial behavioural intervention, few have focused exclusively on changing sedentary behaviour. Overall, current results are encouraging and it appears that response to an internet-based physical activity intervention is similar to response to other more established, effective interventions. Given that primary care referrals for physical activity are successful in changing sedentary behaviour to some extent, there is an urgent need for investigations into the effect of using an internet-based physical activity programme within the context of primary care. Although no studies that have combined an established internet-based physical activity programme with primary care were found, there is evidence that significant progress would probably be made by providing clinicians with information on internet-based physical activity programmes.

"Take in two parks and call me in the morning" - Perception of parks as an essential component of our healthcare system.

As a feature of the built neighborhood environment, parks have been associated with a range of positive health outcomes. Recognition of these contributions has prompted advocates to suggest parks are a part of our healthcare system. Despite these developments, park investments have declined over the past decade nationally, lagging behind expenditures on other community services such as health. Perhaps the idea of parks as a solution to the nation's health concerns has not diffused across the population. To date, however, public perception of parks' role in healthcare has not been documented. This study responds to this gap by assessing whether parks are perceived as an essential part of the healthcare system. Self-administered surveys were completed by a statewide sample of Pennsylvania adults (2014) and by a sample of primary care clinic visitors in Hershey, Pennsylvania (2015). Participants from both studies were asked the extent they agreed with the following statement: Parks, trails, and open space are an essential component of our healthcare system. Response was also compared across demographic characteristics to assess whether this belief was universally held. Findings indicate 73% of the statewide sample and 68% of the clinical sample agreed parks, trails, and open space are an essential element of the healthcare system. Males, those with lower levels of educational attainment, and rural residents were statistically less likely to agree with this statement. Results indicate widespread belief in parks as an essential part of the healthcare system, suggesting consideration of health-sector investments in these settings.

Who reports receiving advice to lose weight? Results from a multistate survey.

BACKGROUND: Overweight and obesity are increasingly prevalent in the United States. The prevalence of health care provider advice to lose weight is not clear. METHODS: We examined the percentage of individuals who reported being advised to lose weight by a health care practitioner in the past year by population subgroup. Participants were individuals in the 10 states participating in the 1996 Behavioral Risk Factor Surveillance System, which assessed advice to lose weight, hypertension awareness, and cholesterol awareness. RESULTS: The prevalence of reporting advice to lose weight was most strongly associated with body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) and weight-related comorbidities. In individuals with a BMI of 25 to 27, only 5.6% of those with no comorbidities and 13.6% of those with comorbidities received advice. These rates were increased to 32.4% and 47.3%, respectively, in those with a BMI greater than 30. Middle-aged individuals, those with more education, and those living in the northeast were also more likely to receive advice. Receiving advice to maintain weight was reported by only 2. 5% of respondents. Receiving advice to lose weight was strongly associated with trying to lose weight, especially in those with a BMI of 25 to 27, where 77.5% who received advice reported trying to lose weight vs 33.4% of those who did not receive advice. CONCLUSIONS: Advice to lose weight is uncommon and is given primarily to those who are already obese, are middle-aged, and have comorbidities. Practitioners may be missing important opportunities to counsel mildly overweight individuals to lose weight or to maintain their weight and thereby prevent comorbidities.

Design and acceptability of patient-oriented computerized diabetes care reminders for use at the point of care.

Despite the widespread availability of guidelines for caring for patients with diabetes and decades of research on computerized reminder systems, large gaps in quality remain in diabetes care remain and computerized reminder systems are rarely used for patients with diabetes. We set out to develop and test the feasibility of a system that would overcome many of the barriers preventing the widespread use of point-of-care computerized reminders to improve diabetes care. Five primary care physicians and 32 patients with type 2 diabetes pilot tested the system. We set out to design and measure the preliminary acceptability of patient-oriented point of care computerized diabetes care reminders. The main findings of our study were that (1) the reports were well accepted by both patients and providers and (2) survey and audiotape data suggest that they may be helpful at improving the quality of outpatient care for patients with diabetes.

An evidence-based interactive computer program to assist physicians in counseling smokers to quit.

Computerized expert systems offer the promise of increasing the frequency and efficiency of physician counseling of smokers to quit by collecting pertinent data and presenting it to physicians in a useful manner to guide and inform the counseling session. This article explores one such program that collects patient information, before the physician visit, that is pertinent to counseling smokers as described in the Agency for Health Care Policy and Research's Smoking Cessation Guidelines and supported in the medical literature. The program uses the information collected to produce two reports: one for the physician to use during the visit and the other for the patient as a means of supplementing and reinforcing the counseling message. Pilot data are presented from volunteers and primary care patients.

Opportunities for improving inpatient smoking cessation programs: a community hospital experience.

BACKGROUND: This cohort study examined the role of smoking during hospitalization, duration of cessation counseling, patient awareness of the hospital's smoke-free policy, belief that smoking is associated with a current symptom or disease, and the presence of withdrawal symptoms with 12-month smoking cessation among inpatients enrolled in a smoking cessation program. METHODS: Inpatients in four community hospitals (N = 1,317) participated in a smoking cessation intervention consisting of face-to-face counseling at baseline and four follow-up counseling phone calls. Patients were classified as nonsmokers only if they reported not smoking at both the 6- and the 12-month interviews. All patients lost to follow-up were considered smokers. RESULTS: At 1 year the smoking cessation rate was 22.5%. Cessation was independently associated with reporting no smoking during hospitalization, noting no withdrawal symptoms at baseline, and believing that a current illness or symptom is related to smoking. Length of counseling interview and awareness of the hospital's smoke-free policy were not independently associated with cessation. CONCLUSIONS. Smoking cessation programs and hospital policies that decrease smoking during hospitalization, address withdrawal symptoms during hospitalization, and make clear the connection between a patient's health and cigarette smoking may increase the effectiveness of their smoking cessation efforts.

Dissemination of the AHCPR clinical practice guideline in community health centres.

OBJECTIVE: To evaluate dissemination of the Agency for Health Care Policy and Research (AHCPR) Smoking cessation clinical practice guideline in community health centres. DESIGN: Pre- and post-trial. SETTING: Fourteen community health centres in Rhode Island. SUBJECTS: Provider performance was assessed with 1798 and 1591 patient contacts, in pre-post cross sectional consecutive samples, respectively, and 891 contacts at one year follow up. INTERVENTIONS: Three, one hour on-site provider training sessions, on review of effective tobacco interventions, use of office systems, and tobacco counselling skill building. OUTCOME MEASURES: Chart documentation of four A's (Ask, Advise, Assist, and Arrange follow up) at most recent primary care visit. RESULTS: While average performance rates increased for Ask and Advise (from 30% to 44%, and 19% to 26%, pre-post, respectively), significant increases were found only for some visit types, with further differences by patient sex. There were significant increases for Ask for all except obstetric/gynaecological (ob/gyn) visit types. Patients at yearly physicals and first visits were more likely to be asked at all time points, while males were more likely to be asked at acute visits than were females. There were no significant increases for Advise, Assist, and Arrange across time, although female patients showed a differential increase in Advise post-training. Advise was significantly more likely in yearly physicals and first visits, and less likely in ob/gyn visits, at all time points. CONCLUSIONS: This guideline dissemination effort resulted in quite different provider counselling rates across patient sexes, and visit types. Guideline implementation may require more sustained efforts, with multiple strategies, which are reinforced at higher policy levels, to more fully integrate tobacco interventions into routine primary care practice with all patients who smoke.

Comparison of five measures of motivation to quit smoking among a sample of hospitalized smokers.

OBJECTIVE: To compare the predictive validity of several measures of motivation to quit smoking among inpatients enrolled in a smoking cessation program. METHODS: Data collected during face-to-face counseling sessions included a standard measure of motivation to quit (stage of readiness [Stage]: precontemplation, contemplation, or preparation) and four items with responses grouped in three categories: "How much do you want to quit smoking" (Want), "How likely is it that you will stay off cigarettes after you leave the hospital" (Likely), "Rate your confidence on a scale from 0 to 100 about successfully quitting in the next month" (Confidence), and a counselor assessment in response to the question, "How motivated is this patient to quit?" (Motivation). Patients were classified as nonsmokers if they reported not smoking at both the 6-month and 12-month interviews. All patients lost to follow-up were considered smokers. MAIN RESULTS: At 1 year, the smoking cessation rate was 22. 5%. Each measure of motivation to quit was independently associated with cessation ( p <.001) when added individually to an adjusted model. Likely was most closely associated with cessation and Stage was least. Likely had a sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of 70.2%, 68.1%, 39.3%, 88.6%, and 2.2, respectively. CONCLUSIONS: The motivation of inpatient smokers to quit may be as easily and as accurately predicted with a single question as with the series of questions that are typically used.

Nutrition counseling in the promoting cancer prevention in primary care study.

BACKGROUND: Little is known about the influence of personal and practice-level factors on physicians' dietary counseling practices. METHODS: Primary care physicians (n = 130) were surveyed regarding the frequency that they "ask" patients about their diet, "assess" patients' reasons for and against dietary changes, "advise" patients to eat less fat and more fiber, "assist" patients in changing their diet, and "arrange" a follow-up contact to discuss their diet. In addition, physicians were asked their personal dietary practices, counseling confidence, practice demographics, and medical specialty. RESULTS: Physicians who (a) reported consistently avoiding dietary fat, (b) were more confident in their diet counseling abilities, and (c) were sole owners of their practice were more likely to counsel than physicians who were employees or part owners of the practice. For example, physicians who reported consistently avoiding dietary fat (50.7% of physicians) were 3.2 (95% CI: 1.3-7.9) times more likely to "ask" their patients about their diet and 3.5 (95% CI: 1.5-8.6) times likely to "advise" their patients to eat less fat and more fiber. CONCLUSIONS: Given the strong and consistent effects of a physician's dietary pattern on their counseling practices, future studies should examine the impact of modifying a physician's diet on their patients' dietary behavior.