Association between Transfusion Status and Overall Survival in Patients with Myelodysplastic Syndromes: A Systematic Literature Review and Meta-Analysis.

INTRODUCTION: Multiple studies show that transfusion independence (TI) in myelodysplastic syndrome (MDS) has a positive impact on overall survival (OS). To assess this, a systematic review and meta-analysis of the association between TI and OS in patients with MDS was conducted (PROSPERO ID: CRD42014007264). METHODS: Comprehensive searches of 5 key bibliographic databases were conducted and supplemented with additional search techniques. Included were studies that had recruited adults aged >18 years with MDS and had examined the impact of transfusion status on OS. RESULTS: Fifty-five studies (89 citations) were included. The vast majority reported a statistically significant hazard ratio (HR) for OS in favor of TI patients or in patients who acquired TI after treatment. A random-effects meta-analysis was conducted. Patients classed as TI at baseline showed a 59% decrease in the risk of death compared with transfusion-dependent (TD) patients [HR 0.41; 95% credible interval (CrI) 0.29-0.56], and this effect did not appear to interact significantly with illness severity (interaction coefficient HR 1.38; 95% CrI 0.62-3.41). A meta-analysis of studies where patients acquired TI was not possible, but those studies consistently reported a survival benefit for those who acquired TI. CONCLUSION: The findings revealed a 59% pooled reduction in mortality among TI patients when compared with TD patients.

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for the treatment of rheumatoid arthritis not previously treated with disease-modifying antirheumatic drugs and after the failure of conventional disease-modifying antirheumatic drugs only: systematic review and economic evaluation.

OBJECTIVES: Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increasing disability, reduced quality of life and substantial costs (as a result of both intervention acquisition and hospitalisation). The objective was to assess the clinical effectiveness and cost-effectiveness of seven biologic disease-modifying antirheumatic drugs (bDMARDs) compared with each other and conventional disease-modifying antirheumatic drugs (cDMARDs). The decision problem was divided into those patients who were cDMARD naive and those who were cDMARD experienced; whether a patient had severe or moderate to severe disease; and whether or not an individual could tolerate methotrexate (MTX). DATA SOURCES: The following databases were searched: MEDLINE from 1948 to July 2013; EMBASE from 1980 to July 2013; Cochrane Database of Systematic Reviews from 1996 to May 2013; Cochrane Central Register of Controlled Trials from 1898 to May 2013; Health Technology Assessment Database from 1995 to May 2013; Database of Abstracts of Reviews of Effects from 1995 to May 2013; Cumulative Index to Nursing and Allied Health Literature from 1982 to April 2013; and TOXLINE from 1840 to July 2013. Studies were eligible for inclusion if they evaluated the impact of a bDMARD used within licensed indications on an outcome of interest compared against an appropriate comparator in one of the stated population subgroups within a randomised controlled trial (RCT). Outcomes of interest included American College of Rheumatology (ACR) scores and European League Against Rheumatism (EULAR) response. Interrogation of Early Rheumatoid Arthritis Study (ERAS) data was undertaken to assess the Health Assessment Questionnaire (HAQ) progression while on cDMARDs. METHODS: Network meta-analyses (NMAs) were undertaken for patients who were cDMARD naive and for those who were cDMARD experienced. These were undertaken separately for EULAR and ACR data. Sensitivity analyses were undertaken to explore the impact of including RCTs with a small proportion of bDMARD experienced patients and where MTX exposure was deemed insufficient. A mathematical model was constructed to simulate the experiences of hypothetical patients. The model was based on EULAR response as this is commonly used in clinical practice in England. Observational databases, published literature and NMA results were used to populate the model. The outcome measure was cost per quality-adjusted life-year (QALY) gained. RESULTS: Sixty RCTs met the review inclusion criteria for clinical effectiveness, 38 of these trials provided ACR and/or EULAR response data for the NMA. Fourteen additional trials contributed data to sensitivity analyses. There was uncertainty in the relative effectiveness of the interventions. It was not clear whether or not formal ranking of interventions would result in clinically meaningful differences. Results from the analysis of ERAS data indicated that historical assumptions regarding HAQ progression had been pessimistic. The typical incremental cost per QALY of bDMARDs compared with cDMARDs alone for those with severe RA is > £40,000. This increases for those who cannot tolerate MTX (£50,000) and is > £60,000 per QALY when bDMARDs were used prior to cDMARDs. Values for individuals with moderate to severe RA were higher than those with severe RA. Results produced using EULAR and ACR data were similar. The key parameter that affected the results is the assumed HAQ progression while on cDMARDs. When historic assumptions were used typical incremental cost per QALY values fell to £38,000 for those with severe disease who could tolerate MTX. CONCLUSIONS: bDMARDs appear to have cost per QALY values greater than the thresholds stated by the National Institute for Health and Care Excellence for interventions to be cost-effective. Future research priorities include: the evaluation of the long-term HAQ trajectory while on cDMARDs; the relationship between HAQ direct medical costs; and whether or not bDMARDs could be stopped once a patient has achieved a stated target (e.g. remission). STUDY REGISTRATION: This study is registered as PROSPERO CRD42012003386. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Reducing the impact of physical inactivity: evidence to support the case for targeting people with chronic mental and physical conditions.

BACKGROUND: Recent evidence suggests that small increases in the physical activity of those considered least active can have a bigger health impact than raising levels of those already achieving or close to achieving recommendations. Profiling the characteristics of those who are least active allows for appropriate targeting of interventions. This study therefore examined the characteristics of people in the lowest physical activity bracket. METHODS: Data were taken from the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) funded 'South Yorkshire Cohort', a longitudinal observational dataset of residents of South Yorkshire, England. Five separate outcomes based on a shortened version of the GPPAQ were used to represent the lowest levels of physical activity. Potential predictors examined were age, sex, body mass index, ethnicity, chronic conditions, current employment and deprivation. Descriptive statistics and logistic regression were conducted. RESULTS: Individuals with chronic mental and physical conditions (fatigue, insomnia, anxiety, depression, diabetes, breathing problems, high blood pressure, heart disease, stroke and cancer) were more likely to report the lowest levels of physical activity across all five outcomes. Demographic variations were also observed. CONCLUSIONS: Targeting people with chronic mental and physical conditions has the potential to reduce the impact of physical inactivity.

A systematic review and economic evaluation of exercise referral schemes in primary care: a short report.

BACKGROUND: It is estimated that only 39% of men and 29% of women in England achieve the levels of physical activity that are recommended to protect health and prevent disease. One approach to addressing this problem has been the development of exercise referral schemes (ERSs), in which health professionals refer patients to external exercise providers. These schemes have been widely rolled out across the UK despite concerns that they may not produce sustained changes in levels of physical activity and, therefore, may not be cost-effective interventions. The evidence to determine clinical effectiveness and cost-effectiveness was evaluated in 2009. This review seeks to update this earlier work by incorporating new evidence and re-examining the cost-effectiveness. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of ERSs compared with usual care. DESIGN: Exhaustive searches of relevant electronic databases and journals were undertaken to identify new studies evaluating ERSs using a randomised controlled trial (RCT) design. RCTs that incorporated a qualitative evaluation of the intervention were identified in order to explore the barriers and facilitators to the uptake of and adherence to ERSs. Data were extracted using a previously designed tool and study quality assessed for potential bias. Where data could be pooled, meta-analyses were carried out. Qualitative analysis was also undertaken using a thematic approach. The cost-effectiveness was evaluated using a Markov structure which estimated the likelihood of becoming physically active and the subsequent risk reduction on coronary heart disease (CHD), stroke and type 2 diabetes mellitus. The model adopts a lifetime horizon, and a NHS and Personal Social Services perspective was taken with discounting at 1.5% for both costs and benefits. RESULTS: The search identified one new RCT and one new qualitative study. The new data were pooled with existing data from the 2011 review by Pavey et al. [Pavey TG, Anokye N, Taylor AH, Trueman P, Moxham T, Fox KR, et al. The clinical effectiveness and cost-effectiveness of exercise referral schemes: a systematic review and economic evaluation. Health Technol Assess 2011;15(44)] to give a total of eight studies with 5190 participants. The proportion of individuals achieving 90-150 minutes of at least moderate-intensity activity per week at 6-12 months' follow-up was greater for ERSs than usual care (relative risk 1.12; 95% confidence interval 1.04 to 1.20). Older patients and those referred for CHD risk factors appeared to be more likely than others to increase their levels of physical activity. Qualitative evidence suggests that interventions enabling the development of social support networks are beneficial in promoting uptake and adherence. Exercise referral gained 0.003 quality-adjusted life-years (QALYs) at an additional cost of £225 per person. The estimated mean incremental cost-effectiveness ratio (ICER) in the probabilistic sensitivity analysis was £76,276. In the univariate sensitivity analysis the results were very sensitive (ICERs ranged from < £30,000 to > £100,000) to changes in the effect of ERSs on physical activity uptake and the duration of the protective effects and the direct health-related quality-of-life gains attributable to physical activity. CONCLUSIONS: Exercise referral schemes result in a small improvement in the number of people who increase their levels of physical activity. The cost-effectiveness analysis indicates that the ICER for ERSs compared with usual care is around £76,000 per QALY, although the cost-effectiveness of ERSs is subject to considerable uncertainty. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013005200. FUNDING: National Institute for Health Research Health Technology Assessment programme.

The safety of intravitreal bevacizumab monotherapy in adult ophthalmic conditions: systematic review.

OBJECTIVES: To assess the safety of intravitreal bevacizumab (IVB) as a monotherapy and to evaluate the relationship between quality of treatment and adverse events. DATA SOURCES: Cochrane Library, Ovid MEDLINE, MEDLINE in-process, Ovid EMBASE and Toxicology Literature Online (TOXLINE) from January 2009 to May 2012. Studies included in an earlier systematic review were also assessed for inclusion. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS: Randomised controlled trials (RCTs), controlled trials or observational studies including ≥10 participants reporting adverse events data following IVB monotherapy as a primary treatment in patients (aged 18 years or more) with any eye condition were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Study selection was undertaken independently by a minimum of two reviewers using pre-defined criteria. Data abstraction and quality assessment were performed by one reviewer, and then checked by a second reviewer. Study quality was assessed for only RCTs in accordance to the Cochrane Risk of Bias Tool. Additional items relating to safety data were also assessed. Results were tabulated or meta-analysed as appropriate. RESULTS: 22 RCTs and 67 observational studies were included. Only two RCTs reported valid safety data. Rates of serious adverse events following treatment were low. There was insufficient data to explore the relationship between the incidence of adverse events and quality of IVB injection. LIMITATIONS: A majority of relevant existing studies were characterised by small sample sizes, unclear diagnostic criteria and reporting of safety outcomes. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Available evidence demonstrates low rates of serious local and systemic adverse events following treatment. However, the role of IVB quality in the incidence of adverse events remains unclear. Robust evidence is needed to examine the relationship between the incidence of adverse events and variables such as injection techniques, pre-existing risk factors (eg, immunosuppression, cross-contamination) and quality of IVB treatment.

What is the clinical effectiveness and cost-effectiveness of cytisine compared with varenicline for smoking cessation? A systematic review and economic evaluation.

BACKGROUND: Tobacco smoking is one of the leading causes of deaths worldwide. Nearly one-fifth of adults in the UK regularly smoke cigarettes. The ill-health associated with smoking costs the NHS over £3B every year. A number of pharmacological interventions are available that can help people to quit smoking. These include nicotinic receptor partial agonists such as varenicline or cytisine. Varenicline is a synthetic product licensed for use in the UK, while cytisine is derived naturally from the seeds of the plant Cytisus laborinum L. (golden rain acacia). OBJECTIVES: To review the evidence on the clinical effectiveness and safety of cytisine from smoking cessation compared with varenicline; to develop an economic model to estimate the cost-effectiveness of cytisine and varenicline; and to provide recommendations based on value of information analyses as to whether or not a head-to-head trial of cytisine and varenicline would represent effective use of resources. DATA SOURCES: Efficacy and adverse events data were sourced from a recent Cochrane review. These data were supplemented with an updated search of twelve electronic databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and The Cochrane Library, for the period from December 2011 to January 2013. The review included randomised controlled trials (RCTs) of adult smokers attempting to quit using varenicline or cytisine. Further interventions were considered (placebo, nicotine replacement therapy, bupropion) to allow an indirect comparison between varenicline and cytisine. The primary outcome was abstinence at a minimum of 6 months' follow-up. Secondary outcomes were common adverse events such as abnormal dreams, headache, nausea, insomnia and serious adverse events. REVIEW METHODS: A systematic review and network meta-analysis of the clinical evidence was undertaken. A random-effects model was used to allow for heterogeneity between studies. The economic model structure was based on a published model. Probabilistic sensitivity analyses were undertaken to estimate the treatment expected to be most cost-effective given current information. Formal expected value of perfect information, perfect partial information and of sample information were performed. RESULTS: Twenty-three (RCTs) were included in the systematic review, comprising a total of 10,610 participants. Twenty-one trials of varenicline of differing dosing schedules and two trials of cytisine at standard dose met the inclusion criteria. No head-to-head trials comparing varenicline with cytisine were identified. The methodological quality of the studies was judged to be moderate to good. Cytisine was more efficacious than placebo [hazard ratio (HR) 4.27, 95% credible interval (CrI) 2.05 to 10.05], as was standard-dose varenicline (HR 2.58, 95% Crl 2.16 to 3.15). Standard-dose varenicline treatment was associated with significantly higher rates of headache, insomnia and nausea than placebo; there was no significant difference in the rates of abnormal dreams. There were no significant differences in the rates of headache or nausea between cytisine and placebo; data were identified for neither abnormal dreams nor insomnia. Using expected values, cytisine is anticipated to dominate varenicline, in that it produces more quality-adjusted life-years at a lower associated cost. This occurred in approximately 90% of the scenarios performed. However, owing to the large number of people who wish to quit smoking (estimated to be 3 million over a 10-year period), the implications of making an incorrect decision is large. The expected value of sample information indicated that conducting a head-to-head trial of cytisine and varenicline was worthwhile, and that 1000 smokers per arm was an appropriate number to recruit. CONCLUSIONS: On the basis of the evidence included in this review, varenicline and cytisine are both effective interventions to aid smoking cessation when compared with placebo. Cytisine is estimated to be both more clinically effective and cost-effective than varenicline. However, there is uncertainty in the decision, and a head-to-head trial of cytisine and varenicline would appear to be an effective use of resources. STUDY REGISTRATION: The study was registered as PROSPERO CRD42012003455. FUNDING DETAILS: The National Institute for Health Research Health Technology Assessment programme.

A randomised controlled trial and cost-effectiveness evaluation of 'booster' interventions to sustain increases in physical activity in middle-aged adults in deprived urban neighbourhoods.

BACKGROUND: More evidence is needed on the potential role of 'booster' interventions in the maintenance of increases in physical activity levels after a brief intervention in relatively sedentary populations. OBJECTIVES: To determine whether objectively measured physical activity, 6 months after a brief intervention, is increased in those receiving physical activity 'booster' consultations delivered in a motivational interviewing (MI) style, either face to face or by telephone. DESIGN: Three-arm, parallel-group, pragmatic, superiority randomised controlled trial with nested qualitative research fidelity and geographical information systems and health economic substudies. Treatment allocation was carried out using a web-based simple randomisation procedure with equal allocation probabilities. Principal investigators and study statisticians were blinded to treatment allocation until after the final analysis only. SETTING: Deprived areas of Sheffield, UK. PARTICIPANTS: Previously sedentary people, aged 40-64 years, living in deprived areas of Sheffield, UK, who had increased their physical activity levels after receiving a brief intervention. INTERVENTIONS: Participants were randomised to the control group (no further intervention) or to two sessions of MI, either face to face ('full booster') or by telephone ('mini booster'). Sessions were delivered 1 and 2 months post-randomisation. MAIN OUTCOME MEASURES: The primary outcome was total energy expenditure (TEE) per day in kcal from 7-day accelerometry, measured using an Actiheart device (CamNtech Ltd, Cambridge, UK). Independent evaluation of practitioner competence was carried out using the Motivational Interviewing Treatment Integrity assessment. An estimate of the per-participant intervention costs, resource use data collected by questionnaire and health-related quality of life data were analysed to produce a range of economic models from a short-term NHS perspective. An additional series of models were developed that used TEE values to estimate the long-term cost-effectiveness. RESULTS: In total, 282 people were randomised (control = 96; mini booster = 92, full booster = 94) of whom 160 had a minimum of 4 out of 7 days' accelerometry data at 3 months (control = 61, mini booster = 47, full booster = 52). The mean difference in TEE per day between baseline and 3 months favoured the control arm over the combined booster arm but this was not statistically significant (-39 kcal, 95% confidence interval -173 to 95, p = 0.57). The autonomy-enabled MI communication style was generally acceptable, although some participants wanted a more paternalistic approach and most expressed enthusiasm for monitoring and feedback components of the intervention and research. Full boosters were more popular than mini boosters. Practitioners achieved and maintained a consistent level of MI competence. Walking distance to the nearest municipal green space or leisure facilities was not associated with physical activity levels. Two alternative modelling approaches both suggested that neither intervention was likely to be cost-effective. CONCLUSIONS: Although some individuals do find a community-based, brief MI 'booster' intervention supportive, the low levels of recruitment and retention and the lack of impact on objectively measured physical activity levels in those with adequate outcome data suggest that it is unlikely to represent a clinically effective or cost-effective intervention for the maintenance of recently acquired physical activity increases in deprived middle-aged urban populations. Future research with middle-aged and relatively deprived populations should explore interventions to promote physical activity that require less proactive engagement from individuals, including environmental interventions. STUDY REGISTRATION: Current Controlled Trials ISRCTN56495859, ClinicalTrials.gov NCT00836459. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 13. See the NIHR Journals Library website for further project information.

Exploring the relationship between baseline physical activity levels and mortality reduction associated with increases in physical activity: a modelling study.

BACKGROUND: Increasing physical activity (PA) levels among the general adult population of developed nations is important for reducing premature mortality and the burdens of preventable illness. Assessing how effective PA interventions are as health interventions often involves categorising participants as either 'active' or 'sedentary' after the interventions. A model was developed showing that doing this could significantly misestimate the health effect of PA interventions. METHODS: A life table model was constructed combining evidence on baseline PA levels with evidence indicating the non-linear relationship between PA levels and all-cause mortality risks. PA intervention scenarios were modelled which had the same mean increase in PA but different levels of take-up by people who were more active or more sedentary to begin with. RESULTS: The model simulations indicated that, compared with a scenario where already-active people did most of the additional PA, a scenario where the least active did the most additional PA was around a third more effective in preventing deaths between the ages of 50 and 60 years. The relationship between distribution of PA take-up and health effect was explored systematically and appeared non-linear. CONCLUSIONS: As the health gains of a given PA increase are greatest among people who are most sedentary, smaller increases in PA in the least active may have the same health benefits as much larger PA increases in the most active. To help such health effects to be assessed, PA studies should report changes in the distribution of PA level between the start and end of the study.

The acute effects of physical activity on cigarette cravings: systematic review and meta-analysis with individual participant data.

AIMS: To conduct an updated systematic review and the first meta-analysis of experimental trials investigating the acute effects of short bouts of physical activity (PA) on strength of desire (SoD) and desire to smoke (DtS) using individual participant data (IPD). METHODS: A systematic review of literature and IPD meta-analyses included trials assessing the acute effects of shorts bouts of PA on SoD and DtS among temporarily abstaining smokers not using pharmaceutical aids for smoking cessation. Authors of eligible studies were contacted and raw IPD were obtained. Two-stage and one-stage IPD random-effects meta-analyses were conducted. Participants engaging in PA were compared against control participants, using post-intervention SoD and DtS with baseline adjustments. RESULTS: A two-stage IPD meta-analysis assessing effects of PA on SoD yielded an average standardized mean difference (SMD) between PA and control conditions (across 15 primary studies) of -1.91 [95% confidence interval (CI): -2.59 to -1.22]. A two-stage IPD meta-analysis assessing effects of PA on DtS yielded an average SMD between PA and control conditions (across 17 primary studies) of -2.03 (95% CI: -2.60 to -1.46). Additional meta-analyses, including those using a one-stage model, those including only parallel arm studies and meta-analyses comparing only moderate exercise against a control condition, showed significant craving reduction following PA. Despite a high degree of between-study heterogeneity, effects sizes of all primary studies were in the same direction, with PA showing a greater reduction in cravings compared with controls. CONCLUSIONS: There is strong evidence that physical activity acutely reduces cigarette craving.

What are the barriers to primary prevention of type 2 diabetes in black and minority ethnic groups in the UK? A qualitative evidence synthesis.

BACKGROUND: This review aimed to synthesise available qualitative evidence on barriers and facilitators to the implementation of community based lifestyle behaviour interventions to reduce the risk of diabetes in black and minority ethnic (BME) groups in the UK. METHODS: A search of medical and social science databases was carried out and augmented by hand-searching of reference lists and contents of key journals. Qualitative evidence was synthesised thematically. RESULTS: A total of 13 papers varying in design and of mainly good quality were included in the review. A limited number of intervention evaluations highlighted a lack of resources and communication between sites. A lack of understanding by providers of cultural and religious requirements, and issues relating to access to interventions for users was reported. Behaviour change was impeded by cultural and social norms, and resistance to change. There were variations in the way dietary change and physical activity was approached by different groups and contrasting practices between generations. CONCLUSIONS: Qualitative data provided insight into the ways that providers might improve or better design future interventions. Acknowledgement of the way that different groups approach lifestyle behaviours may assist acceptability of interventions.

The effectiveness of interventions to establish smoke-free homes in pregnancy and in the neonatal period: a systematic review.

This review considers the effectiveness of interventions to encourage the establishment of smoke-free homes during pregnancy and the neonatal period. A comprehensive search of the literature was undertaken to find relevant studies via electronic databases, citations and reference lists of included studies. The searches identified 17 papers that met the inclusion criteria. These were quality assessed and data extracted. Due to heterogeneity of the papers, a narrative synthesis was completed. Interventions were categorized in terms of those based on counselling, counselling plus additional elements, individually adapted programmes and motivational interviewing. The findings suggest inconclusive evidence relating to these intervention types, with a range of outcome measures reported. There were limitations throughout the papers in terms of study quality (especially sample size) and poor reporting of results in relation to effectiveness. The review was limited by its very specific population; however, it suggests that currently there is mixed evidence for the effectiveness of interventions to reduce parental environmental tobacco smoke in early infancy.

Integrating the promotion of physical activity within a smoking cessation programme: findings from collaborative action research in UK Stop Smoking Services.

BACKGROUND: Within the framework of collaborative action research, the aim was to explore the feasibility of developing and embedding physical activity promotion as a smoking cessation aid within UK 6/7-week National Health Service (NHS) Stop Smoking Services. METHODS: In Phase 1 three initial cycles of collaborative action research (observation, reflection, planning, implementation and re-evaluation), in an urban Stop Smoking Service, led to the development of an integrated intervention in which physical activity was promoted as a cessation aid, with the support of a theoretically based self-help guide, and self monitoring using pedometers. In Phase 2 advisors underwent training and offered the intervention, and changes in physical activity promoting behaviour and beliefs were monitored. Also, changes in clients' stage of readiness to use physical activity as a cessation aid, physical activity beliefs and behaviour and physical activity levels were assessed, among those who attended the clinic at 4-week post-quit. Qualitative data were collected, in the form of clinic observation, informal interviews with advisors and field notes. RESULTS: The integrated intervention emerged through cycles of collaboration as something quite different to previous practice. Based on field notes, there were many positive elements associated with the integrated intervention in Phase 2. Self-reported advisors' physical activity promoting behaviour increased as a result of training and adapting to the intervention. There was a significant advancement in clients' stage of readiness to use physical activity as a smoking cessation aid. CONCLUSIONS: Collaboration with advisors was key in ensuring that a feasible intervention was developed as an aid to smoking cessation. There is scope to further develop tailored support to increasing physical activity and smoking cessation, mediated through changes in perceptions about the benefits of, and confidence to do physical activity.

Factors relating to the uptake of interventions for smoking cessation among pregnant women: a systematic review and qualitative synthesis.

INTRODUCTION: The review had the aim of investigating factors enabling or discouraging the uptake of smoking cessation services by pregnant women smokers. METHODS: The literature was searched for papers relating to the delivery of services to pregnant or recently pregnant women who smoke. No restrictions were placed on study design. A qualitative synthesis strategy was adopted to analyze the included papers. RESULTS: Analysis and synthesis of the 23 included papers suggested 10 aspects of service delivery that may have an influence on the uptake of interventions. These were whether or not the subject of smoking is broached by a health professional, the content of advice and information provided, the manner of communication, having service protocols, follow-up discussion, staff confidence in their skills, the impact of time and resource constraints, staff perceptions of ineffectiveness, differences between professionals, and obstacles to accessing interventions. DISCUSSION: The findings suggest variation in practice between services and different professional groups, in particular regarding the recommendation of quitting smoking versus cutting down but also in regard to procedural aspects, such as recording status and repeat advice giving. These differences offer the potential for a pregnant woman to receive contradicting advice. The review suggests a need for greater training in this area and the greater use of protocols, with evidence of a perception of ineffectiveness/pessimism toward intervention among some service providers.

Readiness to use physical activity as a smoking cessation aid: a multiple behaviour change application of the Transtheoretical Model among quitters attending Stop Smoking Clinics.

OBJECTIVE: Physical activity (PA) reduces cravings during smoking abstinence. Little is known about quitters' use of PA. This study aimed to: (1) determine the extent of quitters' past and current use of PA as a cessation aid, while attempting to quit; (2) examine relationships between use of PA and quitter characteristics and cognitions. METHODS: Self-report surveys were completed by 181 smokers attempting to quit. RESULTS: Twenty-two percent of quitters reported currently using PA to control their smoking, and 35% had used it during a previous quit attempt. Those in later stages of readiness for using PA as a cessation aid held more positive beliefs regarding self-efficacy, outcome efficacy and did more vigorous PA. CONCLUSION: Quitters were more likely to use PA to help them quit when they had greater belief in their own ability to use PA and in the efficacy of PA to help them to quit, and were also meeting weekly PA targets for health. PRACTICE IMPLICATIONS: Strategies by stop smoking advisors aiming to enhance client self-efficacy and outcome efficacy beliefs regarding PA as a cessation aid may help to increase the use of this behavioural strategy, since it seems that most quitters do not use PA.