They Came, But Will They Come Back? An Observational Study of Re-Enrollment Predictors for the Oklahoma Tobacco Helpline.

PURPOSE: Although quitlines reach 1% to 2% of tobacco users annually, additional efforts are needed to increase their impact. We hypothesized that offering less intensive services would increase the rate of re-enrollment in any service, as well as re-enrollment in more intensive services. This study describes the enrollment patterns and identifies re-enrollment predictors for Oklahoma Tobacco Helpline (OTH) participants. DESIGN: This study used a comparative observational design. SETTING: The setting for this study was the OTH, a telephone-based cessation program funded by the Oklahoma Tobacco Settlement Endowment Trust. The OTH participants could select either a multicall telephone-based cessation program (MC) or one or more individual services (IS), including a 2-week nicotine replacement therapy (NRT) starter kit, e-mail or text-based support, and a printed quit guide. PARTICIPANTS: A total of 35 648 first-time adult OTH participants eligible for the multicall program from October 2015 through September 2018 were included. MEASURES: Demographic and tobacco use variables and initial quitline service selection were collected at intake. Additional service utilization was tracked for 6 months following initial registration. ANALYSIS: Pearson chi-square and t tests were used to test for significant differences between groups. Multinomial logistic regression was used to examine predictors of re-enrollment. RESULTS: Individual services were more frequently selected (n = 17 266) than MC (n = 14 326), despite all users being eligible for MC. A much higher proportion of IS registrants re-enrolled than MC registrants (16% vs 3%, P < .0001) Among the IS cohort, those who received an NRT follow-up call were 14.7 times more likely to re-enroll in IS, and 7.8 times more likely to re-enroll in MC, than those who were not reached by phone. CONCLUSIONS: Access to free NRT without a telephone-coaching requirement is a draw for tobacco users, especially those with lower income and the uninsured. The results suggest the value of increasing use of nonphone services in an effort to increase interest in quitting and reach.

A cross-sectional study of the relationship of proximal smoking environments and cessation history, plans, and self-efficacy among low-income smokers.

INTRODUCTION: Proximal environments could facilitate smoking cessation among low-income smokers by making cessation appealing to strive for and tenable. AIMS: We sought to examine how home smoking rules and proximal environmental factors such as other household members' and peers' smoking behaviors and attitudes related to low-income smokers' past quit attempts, readiness, and self-efficacy to quit. METHODS: This analysis used data from Offering Proactive Treatment Intervention (OPT-IN) (randomized control trial of proactive tobacco cessation outreach) baseline survey, which was completed by 2,406 participants in 2011/12. We tested the associations between predictors (home smoking rules and proximal environmental factors) and outcomes (past-year quit attempts, readiness to quit, and quitting self-efficacy). RESULTS: Smokers who lived in homes with more restrictive household smoking rules, and/or reported having 'important others' who would be supportive of their quitting, were more likely to report having made a quit attempt in the past year, had greater readiness to quit, and greater self-efficacy related to quitting. CONCLUSIONS: Adjustments to proximal environments, including strengthening household smoking rules, might encourage cessation even if other household members are smokers.

Networks as systems.

Purpose The purpose of this paper is to present a case study of the World Health Organization's Global Healthcare Workforce Alliance (GHWA). Based on a commissioned evaluation of GHWA, it applies network theory and key concepts from systems thinking to explore network emergence, effectiveness, and evolution to over a ten-year period. The research was designed to provide high-level strategic guidance for further evolution of global governance in human resources for health (HRH). Design/methodology/approach Methods included a review of published literature on HRH governance and current practice in the field and an in-depth case study whose main data sources were relevant GHWA background documents and key informant interviews with GHWA leaders, staff, and stakeholders. Sampling was purposive and at a senior level, focusing on board members, executive directors, funders, and academics. Data were analyzed thematically with reference to systems theory and Shiffman's theory of network development. Findings Five key lessons emerged: effective management and leadership are critical; networks need to balance "tight" and "loose" approaches to their structure and processes; an active communication strategy is key to create and maintain support; the goals, priorities, and membership must be carefully focused; and the network needs to support shared measurement of progress on agreed-upon goals. Shiffman's middle-range network theory is a useful tool when guided by the principles of complex systems that illuminate dynamic situations and shifting interests as global alliances evolve. Research limitations/implications This study was implemented at the end of the ten-year funding cycle. A more continuous evaluation throughout the term would have provided richer understanding of issues. Experience and perspectives at the country level were not assessed. Practical implications Design and management of large, complex networks requires ongoing attention to key issues like leadership, and flexible structures and processes to accommodate the dynamic reality of these networks. Originality/value This case study builds on growing interest in the role of networks to foster large-scale change. The particular value rests on the longitudinal perspective on the evolution of a large, complex global network, and the use of theory to guide understanding.

A Good Idea May Not Be Good Enough: Stakeholder Buy In to QuitConnect, a National Smokers' Registry.

PURPOSE: To examine interest and concerns among those who fund and operate state-run smoking cessation helplines (quitlines) about the concept of creating a centralized smokers' registry that could be used to reengage smokers after they receive initial quitline support services. DESIGN: We conducted 3, hour-long focus groups with stakeholders, covering the perceived benefits and barriers to creating a smokers' registry. SETTING: The focus groups were conducted via telephone. PARTICIPANTS: Three groups participated: quitline service providers (n = 14), quitline funders (n = 9), and national quitline partners (n = 8). METHOD: Data collection: Focus groups were recorded, transcribed, and coded for major relevant themes. Analysis Strategies: We used a grounded theory approach. RESULTS: Stakeholders were generally positive about the concept of a centralized smokers' registry (ie, QuitConnect), especially with its potential to link relapsed smokers to ongoing research studies designed to help smokers achieve abstinence from tobacco. However, stakeholders expressed concern about QuitConnect duplicating services already offered by state quitlines. CONCLUSION: Despite a common goal, many state quitline stakeholders had strong reservations about the creation of a centralized smokers' registry unless they could see clear evidence that the registry added value and was not duplicative of their existing services.

A Proactive Smoking Cessation Intervention for Socioeconomically Disadvantaged Smokers: The Role of Smoking-Related Stigma.

Introduction: Smoking denormalization has been paralleled by reduced smoking prevalence, but smoking rates among socioeconomically disadvantaged populations remain high. The social unacceptability of smoking has also led to increased perceptions of smoking-related stigma. By examining how smoking stigma influences cessation intervention effectiveness, we can better tailor interventions to socioeconomically disadvantaged smokers. Aims and Methods: Data are from a randomized controlled trial evaluating the effectiveness of a proactive cessation intervention on abstinence. Current smokers enrolled in Minnesota Health Care Programs were randomized to proactive outreach (n = 1200) or usual care (n = 1206). The intervention included mailings, telephone outreach, counseling, and access to free cessation treatments. Using baseline measurements, groups with lower (n = 1227) and higher (n = 1093) perceived stigma were formed. Intervention, stigma, and their interaction term were added to a logistic regression modeling abstinence at 12 months. Results: Lower perceived smoking-related stigma was associated with less support for quitting, lower rates of physician quitting advice, and less motivation for quitting. A logistic regression modeling abstinence found a significant intervention × stigma interaction. The proactive intervention was more effective among smokers with lower perceived smoking-related stigma (odds ratio 1.94, 95% confidence interval, 1.29 to 2.92) than those with higher perceived smoking-related stigma (odds ratio 1.04, 95% confidence interval, 0.70 to 1.55). Discussion: Smokers with lower perceived smoking-related stigma had social environments that were conducive to smoking, received less physician advice to quit, and were less motivated to quit than higher stigma smokers. Despite these barriers, the intervention was more effective for lower stigma smokers, suggesting that proactive outreach is an efficient treatment for these hard-to-reach smokers. Implications: Smoking denormalization has led to increased perceptions of smoking-related stigma among many smokers; however, little is known about how this stigma influences the cessation process. In the present study, smokers with lower levels of perceived smoking-related stigma lived in social environments that were more conducive to smoking and were less motivated to quit than higher stigma smokers. Despite these barriers, our proactive outreach cessation intervention was more effective for lower stigma smokers, suggesting that interventions which utilize proactive outreach to stimulate interest in quitting and offer facilitated access to free cessation treatments are an effective treatment approach for these hard-to-reach smokers. These strategies may be particularly effective for motivating smokers enrolled in government-subsidized health insurance programs to take advantage of cessation resources.

Treatment barriers among younger and older socioeconomically disadvantaged smokers.

OBJECTIVES: Underutilization of smoking cessation treatments contributes to high rates of smoking in socioeconomically disadvantaged populations. Guided by a conceptual framework, the present study explored how healthcare provider factors, social environment characteristics, and cessation beliefs influence treatment utilization among low-income smokers and whether these associations vary by age. STUDY DESIGN: Analyses were conducted on baseline data from 2406 participants enrolled in a randomized controlled trial that evaluated the effectiveness of a proactive outreach cessation intervention among a sample of younger (18-34 years) and older (35-64 years) smokers enrolled in public healthcare assistance programs. METHODS: Multivariable logistic regression models predicted past year cessation treatment utilization (CTU) among younger and older smokers. Independent variables included measures of healthcare provider barriers, social environment characteristics, and cessation beliefs. RESULTS: Younger smokers were less likely to have CTU than older smokers (27.2% vs 36.2%; P <.001). In both groups, number of cigarettes per day, more problems accessing healthcare, receiving medication-related cessation advice, and readiness to quit were positively associated with CTU (P <.05). Among younger smokers, living with another smoker was associated with lower odds of CTU while receipt of cessation advice was associated (P = .033) with higher odds of CTU. CONCLUSIONS: In this sample of low-income smokers, interest in quitting was high but treatment utilization was low. Increasing utilization of cessation treatments via interventions that target issues specific to low-income smokers, including healthcare provider access and advice, the home environment, and motivation to quit, is an important step toward reducing smoking rates in this population.

Increasing reach by offering choices: Results from an innovative model for statewide services for smoking cessation.

Although state quitlines provide free telephone counseling and often include nicotine replacement therapy (NRT), reach remains limited (1-2% in most states). More needs to be done to engage all smokers in the quitting process. A possible strategy is to offer choices of cessation services through quitlines and to reduce registration barriers. In March 2014, ClearWay MinnesotaSM implemented a new model for QUITPLAN® Services, the state's population-wide cessation services. Tobacco users could choose the QUITPLAN® Helpline or one or more Individual QUITPLAN® Services (NRT starter kit, text messaging, email program, or quit guide). The program website was redesigned, online enrollment was added, and a new advertising campaign was created and launched. In 2014-2015, we evaluated whether these changes increased reach. We also assessed quit attempts, quit outcomes, predictors of 30-day abstinence, and average cost per quit via a seven-month follow-up survey. Between March 2014-February 2015, 15,861 unique tobacco users registered, which was a 169% increase over calendar year 2013. The majority of participants made a quit attempt (83.7%). Thirty-day point prevalence abstinence rates (responder rates) were 26.1% for QUITPLAN Services overall, 29.6% for the QUITPLAN Helpline, and 25.5% for Individual QUITPLAN Services. Several variables predicted quit outcomes, including receiving only one call from the Helpline and using both the Helpline and the NRT starter kit. Providing greater choice of cessation services and reducing registration barriers have the potential to engage more tobacco users, foster more quit attempts, and ultimately lead to long-term cessation and reductions in prevalence.

Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial.

BACKGROUND: Evidenced-based tobacco cessation treatments are underused, especially by socioeconomically disadvantaged smokers. This contributes to widening socioeconomic disparities in tobacco-related morbidity and mortality. METHODS: The Offering Proactive Treatment Intervention trial tested the effects of a proactive outreach tobacco treatment intervention on population-level smoking abstinence and tobacco treatment use among a population-based sample of socioeconomically disadvantaged smokers. Current smokers (n=2406), regardless of interest in quitting, who were enrolled in the Minnesota Health Care Programs, the state's publicly funded healthcare programmes for low-income populations, were randomly assigned to proactive outreach or usual care. The intervention comprised proactive outreach (tailored mailings and telephone calls) and free cessation treatment (nicotine replacement therapy and intensive, telephone counselling). Usual care comprised access to a primary care physician, insurance coverage of Food and Drug Administration-approved smoking cessation medications, and the state's telephone quitline. The primary outcome was self-reported 6-month prolonged smoking abstinence at 1 year and was assessed by follow-up survey. FINDINGS: The proactive intervention group had a higher prolonged abstinence rate at 1 year than usual care (16.5% vs 12.1%, OR 1.47, 95% CI 1.12 to 1.93). The effect of the proactive intervention on prolonged abstinence persisted in selection models accounting for non-response. In analysis of secondary outcomes, use of evidence-based tobacco cessation treatments were significantly greater among proactive outreach participants compared with usual care, particularly combination counselling and medications (17.4% vs 3.6%, OR 5.69, 95% CI 3.85 to 8.40). INTERPRETATION: Population-based proactive tobacco treatment increases engagement in evidence-based treatment and is effective in long-term smoking cessation among socioeconomically disadvantaged smokers. Findings suggest that dissemination of population-based proactive treatment approaches is an effective strategy to reduce the prevalence of smoking and socioeconomic disparities in tobacco use. TRIAL REGISTRATION NUMBER: NCT01123967.

Sustaining organizational culture change in health systems.

PURPOSE: The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues. DESIGN/METHODOLOGY/APPROACH: The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts. FINDINGS: Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement. PRACTICAL IMPLICATIONS: The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application. ORIGINALITY/VALUE: This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.

Engagement and attrition in Internet smoking cessation interventions: Insights from a cross-sectional survey of "one-hit-wonders".

INTRODUCTION: Internet interventions can reach large numbers of individuals. However, low levels of engagement and high rates of follow-up attrition are common, presenting major challenges to evaluation. This study investigated why registrants of an Internet smoking cessation intervention did not return after joining ("one hit wonders"), and explored the impact of graduated incentives on survey response rates and responder characteristics. METHODS: A sample of "one hit wonders" that registered on a free smoking cessation website between 2014 and 2015 were surveyed. The initial invitation contained no incentive. Subsequent invitations were sent to random subsamples of non-responders from each previous wave offering $25 and $50 respectively. Descriptive statistics characterized respondents on demographic characteristics, reasons for not returning, and length of time since last visit. Differences were investigated with Fisher's Exact tests, Kruskal-Wallis, and logistic regression. RESULTS: Of 8779 users who received the initial invitation, 132 completed the survey (1.5%). Among those subsequently offered a $25 incentive, 127 (3.7%) responded. Among those offered a $50 incentive, 97 responded (5.7%). The most common reasons endorsed for not returning were being unable to quit (51%), not having enough time (33%), having forgotten about the website (28%), and not being ready to quit (21%). Notably, however, 23% reported not returning because they had successfully quit smoking. Paid incentives yielded a higher proportion of individuals who were still smoking than the $0 incentive (72% vs. 61%). Among $0 and $25 responders, likelihood of survey response decreased with time since registration; the $50 incentive removed the negative effect of time-since-registration on probability of response. CONCLUSIONS: One third of participants that had disengaged from an Internet intervention reported abstinence at follow-up, suggesting that low levels of engagement are not synonymous with treatment failure in all cases. Paid incentives above $25 may be needed to elicit survey responses, especially among those with longer intervals of disengagement from an intervention.

Coevolution of Information Sharing and Implementation of Evidence-Based Practices Among North American Tobacco Cessation Quitlines.

OBJECTIVES: We examined the coevolution of information sharing and implementation of evidence-based practices among US and Canadian tobacco cessation quitlines within the North American Quitline Consortium (NAQC). METHODS: Web-based surveys were used to collect data from key respondents representing each of 74 participating funders of NAQC quitlines during the summer and fall of 2009, 2010, and 2011. We used stochastic actor-based models to estimate changes in information sharing and practice implementation in the NAQC network. RESULTS: Funders were more likely to share information within their own country and with funders that contracted with the same service provider. Funders contracting with larger service providers shared less information but implemented significantly more practices. Funders connected to larger numbers of tobacco control researchers more often received information from other funders. Intensity of ties to the NAQC network administrative organization did not influence funders' decisions to share information or implement practices. CONCLUSIONS: Our findings show the importance of monitoring the NAQC network over time. We recommend increased cross-border information sharing and sharing of information between funders contracting with different and smaller service providers.

Implementation of tobacco cessation quitline practices in the United States and Canada.

OBJECTIVES: We examined relationships between implementation of tobacco quitline practices, levels of evidence of practices, and quitline reach and spending. METHODS: In June and July 2009, a total of 176 quitline funders and providers in the United States and Canada completed a survey on quitline practices, in particular quitline-level implementation for the reported practices. From these data, we selected and categorized evidence-based and emerging quitline practices by the strength of the evidence for each practice to increase quitline efficacy and reach. RESULTS: The proportion of quitlines implementing each practice ranged from 3% (text messaging) to 92% (providing a multiple-call protocol). Implementation of practices showing higher levels of evidence for increasing either reach or efficacy showed moderate but significant positive correlations with both reach outcomes and spending levels. The strongest correlation was between reach outcomes and spending levels (r=0.80; P<.01). CONCLUSIONS: The strong relationship between quitline spending and reach reinforces the need to increase quitline funding to levels commensurate with national cessation goals.

Culture, acculturation and smoking use in Hmong, Khmer, Laotians, and Vietnamese communities in Minnesota.

BACKGROUND: Southeast Asian communities in the United States have suffered from high rates of tobacco use and high rates of chronic diseases associated with firsthand and secondhand smoking. Research is needed on how best to reduce and prevent tobacco use and exposure to secondhand smoke in these communities. The objective of this study was to examine how tobacco use patterns in Minnesota's Southeast Asian communities have been shaped by culture, immigration, and adjustment to life in America in order to inform future tobacco control strategies. METHODS: The study consisted of semi-structured interviews with 60 formal and informal leaders from Minnesota's Hmong, Khmer (Cambodian), Lao, and Vietnamese communities and incorporated principles of community-based participatory research. RESULTS: Among Khmer, Lao and Vietnamese, tobacco in the homeland was a valued part of material culture and was used to signify social status, convey respect, and support social rituals among adult men (the only group for whom smoking was acceptable). Among the Hmong, regular consumption of tobacco was unacceptable and rarely seen until the civil war in Laos when a number of Hmong soldiers became smokers. In Minnesota, social norms have begun to shift, with smoking becoming less acceptable. Although older male smokers felt social pressure to quit, smoking functioned to reduce the stress of social isolation, economic hardship, prior trauma, and the loss of power and status. Youth and younger women no longer felt as constrained by culturally-rooted social prohibitions to smoke. CONCLUSIONS: Leaders from Minnesota's Southeast Asian communities perceived key changes in tobacco-related attitudes, beliefs, and behaviors which were embedded in the context of shifting power, status, and gender roles within their communities. This has practical implications for developing policy and interventions. Older Southeast Asians are likely to benefit from culturally-tailored programs (e.g., that value politeness and the importance of acting in ways that benefit the family, community, and clan) and programs that work with existing social structures, as well as initiatives that address smokers' psychological distress and social isolation. Leaders remained uncertain about how to address smoking uptake among youth, pointing to a need for additional research.

Diffusion of an evidence-based smoking cessation intervention through Facebook: a randomised controlled trial study protocol.

INTRODUCTION: Online social networks represent a potential mechanism for the dissemination of health interventions including smoking cessation; however, which elements of an intervention determine diffusion between participants is unclear. Diffusion is frequently measured using R, the reproductive rate, which is determined by the duration of use (t), the 'contagiousness' of an intervention (ß) and a participant's total contacts (z). We have developed a Facebook 'app' that allows us to enable or disable various components designed to impact the duration of use (expanded content, proactive contact), contagiousness (active and passive sharing) and number of contacts (use by non-smoker supporters). We hypothesised that these elements would be synergistic in their impact on R, while including non-smokers would induce a 'carrier' state allowing the app to bridge clusters of smokers. METHODS AND ANALYSIS: This study is a fractional factorial, randomised control trial of the diffusion of a Facebook application for smoking cessation. Participants recruited through online advertising are randomised to 1 of 12 cells and serve as 'seed' users. All user interactions are tracked, including social interactions with friends. Individuals installing the application that can be traced back to a seed participant are deemed 'descendants' and form the outcome of interest. Analysis will be conducted using Poisson regression, with event count as the outcome and the number of seeds in the cell as the exposure. RESULTS: The results will be reported as a baseline R0 for the reference group, and incidence rate ratio for the remainder of predictors. ETHICS AND DISSEMINATION: This study uses an abbreviated consent process designed to minimise barriers to adoption and was deemed to be minimal risk by the Institutional Review Board (IRB). Results will be disseminated through traditional academic literature as well as social media. If feasible, anonymised data and underlying source code are intended to be made available under an open source license. CLINICALTRIALSGOV REGISTRATION NUMBER: NCT01746472.

A time-responsive tool for informing policy making: rapid realist review.

BACKGROUND: A realist synthesis attempts to provide policy makers with a transferable theory that suggests a certain program is more or less likely to work in certain respects, for particular subjects, in specific kinds of situations. Yet realist reviews can require considerable and sustained investment over time, which does not always suit the time-sensitive demands of many policy decisions. 'Rapid Realist Review' methodology (RRR) has been developed as a tool for applying a realist approach to a knowledge synthesis process in order to produce a product that is useful to policy makers in responding to time-sensitive and/or emerging issues, while preserving the core elements of realist methodology. METHODS: Using examples from completed RRRs, we describe key features of the RRR methodology, the resources required, and the strengths and limitations of the process. All aspects of an RRR are guided by both a local reference group, and a group of content experts. Involvement of knowledge users and external experts ensures both the usability of the review products, as well as their links to current practice. RESULTS: RRRs have proven useful in providing evidence for and making explicit what is known on a given topic, as well as articulating where knowledge gaps may exist. From the RRRs completed to date, findings broadly adhere to four (often overlapping) classifications: guiding rules for policy-making; knowledge quantification (i.e., the amount of literature available that identifies context, mechanisms, and outcomes for a given topic); understanding tensions/paradoxes in the evidence base; and, reinforcing or refuting beliefs and decisions taken. CONCLUSIONS: 'Traditional' realist reviews and RRRs have some key differences, which allow policy makers to apply each type of methodology strategically to maximize its utility within a particular local constellation of history, goals, resources, politics and environment. In particular, the RRR methodology is explicitly designed to engage knowledge users and review stakeholders to define the research questions, and to streamline the review process. In addition, results are presented with a focus on context-specific explanations for what works within a particular set of parameters rather than producing explanations that are potentially transferrable across contexts and populations. For policy makers faced with making difficult decisions in short time frames for which there is sufficient (if limited) published/research and practice-based evidence available, RRR provides a practical, outcomes-focused knowledge synthesis method.

Doing the dance of culture change: complexity, evidence and leadership.

The challenge of culture change in hospitals must address three distinct but interwoven tensions: the need to shift paradigm and understand healthcare as a complex adaptive system; the challenge of knitting together the contributions of both evidence-based medicine and practice-based evidence; and the critical role of distributed, problem-focused leadership.The authors of the lead paper highlight five key issues in addressing this challenge: (1) the implementation of strategies like front-line ownership (FLO) in the context of macro-level social forces; (2) the central role of distributed leadership and its strengthening within the organization; (3) the need to attend to developing systems thinking skills at all levels; (4) the very significant challenge of how to scale up the labour-intensive change strategies within FLO, the role of "simple rules" and the potential for systems thinking tools such as concept mapping and dynamic modelling; and (5) the concurrent orchestration of not one culture change but three tensions in the challenge FLO represents to simpler versus complex adaptive systems, leadership and management and the balance between evidence-based medicine and practice-based evidence, at the clinical, organizational and macro-system levels.

Assessing the preconditions for communication influence on decision making: the North American Quitline Consortium.

The network of North American quitlines is a loose confederation of telephone-based smoking cessation professionals, including smoking cessation counseling providers, funders, researcher and policy advocates. Each quitline has some leeway in the types of services it provides, and the purpose of this article is to identify factors that explain such choices. Representatives from quitline organizations responded to a survey regarding the importance of several items that were hypothesized to influence general intentions to adopt and implement new cessation methods. Results indicate that internal (to the quitline) constraints are positively associated with consensus processes and that implementation of practices in general was more likely if consensus processes were used. Unilateral decision making (one person within an organization makes decisions for the quitline on his/her own) was unrelated to either internal or external constraints and was negatively associated with adoption of quitline practices. Discussion focuses on factors that influence consensus decision-making processes beyond those investigated in the article.

Experience of smokers and recent quitters with smokefree regulations and quitting.

BACKGROUND: Bans on smoking in public areas have increased as knowledge of secondhand smoke dangers has grown. Restrictions on smoking in public areas may lead to less smoking and increased quitting. PURPOSE: This study examines the experiences of smokers and recent quitters with local smokefree regulations to better understand the possible mechanisms by which smokefree regulations affect individual tobacco users' patterns of tobacco consumption and quitting. METHODS: Fifteen in-depth interviews and thirteen focus groups were conducted with tobacco users and recent quitters formerly enrolled in cessation programs provided by ClearWay Minnesota(SM). Data were collected 3 months after smokefree legislation was adopted in the Minneapolis/St. Paul metropolitan area in 2006, and were stratified by tobacco use status and strength of regulation. Essential themes were extracted using NVivo 8 software in 2011. RESULTS: Study participants reported that smokefree legislation forced them to confront their addiction. They experienced apprehension, frustration, and panic anticipating smoking restrictions. This motivated some to attempt to quit, whereas others felt punished by and angry at government intrusion. Both current and former tobacco users felt smokefree regulations contributed to stigmatizing smokers. They also reported smokefree legislation reduced the temptation to smoke. The physical absence of cigarette smoke in bars and restaurants appeared to support quit attempts. The inconvenience of smoking outside was reported to have a similar effect. CONCLUSIONS: Essential mechanisms by which bans influenced patterns of tobacco use and quitting include confronting addiction, temptation, inconvenience, and social norms. These findings highlight the success of tobacco control advocates in denormalizing tobacco use, and suggest that some tobacco users may be internalizing negative messages about tobacco.

Mapping tobacco quitlines in North America: signaling pathways to improve treatment.

OBJECTIVES: This study was designed to better understand how the network of quitlines in the North American Quitline Consortium (NAQC) interact and share new knowledge on quitline practices. METHODS: Network relationship data were collected from all 63 publicly funded quitlines in North America, including information sharing, partner trust, and reputation. RESULTS: There was a strong tendency for US and Canadian quitlines to seek information from other quitlines in the same country, with few seeking information from quitlines from the other country. Quitlines with the highest reputation tended to more centrally located in the network, but the NAQC coordinating organization is highly central to the quitline network-thus demonstrating their role as a broker of quitline information. CONCLUSIONS: This first "snapshot" of US and Canadian quitlines demonstrated that smoking cessation quitlines in North America are not isolated, but are part of an interconnected network, with some organizations more central than others. As quitline use expands with the inclusion of national toll-free numbers on cigarette packs, how quitlines share information to improve practice will become increasingly important.

Large-system transformation in health care: a realist review.

CONTEXT: An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation (LST) and health care reform. Fundamental conceptual and methodological challenges also must be addressed. The Saskatchewan Ministry of Health in Canada requested a six-month synthesis project to guide four major policy development and strategy initiatives focused on patient- and family-centered care, primary health care renewal, quality improvement, and surgical wait lists. The aims of the review were to analyze examples of successful and less successful transformation initiatives, to synthesize knowledge of the underlying mechanisms, to clarify the role of government, and to outline options for evaluation. METHODS: We used realist review, whose working assumption is that a particular intervention triggers particular mechanisms of change. Mechanisms may be more or less effective in producing their intended outcomes, depending on their interaction with various contextual factors. We explain the variations in outcome as the interplay between context and mechanisms. We nested this analytic approach in a macro framing of complex adaptive systems (CAS). FINDINGS: Our rapid realist review identified five "simple rules" of LST that were likely to enhance the success of the target initiatives: (1) blend designated leadership with distributed leadership; (2) establish feedback loops; (3) attend to history; (4) engage physicians; and (5) include patients and families. These principles play out differently in different contexts affecting human behavior (and thereby contributing to change) through a wide range of different mechanisms. CONCLUSIONS: Realist review methodology can be applied in combination with a complex system lens on published literature to produce a knowledge synthesis that informs a prospective change effort in large-system transformation. A collaborative process engaging both research producers and research users contributes to local applications of universal principles and mid-range theories, as well as to a more robust knowledge base for applied research. We conclude with suggestions for the future development of synthesis and evaluation methods.