Support Provided by Stop-Smoking Practitioners to Co-users of Tobacco and Cannabis: A Qualitative Study.

INTRODUCTION: Co-use of tobacco and cannabis is highly prevalent among cannabis users and is associated with poorer tobacco cessation outcomes. This study explored the barriers and enablers influencing stop-smoking practitioners' ability to provide optimal support to co-users. AIMS AND METHODS: Online semi-structured interviews were audio recorded. Interviewees (n = 20) were UK-based certified stop-smoking practitioners. An interview schedule informed by the "capability", "opportunity", "motivation" (COM-B) model was designed to explore participants' perceived barriers and enablers in better supporting co-users to achieve abstinence of both substances or tobacco harm reduction. The transcripts were analyzed using framework analysis. RESULTS: Capability: Practitioners' lack of knowledge and skills undermines their delivery of smoking cessation interventions to co-users. Interestingly, when cannabis is used for medicinal reasons, practitioners feel unable to provide adequate support. Opportunity: Service recording systems play an important role in screening for co-use and supporting co-users. When responding to clients' specific needs and practitioners' uncertainties, a positive therapeutic relationship and a support network of peers and other healthcare professionals are needed. Motivation: supporting co-users is generally perceived as part of practitioners' roles but there are concerns that co-users are less likely to successfully stop smoking. CONCLUSIONS: Practitioners are willing to support co-users, but their lack of knowledge and access to an appropriate recording system are barriers to doing so. Having a supportive team and a positive therapeutic relationship is perceived as important. Identified barriers can be mostly addressed with further training to improve tobacco cessation outcomes for co-users.

Lung Screen Uptake Trial (LSUT): Randomized Controlled Clinical Trial Testing Targeted Invitation Materials.

Rationale: Low uptake of low-dose computed tomography (LDCT) lung cancer screening, particularly by current smokers of a low socioeconomic position, compromises effectiveness and equity.Objectives: To compare the effect of a targeted, low-burden, and stepped invitation strategy versus control on uptake of hospital-based Lung Health Check appointments offering LDCT screening.Methods: In a two-arm, blinded, between-subjects, randomized controlled trial, 2,012 participants were selected from 16 primary care practices using these criteria: 1) aged 60 to 75 years, 2) recorded as a current smoker within the last 7 years, and 3) no prespecified exclusion criteria contraindicating LDCT screening. Both groups received a stepped sequence of preinvitation, invitation, and reminder letters from their primary care practitioner offering prescheduled appointments. The key manipulation was the accompanying leaflet. The intervention group's leaflet targeted psychological barriers and provided low-burden information, mimicking the concept of the U.K. Ministry of Transport's annual vehicle test ("M.O.T. For Your Lungs").Measurements and Main Results: Uptake was 52.6%, with no difference between intervention (52.3%) and control (52.9%) groups in unadjusted (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.82-1.16) or adjusted (OR, 0.98; 95% CI, 0.82-1.17) analyses. Current smokers were less likely to attend (adjusted OR, 0.70; 95% CI, 0.56-0.86) than former smokers. Socioeconomic deprivation was significantly associated with lower uptake for the control group only (P < 0.01).Conclusions: The intervention did not improve uptake. Regardless of trial arm, uptake was considerably higher than previous clinical and real-world studies, particularly given that the samples were predominantly lower socioeconomic position smokers. Strategies common to both groups, including a Lung Health Check approach, could represent a minimum standard.Clinical trial registered with www.clinicaltrials.gov (NCT02558101) and registered prospectively with the International Standard Registered Clinical/Social Study (N21774741).

'Very brief advice' (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user's perspective.

BACKGROUND: Very Brief Advice on smoking (VBA) is an evidence-based intervention designed to increase quit attempts among patients who smoke. VBA has been widely disseminated in general practice settings in the United Kingdom, however its transferability to Southern European settings is not well established. This study sought to document the perspectives of Greek general practice patients in terms of the acceptability and satisfaction with receiving VBA from their general practitioner (GP) and its influence on patients' motivation to make a quit attempt. We also examine patient identified barriers and facilitators to acting on VBA. METHODS: Semi-structured interviews were conducted with 50 patients who reported current tobacco use recruited from five general practices in Crete, Greece. All patients received VBA from their GP and interviews were conducted immediately after the GP appointment. Thematic analysis was used to analyze data. RESULTS: The majority of patients were satisfied with the VBA intervention. Approximately one quarter of patients reported they were motivated to make an attempt to quit smoking after receiving VBA from their GP. Patients identified a clear preference for VBA to be delivered in a supportive manner, which communicated genuine concern versus fear-based approaches. Patients with an existing smoking-related illness were more likely to report plans to act on their GP's VBA. Patients not ready to quit smoking indicated they would be likely to seek the support of their GP for future quit attempts as a result of VBA. Many patients reported low self-efficacy with quitting and apprehension about available quit smoking supports. CONCLUSIONS: VBA was positively received by the majority of smokers interviewed. Participating patients confirmed the motivational role of advice when delivered in a supportive and caring manner. Personal health status, beliefs about quit smoking supports, and low self-efficacy appear to influence patient's motivation to make an aided quit attempt.

Smokers' interest in a lung cancer screening programme: a national survey in England.

BACKGROUND: Following the recommendation of lung cancer screening in the US, screening committees in several European countries are reviewing the evidence for implementing national programmes. However, inadequate participation from high-risk groups poses a potential barrier to its effectiveness. The present study examined interest in a national lung cancer screening programme and modifiable attitudinal factors that may affect participation by smokers. METHODS: A population-based survey of English adults (n = 1464; aged 50-70 years) investigated screening intentions in different invitation scenarios, beliefs about lung cancer, early detection and treatment, worry about lung cancer risk, and stigma. Data on smoking status and perceived chances of quitting were also collected, but eligibility for lung screening in the event of a national programme was unknown. RESULTS: Intentions to be screened were high in all three invitation scenarios for both current (≥ 89%) and former (≥ 94%) smokers. However, smokers were less likely to agree that early-stage survival is good (43% vs. 53%; OR: 0.64, 0.46-0.88) or be willing to have surgery for an early stage, screen-detected cancer (84% vs. 94%; OR: 0.38, 0.21-0.68), compared with former smokers. Willingness to have surgery was positively associated with screening intentions; with absolute differences of 25% and 29%. Worry about lung cancer risk was also most common among smokers (48%), and one fifth of respondents thought screening smokers was a waste of NHS money. CONCLUSIONS: A national lung cancer screening programme would be well-received in principle. To improve smokers' participation, care should be taken to communicate the survival benefits of early-stage diagnosis, address concerns about surgery, and minimise anxiety and stigma related to lung cancer risk.

National Survey of Smoking and Smoking Cessation Education Within UK Midwifery School Curricula.

INTRODUCTION: Smoking in pregnancy in the United Kingdom remains prevalent (11%). To encourage and support pregnant smokers to quit, midwives must be adequately trained to do so. Substantial curricular gaps have been identified in the smoking cessation training of medical, nursing, and optometry schools. This study aimed to identify the extent of smoking cessation training and assessment in UK midwifery schools. METHODS: All UK undergraduate midwifery schools (n = 53) were invited to complete a web-based survey of their curricular coverage and assessment related to smoking cessation, and perceived barriers to delivering smoking cessation training. RESULTS: Twenty-nine (55%) midwifery schools responded. Most teaching was completed in the initial year of study. All reported teaching the harmful effects of tobacco use. The majority of respondents (83%) reported training students in brief intervention delivery and ways to assist quit attempts. Only 24% of schools in this study included relapse prevention in their curriculum. The most frequently reported barriers to teaching smoking cessation were "lack of knowledge amongst staff" (17%), "no space in a crowded curriculum" (17%), and "administrative problems" (13%). CONCLUSIONS: Midwifery schools are teaching the harmful effects of smoking and providing training on brief interventions. However, in some schools student midwives are not being sufficiently trained on relapse prevention or assessed in the practical skills necessary for delivering evidence-based interventions. IMPLICATIONS: Midwifery schools should revise the content and delivery of smoking cessation training to ensure midwives are equipped with the necessary knowledge and skills to contribute to the challenge of smoking cessation in pregnancy.

'Opt-out' referrals after identifying pregnant smokers using exhaled air carbon monoxide: impact on engagement with smoking cessation support.

BACKGROUND: In the UK, free smoking cessation support is available to pregnant women; only a minority accesses this. 'Opt-out' referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object. METHODS: To assess the impact of 'opt-out' referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a 'before-after' service development evaluation. In the 6-month 'before' period, there was a routine 'opt-in' referral system for self-reported smokers at antenatal 'booking' appointments. In the 6-month 'after' period, additional 'opt-out' referrals were introduced at the 12-week ultrasound appointments; women with CO≥4 ppm were referred to, and outcome data were collected from, local SSS. RESULTS: Approximately 2300 women attended antenatal care in each period. Before the implementation, 536 (23.4%) women reported smoking at 'booking' and 290 (12.7%) were referred to SSS. After the implementation, 524 (22.9%) women reported smoking at 'booking', an additional 156 smokers (6.8%) were identified via the 'opt-out' referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after 'opt-out' referrals were implemented (121 (5.3%, 95% CI 4.4% to 6.3%) compared to 57 (2.5%, 95% CI 1.9% to 3.2%) before implementation) and reported being abstinent 4 weeks later (93 (4.1%, 95% CI 3.3% to 4.9%) compared to 46 (2.0%, 1.5% to 2.7%) before implementation). CONCLUSIONS: In a hospital with an 'opt-in' referral system, adding CO screening with 'opt-out' referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation.

Attitudes towards lung cancer screening in socioeconomically deprived and heavy smoking communities: informing screening communication.

BACKGROUND: While discussion continues over the future implementation of lung cancer screening, low participation from higher risk groups could limit the effectiveness of any national screening programme. OBJECTIVES: To compare smokers' beliefs about lung cancer screening with those of former and never smokers within a low socioeconomic status (SES) sample, to explore the views of lower SES smokers and ex-smokers in-depth, and to provide insights into effective engagement strategies. DESIGN, SETTING AND PARTICIPANTS: Using proactive, community-based recruitment methods, we surveyed 175 individuals from socioeconomically deprived communities with high smoking prevalence and subsequently interviewed 21 smokers and ex-smokers. Participants were approached in community settings or responded to a mail-out from their housing association. RESULTS: Interviewees were supportive of screening in principle, but many were doubtful about its ability to deliver long-term survival benefit for their generation of "heavy smokers." Lung cancer was perceived as an uncontrollable disease, and the survey data showed that fatalism, worry and perceived risk of lung cancer were particularly high among smokers compared with non-smokers. Perceived blame and stigma around lung cancer as a self-inflicted smokers' disease were implicated by interviewees as important social deterrents of screening participation. The belief that lungs are not a treatable organ appeared to be a common lay explanation for poor survival and undermined the potential value of screening. CONCLUSIONS: Attitudes towards screening among this high-risk group are complex. Invitation strategies need to be carefully devised to achieve equitable participation in screening.

The Lung Screen Uptake Trial (LSUT): protocol for a randomised controlled demonstration lung cancer screening pilot testing a targeted invitation strategy for high risk and 'hard-to-reach' patients.

BACKGROUND: Participation in low-dose CT (LDCT) lung cancer screening offered in the trial context has been poor, especially among smokers from socioeconomically deprived backgrounds; a group for whom the risk-benefit ratio is improved due to their high risk of lung cancer. Attracting high risk participants is essential to the success and equity of any future screening programme. This study will investigate whether the observed low and biased uptake of screening can be improved using a targeted invitation strategy. METHODS/DESIGN: A randomised controlled trial design will be used to test whether targeted invitation materials are effective at improving engagement with an offer of lung cancer screening for high risk candidates. Two thousand patients aged 60-75 and recorded as a smoker within the last five years by their GP, will be identified from primary care records and individually randomised to receive either intervention invitation materials (which take a targeted, stepped and low burden approach to information provision prior to the appointment) or control invitation materials. The primary outcome is uptake of a nurse-led 'lung health check' hospital appointment, during which patients will be offered a spirometry test, an exhaled carbon monoxide (CO) reading, and an LDCT if eligible. Initial data on demographics (i.e. age, sex, ethnicity, deprivation score) and smoking status will be collected in primary care and analysed to explore differences between attenders and non-attenders with respect to invitation group. Those who attend the lung health check will have further data on smoking collected during their appointment (including pack-year history, nicotine dependence and confidence to quit). Secondary outcomes will include willingness to be screened, uptake of LDCT and measures of informed decision-making to ensure the latter is not compromised by either invitation strategy. DISCUSSION: If effective at improving informed uptake of screening and reducing bias in participation, this invitation strategy could be adopted by local screening pilots or a national programme. TRIAL REGISTRATION: This study was registered with the ISRCTN (International Standard Registered Clinical/soCial sTudy Number: ISRCTN21774741) on the 23rd September 2015 and the NIH ClinicalTrials.gov database (NCT0255810) on the 22nd September 2015.

Structured Smoking Cessation Training for Medical Students: A Prospective Study.

INTRODUCTION: Physician adherence to guideline recommendations regarding the provision of counseling and support for smokers willing to quit is low. A lack of training during undergraduate medical education has been identified as a potential cause. This prospective intervention study evaluated a novel teaching module for medical students. METHODS: As part of a 6-week cardiovascular course, 125 fourth-year undergraduate medical students received a multimodal and interactive teaching module on smoking cessation, including online learning material, lectures, seminars, and practical skills training. Short- and medium-term effects on knowledge, skills, attitudes, and self-reported practice were measured using written examinations and an objective structured clinical examination at the end of the module and 6 months later. Results were compared to data obtained from a historical control cohort (n = 70) unexposed to the intervention. RESULTS: At the 6-month follow-up, scores in the knowledge test were significantly higher in the intervention than the control group (61.1% vs. 51.7%; p < .001). A similar pattern was observed in the objective structured clinical examination (71.5% vs. 60.5%; p < .001). More students in the intervention than control group agreed that smoking was a chronic disease (83.1% vs. 68.1%; p = .045). The control group was more likely to report recording smoking status (p = .018), but no group difference was detected regarding the report of advising to quit (p = .154). CONCLUSIONS: A novel teaching module for undergraduate medical students produced a sustained learning outcome in terms of knowledge, skills, and attitudes but not self-reported practice. IMPLICATIONS: Studies across the world have identified considerable knowledge gaps and deficits in practical training with regard to smoking cessation counseling in undergraduate medical students. This paper describes a teaching intervention informed by current recommendations for the design of educational activities aimed at enabling medical students to deliver adequate behavior change counseling. The teaching module was tailored to the needs of a specific healthcare system. Given its effectiveness as demonstrated in this prospective study, a rollout of this intervention in medical schools might have the potential to substantially improve medical students' knowledge, skills, and attitudes in relation to smoking cessation counseling.

Tobacco Dependence Treatment Training Programs: An International Survey.

INTRODUCTION: In line with Article 14 guidelines for the WHO Framework Convention on Tobacco Control, we aimed to assess the progress in training individuals to deliver tobacco cessation treatment. METHODS: Cross-sectional web-based survey in May-September 2013 among 122 experts in tobacco control and training from 84 countries (73% response rate among 115 countries surveyed). We measured training program prevalence, participants, and challenges faced. RESULTS: Overall, 21% (n = 18/84) of countries, mostly low and middle-income countries (LMICs; P = .002), reported no training program. Among 66 countries reporting at least one training program, most (84%) trained healthcare professionals but 54% also trained other individuals including community health workers, teachers, and religious leaders. Most programs (54%) cited funding challenges, although stability of funding varied by income level. Government funding was more commonly reported in higher income countries (high 56%, upper middle 50%, lower middle 27%, low 25%; P = .03) while programs in LMICs relied more on nongovernmental organizations (high 11%, upper middle 37%, lower middle 27%, low 38%; P = .02). CONCLUSIONS: One in five countries reported having no tobacco treatment training program representing little progress in terms of training individuals to deliver tobacco treatment in LMICs. Without more trained tobacco treatment providers, one of the tenets of Article 14 is not yet being met and health inequalities are likely to widen. More effort and resources are needed to ensure that healthcare worker educational programs include training to assess tobacco use and deliver brief advice and that training is available for individuals outside the healthcare system in areas with limited healthcare access.

Smoking cessation education and training in U.K. medical schools: a national survey.

INTRODUCTION: Smoking cessation is one of the most cost-effective of all health interventions. Physicians are in a strong position to encourage smokers to make a quit attempt and to help them achieve long-term abstinence. Formal teaching on tobacco-related disease, the evidence base of smoking cessation, and practical skills training regarding cessation advice and counseling are therefore important parts of undergraduate medical education. A survey of U.K. medical schools conducted 11 years ago revealed substantial deficits in the curricular coverage of these topics. This study aimed at establishing whether the situation has improved since then. METHODS: In 2013, all U.K. medical schools were invited to participate in an online survey of their curricular coverage of tobacco addiction and smoking cessation. RESULTS: Of the 33 medical schools, 22 (67%) schools responded. Health effects of smoking were addressed in more than 90% of curricula, and factual knowledge on nicotine addiction and withdrawal symptoms was covered in 50% of curricula. Only 1 in 3 medical schools offered practical skills training in artificial (i.e., role play) or clinical settings, and 50% of schools did not address smoking in summative assessments. CONCLUSIONS: Practical skills training regarding cessation counseling is insufficient at most U.K. medical schools and may have become worse during the last 11 years. Increased curricular coverage-including summative assessments-of these topics would ensure that future physicians are adequately equipped to encourage and support effective evidence-based quit attempts in their patients.

Evaluating an online training module on protecting children from secondhand smoke exposure: impact on knowledge, confidence and self-reported practice of health and social care professionals.

BACKGROUND: Healthcare professionals report that a lack of training is the primary barrier to raising the issue of secondhand smoke (SHS). An open access online training module was therefore developed for those working with smoking families to deliver effective very brief advice on SHS. The current study aimed to evaluate the following: (1) does knowledge increase as a result of participating in the online training module, and (2) does the module impact on participant confidence and self-reported practice relating to SHS. METHODS: Those accessing the module were invited to participate in an evaluation to assess participants' knowledge about, and confidence in, delivering very brief advice on SHS. Change in knowledge was assessed via ten multiple choice questions and confidence was assessed by Likert scale responses to three statements. Data were collected across three time points: pre-training, post-training and after 3 months. Data were also collected at 3 months post module completion on self-reported changes in practice and key learning points. RESULTS: Data at all three time points were available for 178 participants (~1 % of those who visited the module homepage over a 2 year period). Knowledge and confidence to deliver effective very brief advice for SHS significantly increased between the pre- and post-training assessments and was maintained at 3 months. Eighty-four percent self-reported that they perceived taking part in the training had led to positive changes in their clinical practice. CONCLUSIONS: There is potential for this module to be embedded within training programmes across health and social care professions, which may help to increase the knowledge and confidence of health and social care professionals to deliver very brief advice for SHS to smoking families. Future research needs to explore whether the smoking families who receive very brief advice for SHS are motivated to make changes to their home smoking behaviours and whether roll-out of this intervention would be cost-effective.

Changes in success rates of smoking cessation treatment associated with take up of a national evidencebased training programme.

OBJECTIVE: The English 'stop smoking services' provide behavioural support to some 700,000 smokers annually. Success rates of the services varied considerably before 2010 and had been in slight decline so, to improve performance, a national programme of evidence-based practitioner training was developed to improve knowledge and skills-based competences. This study evaluated whether uptake of the training was associated with improvements in success rates of services. METHODS: Mean 4-week biochemically verified abstinence rates were compared for 146 (of 151) stop smoking services between 2008-10 (before roll-out of training) and 2011-13 (after roll-out), and the change in success rates for each service was regressed on to the number of practitioners per service trained in a) knowledge (online) and b) skills (face-to-face). RESULTS: Success rate across all services improved between the two periods (34.1% to 36.5%, p=0.01 1-tailed; 95% CI for difference 0.44-4.48). The magnitude of improvement for each service was associated with the number of practitioners who completed the knowledge and skills training (beta=0.22, p=0.005 1-tailed), and marginally with the number who completed the knowledge training (beta=0.14, p=0.047 1-tailed). CONCLUSION: English stop smoking services that have greater uptake of a national evidence-based training programme showed greater improvements in success rates.

Developing anti-tobacco messages for Australian Aboriginal and Torres Strait Islander peoples: evidence from a national cross-sectional survey.

BACKGROUND: Smoking rates in Australian Aboriginal and Torres Strait Islander peoples remain high, with limited impact of government measures for many subgroups. The aim of this cross-sectional study was to investigate differences in organisational practice for developing anti-tobacco messages for these target populations. METHODS: Telephone interviews were conducted with 47 organisation representatives using a structured questionnaire based on health communication and health promotion frameworks. Responses were coded into phases of message development, message types (educational, threat, positive or advocacy), target groups, message recommendations, and evaluations undertaken. Cultural sensitivity for message development was divided into surface structure (use of images, language, demographics) and deep structure (use of socio-cultural values). A categorical principal component analysis explored the key dimensions of the findings and their component relationships. RESULTS: Among organisations interviewed, a community-orientated, bottom-up approach for developing anti-tobacco messages was reported by 47% (n=24); 55% based message development on a theoretical framework; 87% used a positive benefit appeal; 38% used threat messages. More Aboriginal Medical Services (AMSs) targeted youth (p<0.005) and advised smokers to quit (p<0.05) than other types of organisations. AMSs were significantly more likely to report using deep structure in tailoring messages compared with non-government (p<0.05) and government organisations (p<0.05). Organisations that were oriented to the general population were more likely to evaluate their programs (p<0.05). A two-dimensional non-linear principal component analysis extracted components interpreted as "cultural understanding" (bottom-up, community-based approaches, deep structures) and "rigour" (theoretical frameworks, and planned/completed evaluations), and accounted for 53% of the variability in the data. CONCLUSION: Message features, associated with successful campaigns in other populations, are starting to be used for Aboriginal and Torres Strait Islander peoples. A model is proposed to facilitate the development of targeted anti-tobacco messages for Aboriginal and Torres Strait Islander peoples. Organisations could consider incorporating both components of cultural understanding-rigour to enable the growth of evidence-based practice.

Knowledge and views about maternal tobacco smoking and barriers for cessation in Aboriginal and Torres Strait Islanders: A systematic review and meta-ethnography.

INTRODUCTION: Maternal smoking rates in Australian Aboriginal women are triple that of the general population, with little evidence for successful interventions. We reviewed the literature to understand smoking and cessation in Aboriginal and Torres Strait Islander women and provide recommendations for targeted interventions. METHODS: Six databases were searched using terms related to smoking, pregnancy, and Aboriginal Australians. Two reviewers independently assessed papers for inclusion and quality. Meta-ethnography synthesized first- and second-order constructs from included studies and constructed a line of argument. RESULTS: Seven relevant studies were analyzed. The synthesis illustrates 11 third-order constructs operating on the levels of self, family, and social networks, the wider Aboriginal community, and broader external influences. Highlighted are social norms and stressors within the Aboriginal community perpetuating tobacco use; insufficient knowledge of smoking harms; inadequate saliency of antismoking messages; and lack of awareness and use of pharmacotherapy. Indigenous Health Workers have a challenging role, not yet fulfilling its potential. Pregnancy is an opportunity to encourage positive change where a sense of a "protector role" is expressed. CONCLUSIONS: This review gives strength to evidence from individual studies across diverse Indigenous cultures. Pregnant Aboriginal and Torres Strait Islander smokers require comprehensive approaches, which consider the environmental context, increase knowledge of smoking harms and cessation methods, and provide culturally targeted support. Long term, broad strategies should de-normalize smoking in Aboriginal and Torres Strait Islander communities. Further research needs to examine causes of resistance to antitobacco messages, clarify contributing roles of stress and depression, and attitudes to pharmacotherapy.

Factors associated with differences in quit rates between "specialist" and "community" stop-smoking practitioners in the english stop-smoking services.

INTRODUCTION: Behavioral support improves smokers' chances of quitting, but quit rates are typically lower for smokers supported by "community practitioners" for whom smoking cessation is a small part of their job than for those supported by "specialist practitioners" for whom it is the main role. This article examined the factors that might contribute to this. METHOD: A total of 573 specialist practitioners and 466 community practitioners completed a 42-item online survey that covered demographic and employment information, current practices, levels of training, and 4-week CO-verified quit rates. Responses were compared for community and specialist practitioners. Mediation analysis was undertaken to assess how far "structural" and "modifiable" variables account for the difference in quit rates. RESULTS: Specialist practitioners reported higher 4-week CO-verified quit rates than community practitioners (63.6% versus 50.4%, p < .001). Practitioners also differed significantly in employment variables, evidence-based practices, and levels of training. Six "modifiable" variables (proportion of clients using an "abrupt" quit model, duration of first session, always advising on medications, number of days training received, number of sessions observed when starting work, and number of sessions having been observed in practice and received feedback) mediated the association between practitioners' role and quit rates over and above the "structural" variables, explaining 14.3%-35.7% of the variance in the total effect. CONCLUSIONS: "Specialist" practitioners in the English stop-smoking services report higher success rates than "community" practitioners and this is at least in part attributable to more extensive training and supervision and greater adherence to evidence-based practice including advising on medication usage and promoting abrupt rather than gradual quitting.

Should anti-tobacco media messages be culturally targeted for Indigenous populations? A systematic review and narrative synthesis.

OBJECTIVE: To summarise published empirical research on culturally targeted anti-tobacco media messages for Indigenous or First Nations people and examine the evidence for the effectiveness of targeted and non-targeted campaigns. METHODS: Studies were sought describing mass media and new media interventions for tobacco control or smoking cessation in Indigenous or First Nations populations. Studies of any design were included reporting outcomes of media-based interventions including: cognitions, awareness, recall, intention to quit and quit rates. Then, 2 reviewers independently applied inclusion criteria, which were met by 21 (5.8%) of the studies found. One author extracted data with crosschecking by a second. Both independently assessed papers using Scottish Intercollegiate Guidelines Network (SIGN; quantitative studies) and Daly et al (qualitative studies). RESULTS: A total of 21 studies were found (4 level 1 randomised controlled trials (RCTs), 11 level 2 studies and 6 qualitative studies) and combined with narrative synthesis. Eight evaluated anti-tobacco TV or radio campaigns; two assessed US websites; three New Zealand studies examined mobile phone interventions; five evaluated print media; three evaluated a CD-ROM, a video and an edutainment intervention. CONCLUSIONS: Although Indigenous people had good recall of generic anti-tobacco messages, culturally targeted messages were preferred. New Zealand Maori may be less responsive to holistic targeted campaigns, despite their additional benefits, compared to generic fear campaigns. Culturally targeted internet or mobile phone messages appear to be as effective in American Indians and Maori as generic messages in the general population. There is little research comparing the effect of culturally targeted versus generic messages with similar message content in Indigenous people.

How to advise and refer inpatients who smoke.

Patients who smoke are more likely to experience postoperative complications than non-smokers and up to one-third of all hospital patients are estimated to be smokers. Inpatients are receptive to an offer of stop-smoking support but are not always referred to stop-smoking services. A pilot of a acute care referral system trained staff to deliver very brief advice on smoking via a short online training module, and provided a streamlined electronic referral system to local NHS stop-smoking services. The three-month pilot resulted in a 600% increase in referrals. Nursing staff felt that the system was simple and effective, and that patients had benefited.

A randomised controlled trial testing acceptance of practitioner-referral versus self-referral to stop smoking services within the Lung Screen Uptake Trial.

BACKGROUND AND AIMS: Optimising smoking cessation (SC) referral strategies within lung cancer screening (LCS) could significantly reduce lung cancer mortality. This study aimed to measure acceptance of referral to SC support by either practitioner-referral or self-referral among participants attending a hospital-based lung health check appointment for LCS as part of the Lung Screen Uptake Trial. DESIGN: Single-blinded two-arm randomised controlled trial. SETTING: England. PARTICIPANTS: Six hundred forty-two individuals ages 60 to 75 years, who self-reported currently smoking or had a carbon monoxide reading over 10 ppm during the lung health check appointment. INTERVENTION AND COMPARATOR: Participants were randomised (1:1) to receive either a contact information card for self-referral to a local stop smoking service (SSS) (self-referral, n = 360) or a SSS referral made on their behalf by the nurse or trial practitioner (practitioner-referral, n = 329). MEASUREMENTS: The primary outcome was acceptance of the practitioner-referral (defined as participants giving permission for their details to be shared with the local SSS) compared with acceptance of the self-referral (defined as participants taking the physical SSS contact information card to refer themselves to the local SSS). FINDINGS: Half (49.8%) accepted the practitioner-made referral to a local SSS, whereas most (88.5%) accepted the self-referral. The odds of accepting the practitioner-referral were statistically significantly lower (adjusted odds ratio = 0.10; 95% confidence interval = 0.06-0.17) than the self- referral. In analyses stratified by group, greater quit confidence, quit attempts and Black ethnicity were associated with increased acceptance within the practitioner-referral group. There were no statistically significant interactions between acceptance by referral group and any of the participants' demographic or smoking characteristics. CONCLUSIONS: Among participants in hospital-based lung cancer screening in England who self-reported smoking or met a carbon monoxide cut-off, both practitioner-referral and self-referral smoking cessation strategies were highly accepted. Although self-referral was more frequently accepted, prior evidence suggests practitioner-referrals increase quit attempts, suggesting practitioner-referrals should be the first-line strategy within lung cancer screening, with self-referral offered as an alternative.