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The Emergency Department Action in Smoking Cessation (EDASC) Trial: Impact on Delivery of Smoking Cessation Counseling
Katz, David A.
Vander, Mark W.
Holman, John
Nugent, Andrew
Baker, Laurence
Johnson, Skyler
Hillis, Stephen L.
Titler, Marita
Academic Emergency Medicine
The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange), and 2) assess ED nurses' and physicians' perceptions of smoking cessation counseling.
The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians, and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses' and physicians' self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable linear regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates.
Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted OR = 2.0, 95% CI = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5), and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians. ED nurses' self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in "pros" and "cons" attitudes toward smoking cessation in either ED nurses or physicians.
Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.
Related Articles
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD)
Ontario Health Technology Assessment Series
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx.
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.
The objective of this evidence-based analysis was to determine the effectiveness and cost-effectiveness of smoking cessation interventions in the management of chronic obstructive pulmonary disease (COPD).
Clinical Need: Condition and Target Population
Tobacco smoking is the main risk factor for COPD. It is estimated that 50% of older smokers develop COPD and more than 80% of COPD-associated morbidity is attributed to tobacco smoking. According to the Canadian Community Health Survey, 38.5% of Ontarians who smoke have COPD. In patients with a significant history of smoking, COPD is usually present with symptoms of progressive dyspnea (shortness of breath), cough, and sputum production. Patients with COPD who smoke have a particularly high level of nicotine dependence, and about 30.4% to 43% of patients with moderate to severe COPD continue to smoke. Despite the severe symptoms that COPD patients suffer, the majority of patients with COPD are unable to quit smoking on their own; each year only about 1% of smokers succeed in quitting on their own initiative.
Smoking cessation is the process of discontinuing the practice of inhaling a smoked substance. Smoking cessation can help to slow or halt the progression of COPD. Smoking cessation programs mainly target tobacco smoking, but may also encompass other substances that can be difficult to stop smoking due to the development of strong physical addictions or psychological dependencies resulting from their habitual use.
Smoking cessation strategies include both pharmacological and nonpharmacological (behavioural or psychosocial) approaches. The basic components of smoking cessation interventions include simple advice, written self-help materials, individual and group behavioural support, telephone quit lines, nicotine replacement therapy (NRT), and antidepressants. As nicotine addiction is a chronic, relapsing condition that usually requires several attempts to overcome, cessation support is often tailored to individual needs, while recognizing that in general, the more intensive the support, the greater the chance of success. Success at quitting smoking decreases in relation to:
a lack of motivation to quit,
a history of smoking more than a pack of cigarettes a day for more than 10 years,
a lack of social support, such as from family and friends, and
the presence of mental health disorders (such as depression).
Research Question
What are the effectiveness and cost-effectiveness of smoking cessation interventions compared with usual care for patients with COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on June 24, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations (1950 to June Week 3 2010), EMBASE (1980 to 2010 Week 24), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, and the Centre for Reviews and Dissemination for studies published between 1950 and June 2010. A single reviewer reviewed the abstracts and obtained full-text articles for those studies meeting the eligibility criteria. Reference lists were also examined for any additional relevant studies not identified through the search. Data were extracted using a standardized data abstraction form.
Inclusion Criteria
English-language, full reports from 1950 to week 3 of June, 2010;
either randomized controlled trials (RCTs), systematic reviews and meta-analyses, or non-RCTs with controls;
a proven diagnosis of COPD;
adult patients (≥ 18 years);
a smoking cessation intervention that comprised at least one of the treatment arms;
≥ 6 months' abstinence as an outcome; and
patients followed for ≥ 6 months.
Exclusion Criteria
case reports
case series
Outcomes of Interest
≥ 6 months' abstinence
Quality of Evidence
The quality of each included study was assessed taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Nine RCTs were identified from the literature search. The sample sizes ranged from 74 to 5,887 participants. A total of 8,291 participants were included in the nine studies. The mean age of the patients in the studies ranged from 54 to 64 years. The majority of studies used the Global Initiative for Chronic Obstructive Lung Disease (GOLD) COPD staging criteria to stage the disease in study subjects. Studies included patients with mild COPD (2 studies), mild-moderate COPD (3 studies), moderate–severe COPD (1 study) and severe–very severe COPD (1 study). One study included persons at risk of COPD in addition to those with mild, moderate, or severe COPD, and 1 study did not define the stages of COPD. The individual quality of the studies was high. Smoking cessation interventions varied across studies and included counselling or pharmacotherapy or a combination of both. Two studies were delivered in a hospital setting, whereas the remaining 7 studies were delivered in an outpatient setting. All studies reported a usual care group or a placebo-controlled group (for the drug-only trials). The follow-up periods ranged from 6 months to 5 years. Due to excessive clinical heterogeneity in the interventions, studies were first grouped into categories of similar interventions; statistical pooling was subsequently performed, where appropriate. When possible, pooled estimates using relative risks for abstinence rates with 95% confidence intervals were calculated. The remaining studies were reported separately.
Abstinence Rates
Table ES1 provides a summary of the pooled estimates for abstinence, at longest follow-up, from the trials included in this review. It also shows the respective GRADE qualities of evidence.
Summary of Results*
Abbreviations: CI, confidence interval; NRT, nicotine replacement therapy.
Statistically significant (P < 0.05).
One trial used in this comparison had 2 treatment arms each examining a different antidepressant.
Based on a moderate quality of evidence, compared with usual care, abstinence rates are significantly higher in COPD patients receiving intensive counselling or a combination of intensive counselling and NRT.
Based on limited and moderate quality of evidence, abstinence rates are significantly higher in COPD patients receiving NRT compared with placebo.
Based on a moderate quality of evidence, abstinence rates are significantly higher in COPD patients receiving the antidepressant bupropion compared to placebo.
Related Articles
Self-reported tobacco smoking practices among medical students and their perceptions towards training about tobacco smoking in medical curricula: A cross-sectional, questionnaire survey in Malaysia, India, Pakistan, Nepal, and Bangladesh
Sreeramareddy, Chandrashekhar T
Suri, Sushil
Menezes, Ritesh G
Kumar, HN Harsha
Rahman, Mahbubur
Islam, Md R
Pereira, Xavier V
Shah, Mohsin
Sathian, Brijesh
Shetty, Ullasa
Vaswani, Vina R
Substance Abuse Treatment, Prevention, and Policy
Tobacco smoking issues in developing countries are usually taught non-systematically as and when the topic arose. The World Health Organisation and Global Health Professional Student Survey (GHPSS) have suggested introducing a separate integrated tobacco module into medical school curricula. Our aim was to assess medical students' tobacco smoking habits, their practices towards patients' smoking habits and attitude towards teaching about smoking in medical schools.
A cross-sectional questionnaire survey was carried out among final year undergraduate medical students in Malaysia, India, Nepal, Pakistan, and Bangladesh. An anonymous, self-administered questionnaire included items on demographic information, students' current practices about patients' tobacco smoking habits, their perception towards tobacco education in medical schools on a five point Likert scale. Questions about tobacco smoking habits were adapted from GHPSS questionnaire. An 'ever smoker' was defined as one who had smoked during lifetime, even if had tried a few puffs once or twice. 'Current smoker' was defined as those who had smoked tobacco product on one or more days in the preceding month of the survey. Descriptive statistics were calculated.
Overall response rate was 81.6% (922/1130). Median age was 22 years while 50.7% were males and 48.2% were females. The overall prevalence of 'ever smokers' and 'current smokers' was 31.7% and 13.1% respectively. A majority (> 80%) of students asked the patients about their smoking habits during clinical postings/clerkships. Only a third of them did counselling, and assessed the patients' willingness to quit. Majority of the students agreed about doctors' role in tobacco control as being role models, competence in smoking cessation methods, counseling, and the need for training about tobacco cessation in medical schools. About 50% agreed that current curriculum teaches about tobacco smoking but not systematically and should be included as a separate module. Majority of the students indicated that topics about health effects, nicotine addiction and its treatment, counselling, prevention of relapse were important or very important in training about tobacco smoking.
Medical educators should consider revising medical curricula to improve training about tobacco smoking cessation in medical schools. Our results should be supported by surveys from other medical schools in developing countries of Asia.
Related Articles
Smoking Cessation Counseling Beliefs and Behaviors of Outpatient Oncology Providers
Weaver, Kathryn E.
Danhauer, Suzanne C.
Tooze, Janet A.
Blackstock, A. William
Spangler, John
Thomas, Leslie
Sutfin, Erin L.
The Oncologist
Many cancer patients continue to smoke after diagnosis, increasing their risk for treatment complications, reduced treatment efficacy, secondary cancers, and reduced survival. Outpatient oncology providers may not be using the "teachable moment" of cancer diagnosis to provide smoking cessation assistance. Additional training and clinic-based interventions may improve adherence to tobacco cessation practice guidelines in the outpatient oncology setting.
Learning Objectives
After completing this course, the reader will be able to: Describe current smoking cessation assessment and counseling behaviors of outpatient oncology providers.Identify key barriers to providing smoking cessation services identified by oncology providers.Describe available resources for enhancing training in smoking cessation counseling.
This article is available for continuing medical education credit at CME.TheOncologist.com
Many cancer patients continue to smoke after diagnosis, increasing their risk for treatment complications, reduced treatment efficacy, secondary cancers, and reduced survival. Outpatient oncology providers may not be using the "teachable moment" of cancer diagnosis to provide smoking cessation assistance.
Providers and Methods.
Physicians and midlevel providers (n = 74) who provide outpatient oncology services completed an online survey regarding smoking cessation counseling behaviors, beliefs, and perceived barriers. Outpatient medical records for 120 breast, lung, head and neck, colon, prostate, and acute leukemia cancer patients were reviewed to assess current smoking cessation assessment and intervention documentation practices.
Providers reported commonly assessing smoking in new patients (82.4% frequently or always), but rates declined at subsequent visits for both current smokers and recent quitters. Rates of advising patients to quit smoking were also high (86.5% frequently or always), but <30% of providers reported frequently or always providing intervention to smoking patients (e.g., nicotine replacement therapy or other medications, self-help materials, and/or referrals). Only 30% of providers reported that they frequently or always followed up with patients to assess progress with quitting. Few providers (18.1%) reported high levels of confidence in their ability to counsel smoking patients. Patients' lack of motivation was identified as the most important barrier to smoking cessation.
Although beliefs about providing cessation services to smoking patients were generally positive, few providers reported commonly providing interventions beyond advice to quit. Additional training and clinic-based interventions may improve adherence to tobacco cessation practice guidelines in the outpatient oncology setting.
Smoking cessation; Clinical oncology; Health care providers; Cancer
Related Articles
Predictors of Adherence to Nicotine Gum and Counseling among African-American Light Smokers
Okuyemi, Kolawole S.
Zheng, Hui
Guo, Hongfei
Ahluwalia, Jasjit S.
Journal of General Internal Medicine
A high proportion of African-American smokers are light smokers, and they experience low smoking cessation rates and disproportionately high tobacco-related morbidity; yet no studies have examined tobacco treatment adherence in this group.
To determine the predictors of adherence to nicotine gum and counseling among African-American light smokers (defined as smoking ≤10 cigarettes/day), and the effects of adherence on smoking cessation.
Data were from a 2 × 2 randomized, placebo-controlled smoking cessation trial of nicotine gum (2 mg versus placebo) and counseling (motivational interviewing versus health education).
Seven hundred fifty-five African-American light smokers at a community-based clinic.
Demographic and health-related information, smoking behaviors, psychosocial variables, adherence to nicotine gum and counseling, and cotinine-verified 7-day abstinence from smoking at week-26 follow-up.
A logistic regression model showed that having a higher body mass index (OR = 1.03, 95% CI = 1.01 to 1.05), more quit attempts in the past year (OR = 1.04, 95% CI = 1.01 to 1.07), higher baseline exhaled carbon monoxide (OR = 1.22, 95% CI = 1.01 to 1.48), and higher perceived stress (OR = 1.12, 95% CI = 1.03 to 1.22) increased the likelihood of adherence to nicotine gum. Being a high school graduate was a predictor of adherence to counseling (OR = 1.58, 95% CI = 1.02 to 2.44). Surprisingly, being adherent to nicotine gum significantly reduced the odds of smoking cessation (OR = 0.50, CI = 0.28 to 0.87). On the other hand, adherence to counseling dramatically increased the likelihood of smoking cessation (OR = 3.32, CI = 1.36 to 8.08).
Individual risk factors may influence adherence to nicotine gum and counseling. Improving psychological interventions and promoting adherence to counseling may increase overall smoking cessation success among African-American light smokers.
smoking cessation; nicotine gum; counseling; African American
Related Articles
Physician Counseling of Pregnant Women About Active and Second-hand Smoking in Argentina
Mejia, Raul
Martinez, Valeria Guil
Gregorich, Steven E.
Pérez-Stable, Eliseo J.
Acta obstetricia et gynecologica Scandinavica
Describe physicians' practices of smoking cessation and secondhand smoke (SHS) exposure counseling during prenatal visits.
Cross-sectional survey
13 public and private hospitals from three cities in Argentina
300 obstetrician/gynecologists
Self-administered survey included knowledge and attitudes about tobacco use during pregnancy, frequency, type and duration of smoking cessation counseling, barriers to counseling, communication skills, level of understanding, and personal smoking history.
Main Outcome Measures
Composite outcomes of 4 items, each representative of counseling on smoking cessation and SHS exposure.
235 (78.3%) questionnaires were completed; 54.5% men, mean age 45, 35% current smokers. Only 22% had received training in smoking cessation counseling and 48.5% reported insufficient knowledge to provide smoking cessation advice. Although 88.9% always or almost always advised women to stop smoking, 75% believed it was acceptable for pregnant women to smoke up to 6 cigarettes per day. The risk of SHS exposure was "always or almost always discussed" by only 34.5% of physicians. Multivariate logistic regression showed that lack of training was associated with less counseling about smoking cessation (OR 0.18; 95%CI 0.04-0.82) and SHS exposure (OR 0.27; 95%CI 0.12-0.59). Current compared to never smokers had lower odds of smoking cessation counseling (OR 0.39; 95%CI 0.05-0.82). Current smokers were less likely than former smokers to counsel about SHS (OR 0.25, 95%CI 0.11-0.62).
Smoking cessation counseling during pregnancy in Argentina occurs infrequently, interventions are needed to assist physicians motivate and counsel women to quit smoking and avoid SHS exposure. Physicians taking care of pregnant women also need to quit smoking.
Tobacco use; adolescents; Latin America; ethnicity; pregnancy; smoking; second hand smoke; counselling
Related Articles
Physicians Taking Action Against Smoking: an intervention program to optimize smoking cessation counselling by Montreal general practitioners
Tremblay, Michèle
Gervais, André
Lacroix, Chantal
O'Loughlin, Jennifer
Makni, Hela
Paradis, Gilles
CMAJ: Canadian Medical Association Journal
In 1997 the Direction del la santé publique de Montréal-Centre initiated "Physicians Taking Action Against Smoking," a 5-year intervention program to improve the smoking cessation counselling practices of general practitioners (GPs) in Montreal. Program development was guided by the precede-proceed model. This model advocates identifying factors influencing the outcome, in this case counselling practices. These factors are then used to determine the program objectives, to develop and tailor program activities and to design the evaluation. Program activities during the first 3 years included cessation counselling workshops and conferences for GPs, publication of articles in professional interest journals, publication of clinical guidelines for smoking cessation counselling and dissemination of educational material for both GPs and smokers. The program also supported activities encouraging smokers to ask their GPs to help them stop smoking. Results from 2 cross-sectional surveys, conducted in 1998 and 2000, of random samples of approximately 300 GPs suggest some improvements over time in several counselling practices, including offering counselling to more patients and discussing setting a quit date. More improvements were observed among female than male GPs in both psychosocial factors related to counselling and specific counselling practices. For example, improvements were noted among female GPs in self-perceived ability to provide effective counselling and in the belief that it is important to schedule specific appointments to help patients quit; in addition, the perceived importance of several barriers to counselling decreased among female GPs. A greater proportion of the female respondents to the 2000 survey offered written educational material than was the case in 1998, and a greater proportion of the male GPs devoted more time to counselling in 2000 than in 1998; however, among male GPs the proportion who discussed the pros and cons of smoking with patients in the precontemplation stage declined between 1998 and 2000, as did the proportion who referred patients in the preparation stage to community resources. Our experience suggests that an integrated, theory-based program to improve physicians' counselling practices could be a key component of a comprehensive strategy to reduce tobacco use.
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Population-Based Smoking Cessation Strategies
Ontario Health Technology Assessment Series
Executive Summary
The objective of this report was to provide the Ministry of Health Promotion (MHP) with a summary of existing evidence-based reviews of the clinical and economic outcomes of population-based smoking cessation strategies.
Tobacco use is the leading cause of preventable disease and death in Ontario, linked to approximately 13,000 avoidable premature deaths annually – the vast majority of these are attributable to cancer, cardiovascular disease, and chronic obstructive lung disease. (1) In Ontario, tobacco related health care costs amount to $6.1 billion annually, or about $502 per person (including non-smokers) and account for 1.4% of the provincial domestic product. (2) In 2007, there were approximately 1.7 to 1.9 million smokers in Ontario with two-thirds of these intending to quit in the next six months and one-third wanting to quit within 30 days. (3) In 2007/2008, Ontario invested $15 million in cessation programs, services and training. (4) In June 2009, the Ministry of Health Promotion (MHP) requested that MAS provide a summary of the evidence base surrounding population-based smoking cessation strategies.
Project Scope
The MAS and the MHP agreed that the project would consist of a clinical and economic summary of the evidence surrounding nine population-based strategies for smoking cessation including:
Mass media interventions
Telephone counselling
Post-secondary smoking cessation programs (colleges/universities)
Community-wide stop-smoking contests (i.e. Quit and Win)
Community interventions
Physician advice to quit
Nursing interventions for smoking cessation
Hospital-based interventions for smoking cessation
Pharmacotherapies for smoking cessation, specifically:
Nicotine replacement therapies
Anxiolytic drugs
Opioid antagonists
Nicotine receptor partial agonists
Reviews examining interventions for Cut Down to Quit (CDTQ) or harm reduction were not included in this review. In addition, reviews examining individual-level smoking cessation strategies (i.e. self-help interventions, counselling, etc.), web-based smoking cessation interventions, and smoking cessation strategies for special population groups outside of those identified from reviews included in this analysis were excluded from the scope. Information on cessation programs or strategies in other provinces or an evaluation of current population-based programs in Ontario was also not included in the scope.
Status in Ontario
In 2005, the McGuinty government launched the Smoke-Free Ontario Strategy, focusing on initiatives aimed at young people to encourage them not to smoke, protection from exposure to second-hand smoke, and programs to help smokers quit. There are currently many smoking cessation programs funded across the province and in 2007/2008, Ontario invested $15 million in cessation programs, services and training. Ontario Health Insurance Plan (OHIP) fee codes for physician advice to quit also exist.
Evidence-Based Analysis
Research Question
What are the efficacy and cost-effectiveness of the selected population-based strategies for smoking cessation?
Literature Search
A preliminary scan of Medline was conducted to identify major systematic reviews, meta-analyses, and health technology assessments (HTAs) in the area of smoking cessation. Based on the availability of a number of Cochrane Reviews on the topic of smoking cessation, a more systematic search of the literature was not conducted. For the economic analysis, a literature search was conducted of relevant databases for recently published article reviews, HTAs, and Cochrane Reviews of the nine identified population-based smoking cessation strategies. This analysis is limited as it is a summary of existing reviews and not a systematic review.
Outcomes of Interest
The primary outcome of interest for the clinical summary was abstinence from smoking at 6 months follow up; additional outcomes were examined where available. The primary outcomes of interest for the economic analysis were cost-effectiveness ratios.
Summary of Findings
The evidence suggests that pharmacotherapy, physician advice to quit, nursing interventions, hospital-based interventions, and proactive telephone counselling are effective and cost-effective in the short-term.
There is poor quality data around other population-based smoking cessation strategies including mass media campaigns, community interventions, quit and win contests, access to 'quitlines', and interventions for university and college campuses, making evaluation of their effectiveness and cost-effectiveness difficult.
Based on pooled summary estimates of effect and safety data, the most effective strategies are varenicline, buproprion, and nicotine replacement therapies, followed by physician advice to quit and nursing interventions (in non-hospitalized smokers without cardiovascular disease).
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Hispanic physicians' tobacco intervention practices: a cross-sectional survey study
Soto Mas, Francisco G
Papenfuss, Richard L
Jacobson, Holly E
Ed Hsu, Chiehwen
Urrutia-Rojas, Ximena
Kane, William M
BMC Public Health
U.S. Hispanic physicians constitute a considerable professional collective, and they may be most suited to attend to the health education needs of the growing U.S. Hispanic population. These educational needs include tobacco use prevention and smoking cessation. However, there is a lack of information on Hispanic physicians' tobacco intervention practices, their level of awareness and use of cessation protocols, and the type of programs that would best address their tobacco training needs. The purpose of this study was to assess the tobacco intervention practices and training needs of Hispanic physicians.
Data was collected through a validated survey instrument among a cross-sectional sample of self-reported Hispanic physicians. Data analyses included frequencies, descriptive statistics, and factorial analyses of variance.
The response rate was 55.5%. The majority of respondents (73.3%) were middle-age males. Less than half of respondents routinely performed the most basic intervention: asking patients about smoking status (44.4%) and advising smoking patients to quit (42.2%). Twenty-five percent assisted smoking patients by talking to them about the health risks of smoking, providing education materials or referring them to cessation programs. Only 4.4% routinely arranged follow-up visits or phone calls for smoking patients. The majority of respondents (64.4%) indicated that they prescribe cessation treatments to less than 20% of smoking patients. A few (4.4%) routinely used behavioral change techniques or programs. A minority (15.6%) indicated that they routinely ask their patients about exposure to tobacco smoke, and 6.7% assisted patients exposed to secondhand smoke in understanding the health risks associated with environmental tobacco smoke (ETS). The most frequently encountered barriers preventing respondents from intervening with patients who smoke included: time, lack of training, lack of receptivity by patients, and lack of reimbursement by third party payers. There was no significant main effect of type of physician, nor was there an interaction effect (gender by type of physician), on tobacco-related practices.
The results indicate that Hispanic physicians, similarly to U.S. physicians in general, do not meet the level of intervention recommended by health care agencies. The results presented will assist in the development of tobacco training initiatives for Hispanic physicians.
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Prevalence and correlates of tobacco use amongst junior collegiates in twin cities of western Nepal: A cross-sectional, questionnaire-based survey
Sreeramareddy, Chandrashekhar T
Kishore, PV
Paudel, Jagadish
Menezes, Ritesh G
BMC Public Health
College students are vulnerable to tobacco addiction. Tobacco industries often target college students for marketing. Studies about prevalence of tobacco use and its correlates among college students in Nepal are lacking.
A cross-sectional survey was carried out in two cities of western Nepal during January-March, 2007. A pre-tested, anonymous, self-administered questionnaire (in Nepali) adapted from Global Youth Tobacco Survey (GYTS) and a World Bank study was administered to a representative sample of 1600 students selected from 13 junior colleges by two-stage stratified random sampling.
Overall prevalence of 'ever users' of tobacco products was 13.9%. Prevalence among boys and girls was 20.5% and 2.9% respectively. Prevalence of 'current users' was 10.2% (cigarette smoking: 9.4%, smokeless products: 6.5%, and both forms: 5.7%). Median age at initiation of cigarette smoking and chewable tobacco was 16 and 15 years respectively. Among the current cigarette smokers, 58.7% (88/150) were smoking at least one cigarette per day. Most (67.8%) 'Current users' purchased tobacco products by themselves from stores or got them from friends. Most of them (66.7%) smoked in tea stalls or restaurants followed by other public places (13.2%). The average daily expenditure was 20 Nepalese rupees (~0.3 USD) and most (59%) students reported of having adequate money to buy tobacco products. Majority (82%) of the students were exposed to tobacco advertisements through magazines/newspapers, and advertising hoardings during a period of 30 days prior to survey. The correlates of tobacco use were: age, gender, household asset score and knowledge about health risks, family members, teachers and friends using tobacco products, and purchasing tobacco products for family members.
School/college-based interventions like counseling to promote cessation among current users and tobacco education to prevent initiation are necessary. Enforcement of legislations to decrease availability, accessibility and affordability of tobacco products and policies to change social norms of tobacco use among parents and teachers are necessary to curb the tobacco use among college students.
Related Articles
Prevalence and Correlates of Smoking Cessation Pharmacotherapy in Hospitalized Smokers with Acute Myocardial Infarction
Katz, David A.
Tang, Fengming
Faseru, Babalola
Horwitz, Phillip A.
Jones, Philip
Spertus, John
American Heart Journal
Although current performance measures recommend smoking cessation counseling at the time of acute myocardial infarction (AMI), ACC/AHA guidelines recommend pharmacotherapy as well. The aim of this study was to describe the prevalence and correlates of smoking cessation pharmacotherapy in hospitalized patients with AMI.
In the 24-center TRIUMPH registry, 4340 AMI patients underwent detailed interviews and 1631 reported smoking within 30 days of admission. Prescription of first-line smoking cessation medications at discharge was assessed by medical record review. All patient-related factors associated with smoking cessation treatment, based on literature review, were included in hierarchical modified log Poisson models.
Only 14% (222/1631) of AMI patients who smoked were prescribed smoking cessation medication at discharge. After multivariable adjustment for patient characteristics, there was significant variation across sites (range: 0–28%, median rate ratio 1.41 (95% CI 1.23–2.67)). Independent factors associated with smoking cessation pharmacotherapy included older age (rate ratio 0.81 per 10-year increment, 95% CI 0.71–0.93), high school graduation (rate ratio 1.37, 95% CI 1.13–1.66), heavy cigarette usage (≥ 20/day)(rate ratio 3.08, 95% CI 2.20–4.12), in-hospital revascularization (rate ratio 1.41, 95% CI 1.03–1.94), and instructions on smoking cessation (rate ratio 2.37, 95% CI 1.40–4.01).
Smokers surviving an AMI are infrequently prescribed guideline recommended smoking cessation treatments and there is considerable variation across hospitals. Older, less educated, and lighter smokers are less likely to receive aggressive smoking cessation treatment. Novel strategies to augment current practice are needed.
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The Pap smear screening as an occasion for smoking cessation and physical activity counselling: baseline characteristics of women involved in the SPRINT randomized controlled trial
Chellini, Elisabetta
Gorini, Giuseppe
Carreras, Giulia
Giordano, Livia
Anghinoni, Emanuela
Iossa, Anna
Bellati, Cristina
Grechi, Elisa
Coppo, Alessandro
Talassi, Fiorella
Giovacchini, Maria Rosa
BMC Public Health
Gender-specific smoking cessation strategies have rarely been developed. Evidence of effectiveness of physical activity (PA) promotion and intervention in adjunct to smoking cessation programs is not strong. SPRINT study is a randomized controlled trial (RCT) designed to evaluate a counselling intervention on smoking cessation and PA delivered to women attending the Italian National Health System Cervical Cancer Screening Program. This paper presents study design and baseline characteristics of the study population.
Among women undergoing the Pap examination in three study centres (Florence, Turin, Mantua), participants were randomized to the smoking cessation counselling [S], the smoking cessation + PA counselling [S + PA], or the control [C] groups. The program under evaluation is a standard brief counselling on smoking cessation combined with a brief counselling on increasing PA, and was delivered in 2010. A questionnaire, administered before, after 6 months and 1 year from the intervention, was used to track behavioural changes in tobacco use and PA, and to record cessation rates in participants.
Out of the 5,657 women undergoing the Pap examination, 1,100 participants (55% of smokers) were randomized in 1 of the 3 study groups (363 in the S, 366 in the S + PA and 371 in the C groups). The three arms did not differ on any demographic, PA, or tobacco-use characteristics. Recruited smokers were older, less educated than non-participant women, more motivated to quit (33% vs.9% in the Preparation stage, p < 0.001), smoked more cigarettes per day (12 vs.9, p < 0.001), and were more likely to have already done 1 or more quit attempts (64% vs.50%, p < 0.001). The approach of SPRINT study appeared suitable to enrol less educated women who usually smoke more and have more difficulties to quit.
Trial registration number
Related Articles
Comparative effectiveness of post-discharge interventions for hospitalized smokers: study protocol for a randomized controlled trial
Japuntich, Sandra J
Regan, Susan
Viana, Joseph
Tymoszczuk, Justyna
Reyen, Michele
Levy, Douglas E
Singer, Daniel E
Park, Elyse R
Chang, Yuchiao
Rigotti, Nancy A
A hospital admission offers smokers an opportunity to quit. Smoking cessation counseling provided in the hospital is effective, but only if it continues for more than one month after discharge. Providing smoking cessation medication at discharge may add benefit to counseling. A major barrier to translating this research into clinical practice is sustaining treatment during the transition to outpatient care. An evidence-based, practical, cost-effective model that facilitates the continuation of tobacco treatment after discharge is needed. This paper describes the design of a comparative effectiveness trial testing a hospital-initiated intervention against standard care.
A two-arm randomized controlled trial compares the effectiveness of standard post-discharge care with a multi-component smoking cessation intervention provided for three months after discharge. Current smokers admitted to Massachusetts General Hospital who receive bedside smoking cessation counseling, intend to quit after discharge and are willing to consider smoking cessation medication are eligible. Study participants are recruited following the hospital counseling visit and randomly assigned to receive Standard Care or Extended Care after hospital discharge. Standard Care includes a recommendation for a smoking cessation medication and information about community resources. Extended Care includes up to three months of free FDA-approved smoking cessation medication and five proactive computerized telephone calls that use interactive voice response technology to provide tailored motivational messages, offer additional live telephone counseling calls from a smoking cessation counselor, and facilitate medication refills. Outcomes are assessed at one, three, and six months after hospital discharge. The primary outcomes are self-reported and validated seven-day point prevalence tobacco abstinence at six months. Other outcomes include short-term and sustained smoking cessation, post-discharge utilization of smoking cessation treatment, hospital readmissions and emergency room visits, and program cost per quit.
This study tests a disseminable smoking intervention model for hospitalized smokers. If effective and widely adopted, it could help to reduce population smoking rates and thereby reduce tobacco-related mortality, morbidity, and health care costs.
Trial registration
United States Clinical Trials Registry NCT01177176.
Smoking cessation; Hospitalization; Pharmacotherapy; Counseling; Randomized clinical trial; Interactive voice response
Related Articles
Smoking prevention and cessation programme in Cystic Fibrosis: integrating an environmental health approach
Ortega-García, Juan Antonio
López-Fernández, María Trinidad
Llano, Rayden
Pastor-Vivero, María Dolores
Mondéjar-López, Pedro
Sánchez-Sauco, MF
Sánchez-Solís, M
Journal of Cystic Fibrosis
There have been several studies assessing the epidemiology and effects of tobacco smoke in the cystic fibrosis (CF) population, but few address the efforts of smoking cessation interventions. Our objective is to present one tobacco prevention and cessation programme targeting patients with CF in the Mediterranean region of Murcia (Spain).
All registered patients in the Regional CF unit (n=105) in 2008 were included in a cross-sectional and prospective uncontrolled study of tobacco use and exposure in CF patients using a baseline and one-year follow-up. Target population includes both patients and other family members living at home. The study included an initial telephone questionnaire, measurement of lung function, urinary cotinine levels, and several telephone counselling calls and/or personalized smoking cessation services.
Of the 97 contacted patients, 59.8% (n=58) were exposed to environmental tobacco smoke (ETS), 12.4% (n=12) had smoked at one time, and 14.3% (n=8) of patients over the age of 15 actively smoked. The mean age was 31.13 (range: 19-45). Of the non-smokers (n=89), 56.2% reported ETS and 26.9% live with at least one smoker at home. 49.2% had urinary cotinine levels >10 ng/ml. The correlation found between patients' cotinine levels and their reported tobacco exposure was (0.77, p<0.0001). Active smoking by mothers during pregnancy was associated with significantly lower lung function in young CF patients (-0,385, p= 0.04). At the one-year follow-up, 13 individuals made attempts to stop smoking, 6 of which are now ex-smokers (12.5% of all smokers).
Smoking during pregnancy adversely affects lung function in individuals with CF. Tobacco he targeted tobacco prevention and cessation programmes are an effective and vital component for CF disease management. The trained professionals in prevention and smoking cessation services could provide patients with adequate follow-up, integrating an environmental health approach into CF patients' healthcare
Environmental tobacco smoke; cystic fibrosis; smoking prevention
Related Articles
Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions
Katz, David A
Paez, Monica W
Reisinger, Heather S
Gillette, Meghan T
Weg, Mark W Vander
Titler, Marita G
Nugent, Andrew S
Baker, Laurence J
Holman, John E
Ono, Sarah S
Addiction Science & Clinical Practice
The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians' (EPs) and nurses' (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A's framework (Ask-Advise-Assess-Assist-Arrange) in the ED.
We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts.
The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients' receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A's in the ED.
There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies.
Trial registration
ClinicalTrials.gov registration number NCT00756704
Emergency medical services; Smoking cessation; Attitude of health personnel; Qualitative research; Content analysis
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Assessment of the effectiveness of sustained release Bupropion and intensive physician advice in smoking cessation
Singh, Pranav
Kumar, Raj
Lung India : Official Organ of Indian Chest Society
Tobacco use is the cause of immense burden on our nation in terms of mortality and morbidity, being the single leading cause of preventable illnesses and death. Smoking cessation interventions in our country will be the most cost effective of all interventions considering that the cost incurred on the three main tobacco related illnesses (COPD, CAD, and Cancer) being around Rs 27,761 crore in the year 1999.
Matrials and Methods
A double blind placebo controlled trial was conducted to see the efficacy of Bupropion in smoking cessation. Smokers with current depression were excluded. The subjects (n = 30) were randomly assigned to receive Bupropion SR 300 mg/day or placebo for seven weeks. Target quit date was preferentially 8th day of starting the treatment. Intensive counseling was provided by the physician at the baseline and brief counseling at every visit weekly during the treatment phase and at weeks 12 and 16. Self reported abstinence was confirmed by a carbon monoxide concentration in expired air of less than 10 ppm.
The seven-day point prevalence abstinence rate at the end of week 2 and week 16 in the drug group was 46.67% and 53.33 % respectively and in the placebo group was 13.33% and 20% respectively with the 'P' value of 0.04 and 0.05 respectively. Rates of continuous abstinence at weeks 4, 7 and 16 were 46.67%, 40% and 33.33% in the drug group and 13.33%, 13.33% and 13.33% in the placebo group respectively. The rates were significantly higher in the drug group till week 4 starting from week 2 of the treatment phase. The mean weight gain in drug group was found to be significant less as compared to the placebo at week 16 (P = 0.025) The mean change of depression scores from the baseline was not significantly different between the two groups at any point of time. The withdrawal symptom score increase from the baseline was not significantly higher at any point of time in the drug group but in the placebo group the increase was significantly higher for seven days after target quit date and at weeks 3 and 4 (P < 0.05). The most common adverse events in the drug group were insomnia, which was seen in 6 (40%) patients and dry mouth and/or altered taste in 4 (26.67%) patients, which was significantly higher as compared to placebo.
Predictors of Outcome:
The univariate predictors of a successful outcome were the point prevalence abstinence at week 16 were older age (>40 years), (P = 0.044) and quitter status at week 2 (P = 0.001). Multivariate predictors in order of importance were Quit status at 2nd week (P = 0.002) and Age >40 years (P = 0.031). The combined predictive value of these two variables was found to be 86.3%.
Bupropion helps in smoking cessation. This has been proved by three large multicenter randomized controlled trials. This study has also reflected the same result in the form of significantly high seven-day point prevalence abstinence at week 16 in the Bupropion group as compared to placebo. Bupropion has a beneficial effect on weight gain and withdrawal symptoms and the benign adverse effects of insomnia and dry mouth or altered taste make it a very effective and cheap treatment for nicotine addiction in smokers.
Smoking cessation; Bupropion quit rate; nicotine addiction
Related Articles
Berlin's medical students' smoking habits, knowledge about smoking and attitudes toward smoking cessation counseling
Kusma, Bianca
Quarcoo, David
Vitzthum, Karin
Welte, Tobias
Mache, Stefanie
Meyer-Falcke, Andreas
Groneberg, David A
Raupach, Tobias
Journal of Occupational Medicine and Toxicology (London, England)
Diseases associated with smoking are a foremost cause of premature death in the world, both in developed and developing countries. Eliminating smoking can do more to improve health and prolong life than any other measure in the field of preventive medicine. Today's medical students will play a prominent role in future efforts to prevent and control tobacco use.
A cross-sectional, self-administered, anonymous survey of fifth-year medical students in Berlin, Germany was conducted in November 2007. The study explored the prevalence of smoking among medical students. We assessed their current knowledge regarding tobacco dependence and the effectiveness of smoking cessation methods. Students' perceived competence to counsel smokers and promote smoking cessation treatments was also explored. Analyses were based on responses from 258 students (86.6% response rate).
One quarter of the medical students surveyed were current smokers. The smoking rate was 22.1% among women, 32.4% among men. Students underestimated smoking-related mortality and the negative effect of smoking on longevity. A considerable number of subjects erroneously assumed that nicotine causes coronary artery disease. Students' overall knowledge of the effectiveness of smoking cessation methods was inadequate. Only one third of the students indicated that they felt qualified to counsel patients about tobacco dependence.
This study reveals serious deficiencies in knowledge and counseling skills among medical students in our sample. The curriculum of every medical school should include a tobacco module. Thus, by providing comprehensive training in nicotine dependence interventions to medical students, smokers will have access to the professional expertise they need to quit smoking.
Related Articles
Smoking behavior, attitudes, and cessation counseling among healthcare professionals in Armenia
Movsisyan, Narine K
Varduhi, Petrosyan
Arusyak, Harutyunyan
Diana, Petrosyan
Armen, Muradyan
Frances, Stillman A
BMC Public Health
Smoking cessation counseling by health professionals has been effective in increasing cessation rates. However, little is known about smoking cessation training and practices in transition countries with high smoking prevalence such as Armenia. This study identified smoking-related attitudes and behavior of physicians and nurses in a 500-bed hospital in Yerevan, Armenia, the largest cancer hospital in the country, and explored barriers to their effective participation in smoking cessation interventions.
This study used mixed quantitative and qualitative methods. Trained interviewers conducted a survey with physicians and nurses using a 42-item self-administered questionnaire that assessed their smoking-related attitudes and behavior and smoking cessation counseling training. Four focus group discussions with hospital physicians and nurses explored barriers to effective smoking cessation interventions. The focus group sessions were audio-taped, transcribed, and analyzed.
The survey response rate was 58.5% (93/159) for physicians and 72.2% (122/169) for nurses. Smoking prevalence was almost five times higher in physicians compared to nurses (31.2% vs. 6.6%, p < 0.001). Non-smokers and ex-smokers had more positive attitudes toward the hospital's smoke-free policy compared to smokers (90.1% and 88.2% vs. 73.0%). About 42.6% of nurses and 26.9% of physicians reported having had formal training on smoking cessation methods. While both groups showed high support for routinely assisting patients to quit smoking, nurses more often than physicians considered health professionals as role models for patients.
This study was the first to explore differences in smoking-related attitudes and behavior among hospital physicians and nurses in Yerevan, Armenia. The study found substantial behavioral and attitudinal differences in these two groups. The study revealed a critical need for integrating cessation counseling training into Armenia's medical education. As nurses had more positive attitudes toward cessation counseling compared to physicians, and more often reported having cessation training, they are an untapped resource that could be more actively engaged in smoking cessation interventions in healthcare settings.
Smoking cessation; Smoke-free hospital policy; Survey research; Qualitative research; Healthcare professionals; Physician smoking; Armenia; Transition economies
Related Articles
Efficacy of confrontational counselling for smoking cessation in smokers with previously undiagnosed mild to moderate airflow limitation: study protocol of a randomized controlled trial
Kotz, Daniel
Wesseling, Geertjan
Huibers, Marcus JH
van Schayck, Onno CP
BMC Public Health
The use of spirometry for early detection of chronic obstructive pulmonary disease (COPD) is still an issue of debate, particularly because of a lack of convincing evidence that spirometry has an added positive effect on smoking cessation. We hypothesise that early detection of COPD and confrontation with spirometry for smoking cessation may be effective when applying an approach we have termed "confrontational counselling"; a patient-centred approach which involves specific communication skills and elements of cognitive therapy. An important aspect is to confront the smoker with his/her airflow limitation during the counselling sessions. The primary objective of this study is to test the efficacy of confrontational counselling in comparison to regular health education and promotion for smoking cessation delivered by specialized respiratory nurses in current smokers with previously undiagnosed mild to moderate airflow limitation.
The study design is a randomized controlled trial comparing confrontational counselling delivered by a respiratory nurse combined with nortriptyline for smoking cessation (experimental group), health education and promotion delivered by a respiratory nurse combined with nortriptyline for smoking cessation (control group 1), and "care as usual" delivered by the GP (control group 2). Early detection of smokers with mild to moderate airflow limitation is achieved by means of a telephone interview in combination with spirometry. Due to a comparable baseline risk of airflow limitation and motivation to quit smoking, and because of the standardization of number, duration, and scheduling of counselling sessions between the experimental group and control group 1, the study enables to assess the "net" effect of confrontational counselling. The study has been ethically approved and registered.
Ethical as well as methodological considerations of the study are discussed in this protocol. A significant and relevant effect of confrontational counselling would provide an argument in favour of early detection of current smokers with airflow limitation. Successful treatment of tobacco dependence in respiratory patients requires repeated intensive interventions. The results of this study may also show that respiratory nurses are able to deliver this treatment and that intensive smoking cessation counselling is more feasible.
Trial registration:
Netherlands Trial Register (ISRCTN 64481813).
Related Articles
A before-after implementation trial of smoking cessation guidelines in hospitalized veterans
Katz, David
Vander Weg, Mark
Fu, Steve
Prochazka, Allan
Grant, Kathleen
Buchanan, Lynne
Tinkelman, David
Reisinger, Heather Schacht
Brooks, John
Hillis, Stephen L
Joseph, Anne
Titler, Marita
Implementation Science : IS
Although most hospitalized smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. US Department of Veterans Affairs (VA) hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Few studies have applied the Chronic Care Model (CCM) to improve inpatient smoking cessation.
Specific objectives
The primary objective of this protocol is to determine the effect of a nurse-initiated intervention, which couples low-intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients. Key secondary aims are to determine the impact of the intervention on staff nurses' attitudes toward providing smoking cessation counseling; to identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals; and to determine the short-term cost-effectiveness of implementing the intervention.
Pre-post study design in four VA hospitals
Hospitalized patients, aged 18 or older, who smoke at least one cigarette per day.
The intervention will include: nurse training in delivery of bedside cessation counseling, electronic medical record tools (to streamline nursing assessment and documentation, to facilitate prescription of pharmacotherapy), computerized referral of motivated inpatients for proactive telephone counseling, and use of internal nursing facilitators to provide coaching to staff nurses practicing in non-critical care inpatient units.
The primary endpoint is seven-day point prevalence abstinence at six months following hospital admission and prolonged abstinence after a one-month grace period. To compare abstinence rates during the intervention and baseline periods, we will use random effects logistic regression models, which take the clustered nature of the data within nurses and hospitals into account. We will assess attitudes of staff nurses toward cessation counseling by questionnaire and will identify barriers and facilitators to implementation by using clinician focus groups. To determine the short-term incremental cost per quitter from the perspective of the VA health care system, we will calculate cessation-related costs incurred during the initial hospitalization and six-month follow-up period.
Trial number
Related Articles
Long-term Retention of Smoking Cessation Counseling Skills Learned in the First Year of Medical School
Kosowicz, Lynn Y.
Pfeiffer, Carol A.
Vargas, Maximilian
Journal of General Internal Medicine
Tobacco use is a significant cause of preventable morbidity and mortality in the United States, yet clinicians underutilize smoking cessation counseling. Medical schools are increasingly including training for smoking cessation skills in preclinical curricula. Information about long-term retention of these skills is needed.
To assess retention of smoking cessation counseling skills learned in the first year of medical school.
Retrospective review of data collected for routine student and curriculum assessment.
Two cohorts of medical students at the University of Connecticut School of Medicine (total N = 112) in 1999–2001 and 2002–2004.
Measurements and Main Results
Scores by standardized patients were compared from first and fourth-year assessments, based on checklist items corresponding to the 5 strategies recommended by the U.S. Public Health Service (Ask, Advise, Assess, Assist, Arrange). In study cases, 97% of first-year students "asked" about smoking and retained this skill in fourth year (p = .08). Ninety-four percent of first-year students "assessed" readiness to quit and retained this skill (p = .21). Ninety-six percent of first-year students "advised" smokers to quit and retained this skill (p = .18). Eighty-six percent of first year students "assisted" smokers in quitting and retained this skill (p = 0.10). Eighty-one percent of first year students "arranged" follow-up contact and performance of this strategy improved in the fourth year to 91% (p = .03).
Smoking cessation counseling skills demonstrated by first year medical students were, with brief formal reinforcement in the third year, well retained into the fourth year of medical school. It is appropriate to begin this training early in medical education.
smoking cessation; medical education-communication skills; medical education-undergraduate; medical education-curriculum; clinical skills assessment
Related Articles
Smoking cessation among diabetes patients: results of a pilot randomized controlled trial in Kerala, India
Thankappan, KR
Mini, GK
Daivadanam, Meena
Vijayakumar, G
Sarma, PS
Nichter, Mark
BMC Public Health
India has the second largest diabetic population (61 million) and tobacco users (275 million) in the world. Data on smoking cessation among diabetic patients are limited in low and middle income countries. The objective of the study was to document the effectiveness of diabetic specific smoking cessation counseling by a non-doctor health professional in addition to a cessation advice to quit, delivered by doctors.
In our parallel-group randomized controlled trial, we selected 224 adult diabetes patients aged 18 years or older who smoked in the last month, from two diabetes clinics in South India. Using a computer generated random sequence with block size four; the patients were randomized equally into intervention-1 and intervention-2 groups. Patients in both groups were asked and advised to quit smoking by a doctor and distributed diabetes specific education materials. The intervention-2 group received an additional diabetes specific 30 minutes counseling session using the 5As (Ask, Advise, Assess, Assist and Arrange), and 5 Rs (Relevance, Risks, Rewards, Roadblocks and Repetition) from a non-doctor health professional. Follow up data were available for 87.5% of patients at six months. The Quit Tobacco International Project is supported by a grant from the Fogarty International Centre of the US National Institutes of Health (RO1TW005969-01).
The primary outcomes were quit rate (seven day smoking abstinence) and harm reduction (reduction of the number of cigarettes / bidis smoked per day > 50% of baseline use) at six months.
In the intention to treat analysis, the odds for quitting was 8.4 [95% confidence interval (CI): 4.1-17.1] for intervention-2 group compared to intervention-1 group. Even among high level smokers the odds of quitting was similar. The odds of harm reduction was 1.9 (CI: 0.8-4.1) for intervention-2 group compared to intervention-1 group.
The value addition of culturally sensitive diabetic specific cessation counseling sessions delivered by non-doctor health professional was an impressive and efficacious way of preventing smoking related diabetic complications.
Trial Registration
Clinical Trial Registry of India (CTRI/2012/01/002327)
Diabetes; Smoking cessation; Counseling; Kerala; India
Related Articles
A Multilevel Analysis of Nonsignificant Counseling Effects in a Randomized Smoking Cessation Trial
McCarthy, Danielle E.
Piasecki, Thomas M.
Jorenby, Douglas E.
Lawrence, Daniel L.
Shiffman, Saul
Baker, Timothy B.
Addiction (Abingdon, England)
To determine, in the context of a trial in which counseling did not improve smoking cessation outcomes, whether this was due to a failure of the conceptual theory identifying treatment targets or the action theory specifying interventions.
Data from a randomized clinical trial of smoking cessation counseling and bupropion SR were submitted to multilevel modeling to test whether counseling influenced real-time reports of cognitions, emotions, and behaviors, and whether these targets predicted abstinence.
Center for Tobacco Research and Intervention, Madison, WI.
403 adult, daily smokers without contraindications to bupropion SR use.
Participants were randomly assigned to receive individual counseling or no counseling and a 9-week course of bupropion SR or placebo pill. Cessation counseling was delivered in eight 10-minute sessions focused on bolstering social support, motivation, problem-solving, and coping skills.
Pre- and post-quit ecological momentary assessments of smoking behavior, smoking triggers, active prevention and coping strategies, motivation to quit, difficulty quitting, and reactions to initial lapses.
Counseling prompted avoidance of access to cigarettes, improved quitting self-efficacy, reduced perceived difficulty of quitting over time, and protected against guilt and demoralization following lapses. Results also supported the importance of limiting cigarette access, receiving social support, strong motivation and confidence, and easing withdrawal distress during cessation efforts. Quitting self-efficacy and perceived difficulty quitting may partially mediate counseling effects on abstinence.
Smoking cessation counseling may work by supporting confidence about quitting and reducing perceived difficulty quitting. Counseling did not affect other targets that protect against relapse.
smoking cessation; tobacco dependence; brief counseling; mediation; randomized clinical trial; mechanisms of change
Related Articles
Predictors of long-term smoking cessation: results from the global adult tobacco survey in Poland (2009–2010)
Kaleta, Dorota
Korytkowski, Przemysław
Makowiec-Dąbrowska, Teresa
Usidame, Bukola
Bąk-Romaniszyn, Leokadia
Fronczak, Adam
BMC Public Health
Expanding the information on determinants of smoking cessation is crucial for developing and implementing more effective tobacco control measures at the national as well as European levels. Data on smoking cessation and its social correlates among adults from middle-income countries of Central and Eastern Europe are still poorly reported in the literature. The aim of the study was to analyze the association of socio-demographic indicators with long term tobacco smoking cessation (quit smoking for at least one year prior to interview) among adults. Moreover, we evaluated motives for giving up smoking from former smokers.
Data on former as well as current smokers' socio-demographic and smoking-related characteristics were derived from the Global Adult Tobacco Survey (GATS). GATS is a cross-sectional, nationally representative household survey implemented in Poland between 2009 and 2010. GATS collected data on a representative sample of 7,840 individuals including 1,206 individuals who met the criteria of long-term smoking cessation and 2,233 current smokers. Smoking cessation rate was calculated as the number of former smokers divided by the number of ever smokers. Logistic regression analyses were used to obtain odds ratios (ORs) and 95% confidence interval (CI) of the broad number of variables on successful cessation of smoking.
Among females the quit rate was 30.4% compared to 37.9% in males (p < 0.01). Former smokers declared concerns about the health hazard of smoking (60.8%) and the high price of cigarettes (11.6%) as primary reasons for smoking cessation. Older age, high education attainment, awareness of smoking health consequences was associated with long-term quitting among both genders. Also employed males had over twice the probability of giving up smoking compared with unemployed, and being religious did not contribute to successful smoking cessation.
Results indicated that smoking cessation policies focused on younger age groups are vital for curbing tobacco epidemic in Poland and should become a public health main concern. There is also the need for interventions to raise awareness on smoking health risks and quitting benefits are crucial to increase cessation potential among adult smokers. Nevertheless further effort needs to be done to prevent smoking uptake.
Tobacco smoking cessation; Socio-demographic factors; Adults; GATS; Poland
Related Articles
An Electronic Health Record–Based Intervention to Improve Tobacco Treatment in Primary Care
Linder, Jeffrey A.
Rigotti, Nancy A.
Schneider, Louise I.
Kelley, Jennifer H. K.
Brawarsky, Phyllis
Haas, Jennifer S.
Archives of internal medicine
To improve the documentation and treatment of tobacco use in primary care, we developed and implemented a 3-part electronic health record enhancement: (1) smoking status icons, (2) tobacco treatment reminders, and (3) a Tobacco Smart Form that facilitated the ordering of medication and fax and e-mail counseling referrals.
We performed a cluster-randomized controlled trial of the enhancement in 26 primary care practices between December 19, 2006, and September 30, 2007. The primary outcome was the proportion of documented smokers who made contact with a smoking cessation counselor. Secondary outcomes included coded smoking status documentation and medication prescribing.
During the 9-month study period, 132 630 patients made 315 962 visits to study practices. Coded documentation of smoking status increased from 37% of patients to 54% (+17%) in intervention practices and from 35% of patients to 46% (+11%) in control practices (P<.001 for the difference in differences). Among the 9589 patients who were documented smokers at the start of the study, more patients in the intervention practices were recorded as nonsmokers by the end of the study (5.3% vs 1.9% in control practices; P<.001). Among 12 207 documented smokers, more patients in the intervention practices made contact with a cessation counselor (3.9% vs 0.3% in control practices; P<.001). Smokers in the intervention practices were no more likely to be prescribed smoking cessation medication (2% vs 2% in control practices; P=.40).
This electronic health record–based intervention improved smoking status documentation and increased counseling assistance to smokers but not the prescription of cessation medication.
Related Articles
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Mummy Girl in Quicksand II by kaolumbiaWatch
©2008-2016 kaolumbiaMature Content
Bound and helpless, Christy continues to be drawn down into the quicksand.
Hope the bog is deep enough to engulf all of helpless Christy!
Sadly, the only sour note of that day was the bog was not cooperative.
more like quickmud...lol
What a way for a girl to go! Poor thing. But, these things happen.

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Lunglust is a five-piece band located in Boston whose style has been described as dirty hardcore with its dissonant guitar chords, driving bass lines, and technical drumming fronted by throaty vocals.
The band's first effort was a four-song demo recorded by Will Killingsworth at Dead Air Studios in June 2010. The lineup consisted of current members: Jeff Sykes (vocals), Eric Lee (guitar) and Eric Kelling (guitar). A short time after the release, Lunglust saw the addition of two new members, Devin Charette on bass and Nate Dress on drums. With a steady line-up finally in place, Lunglust was able to solidify as a band, intent on making their presence felt. Hard work quickly presented great opportunities for the band, who found themselves opening for the likes of Doomriders, Clouds, KEN mode, The Red Chord, Trap Them, and 27. The band has recently worked with Benny Grotto at Mad Oak Studios to record two new songs, Arrows and Heir of Nine, for a split with Western Syndrome. Witch Trial Records will be releasing this split digitally later this year.


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Riccarton, Edinburgh
From Wikipedia, the free encyclopedia
|This article needs additional citations for verification. (December 2011) (Learn how and when to remove this template message)
Riccarton is an area in Edinburgh's Green Belt, in Scotland. It is mainly undeveloped, with much farmland and few houses.
Riccarton is to the west of the Edinburgh City Bypass (the A720), and is known for being the location of Heriot-Watt University's main campus, as well as the Heart of Midlothian F.C. training ground.
There have been a number of wrangles over development of the area in recent years.[citation needed]
The area is bordered by Currie, Juniper Green and Curriehill to the south, The Calders (Wester Hailes) to the east, and Hermiston to the north.
External links[edit]
Coordinates: 55°54′30″N 3°19′20″W / 55.90833°N 3.32222°W
|This Edinburgh location article is a stub. You can help Wikipedia by expanding it.


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Foods can be surprisingly high in salt, fat, saturated fats and sugar, but many people struggle to understand nutrition labels on food packaging. FoodSwitch is a revolutionary, award-winning, free smartphone app that helps you make healthier food choices.Consensus Action on Salt & Health (CASH), in collaboration the George Institute of Global Health (TGI), the Medical Research Council Human Nutrition Research, The British Heart Foundation Health Promotion Research Group and the Nuffield Department of Population Health & Nuffield Department of Primary Care, University of Oxford have brought to you a free and simple to use app for smartphones to help you find out what's in the food you're eating, so you can make simple switches to healthier options. FoodSwitch allows you for the first time to scan the barcodes of your food and drinks products and instantly see whether they are high (red), medium (amber) or low (green) in fat, saturates, sugars and salt per 100g. It also searches the database for similar but healthier alternative products, making it easier than ever to switch to healthier food choices.
SaltSwitch, a new function of FoodSwitch, enables consumers to easily chose healthier choices by suggesting less salty products. This is great for those that are looking to reduce your salt intake, whether for a particular health reason e.g. high blood pressure, or to maintain a healthy diet.
Use FoodSwitch to see what's in your shopping basket, and make better food choices when shopping for you and your family. FoodSwitch is available as a free, UK-only download from iTunes and Google Play.


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Hello to you here on Audiko.net! The best opportunity to download a free The Killers ringtones for your iPhone or mobile. Select your favorite line from your favorite track - Jeff The Killer - Sweet Dreams (Marilyn Manson & Creepypasta, Jeff The Killer - Sweet Dreams (Vocal Piano Ver.) feat. Lady, The Killers - Human, or any other track. Then download the prepared The Killers ringtones to your mobile device, and enjoy Indie music by The Killers every time your phone rings. You may get your ringtone both in the MP3 and m4a formats, compatible with both mobile phones and iPhones. Just select a track, and choose free The Killers ringtones download option.
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Southern Vermont College hosts career fair April 4March 29,2013College hosts career fair
BENNINGTON Southern Vermont College will host its annual spring career and internship fair April 4 from 11 a.m. to 3 p.m. in the Everett Mansions Burgdorff Gallery.
Information will be available at the fair about employment, career and internship opportunities. The event is free and open to the general public, students from other area colleges and current students and alumni from Southern Vermont College.
Representatives will attend from, among others, Avon; Berkshire Family and Individual Resources; the Bennington School; Hillcrest Educational Centers, Inc.; the Lebanon, N.H., Police Department; Peace Corps; Porter Medical Center; Sage Graduate College; Southwestern Vermont Health Care; Union Graduate College; The Vermont Country Store; Vermont Voltage/Bennington Sports Center; and the Vermont State Police.
Employers interested in participating or those seeking more information should contact Southern Vermont College Director of Career Development Denise Spencer by phone at 447-4631 or email at firstname.lastname@example.com IN This Just In
MIDDLEBURY — Middlebury Police arrested Ronald Bean, 52, on two counts of... Full StoryMore than 26,000 people were without power when severe thunderstorms rolled through the state in... Full Story A Rutland man was allegedly drunk and playing Pokémon Go when he crashed his... Full Story
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Deus Ex: Human Revolution is 75% off this weekend on Steam
This weekend only, Deus Ex: Human Revolution and all its various forms and DLC are 75% off on Steam. The best deal of the lot though, is the Deus Ex Collection which includes the Augmented version of the game and everything released for Human Revolution for $14.99. Hit up the link for more.
Sometimes we include links to online retail stores. If you click on one and make a purchase we may receive a small commission. For more information, go here.


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Wiregrass residents got a chance to learn some photography tricks Saturday afternoon.
The Southeast Alabama Photography and Adventure Club held a workshop at Landmark Park.
The event taught participants the essential elements of photography and the beauty of nature shots.
"We want them to have an appreciation for nature and what is here,in the park and in our area. There's so many things to do out in nature," says Sandy Spengler.
Participants used their own cameras and shared with classmates.


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Yohji Yamamoto Pour Homme
Cropped Bomber Jacket
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Tailored in felt with a blouson back and contrast rib-knit shawl collar, Yohji Yamamoto's cropped bomber is trimmed with contrast rib-knit cuffs and a wide contrast rib-knit waistband. The jacket is styled with diagonal welted chest pockets, a vertical leather chest applique and contrast gusseted zip pocket on sleeve. Contrast industrial front zip.
- Available in Green/Navy
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100-Calorie Snacks to Pack (Slide 1)
(Slide 1 of 16) Start at the beginning | View recipes as list
Recipe: Chocolate-Cherry Snack Bars
View as: Thumbnails List
Chocolate-Cherry Snack Bars
These cereal bars are chewy, crunchy and delicious with good-for-you seeds, nuts, fruit and little e…View slide
Lemon-Parm Popcorn
Perk up your popcorn with a bit of lemon pepper and Parmesan cheese.…View slide
Five-Spice Pistachios
Chinese five-spice powder is a blend of cinnamon, cloves, fennel seed, star anise and Szechuan peppe…View slide
Chile-Cocoa Graham Crackers
These crunchy and crispy chocolate graham crackers have a tiny bit of spicy ancho chile on top. Oat …View slide
Try customizing this basic recipe with your favorite dried fruits and nuts.…View slide
Curried Cashews
These curried cashews are impossibly addictive—every time we made them in the Test Kitchen they di…View slide
Oatmeal Chocolate Chip Cookies
These oatmeal chocolate chip cookies have the familiar flavors of brown sugar and chocolate, but get…View slide
Sesame Carrots
Toasted sesame seeds add taste and eye appeal to a cheery plate of carrots.…View slide
Raspberry Bars
Tart raspberry filling is swirled into a low-fat cream filling in these beautiful bars. They're a fe…View slide
Toasted Pita Crisps
A super scooper for your favorite dips.…View slide
Chewy Chocolate Cookies
We can't resist big, soft, fudgy cookies, like those found in glass jars on bake-shop counters. Thes…View slide
Spiced Chickpea "Nuts"
When roasted in a hot oven, chickpeas become super crunchy. They're a great low-fat substitute for…View slide
Tamari Walnuts
Keep these nuts on hand for stir-fries, salads or snacking.…View slide
Cheesy Popcorn
Freshly grated Parmesan cheese and a sprinkle of cayenne pepper dress up air-popped popcorn.…View slide
Long, crispy, thin breadsticks like these grissini are laid right on the tablecloth at many Piedmont…View slide


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Osteoporosis Health Center
Two Studies Suggest Statins Have a Role in Osteoporosis Prevention
June 22, 2000 -- More than 10 million Americans, mostly postmenopausal women, have the bone-wasting disease called osteoporosis, but soon doctors may have new drugs to both treat and prevent the disease and -- as a bonus -- the treatment will also reduce the risk of heart attack.
This new "miracle drug" is actually a class of drugs called statins that has wowed cardiologists for the last 10 years because the drugs can dramatically reduce the levels of bad cholesterol in the blood. Now new studies suggest that the drugs can also stimulate bone growth.
One of two studies published in a recent issue of the journal The Lancet suggests that taking one of the statin drugs regularly for at least two years can cut the risk of fractures associated with osteoporosis by as much as 50%.
Although a role for statins in osteoporosis treatment or prevention needs to be confirmed in future studies, leaders of the osteoporosis community are openly enthusiastic about the statin news.
"The possibility that we could have one drug that would reduce the risk of fracture and heart attack is major," Felicia Cosman, MD, clinical director of the National Osteoporosis Foundation tells WebMD. "It's a pretty exciting picture. That's what we thought we were doing with estrogen."
She says, however, that like estrogen, future studies may lead to a different conclusion about the benefits of the medication. Cosman, who is an associate professor of medicine at Columbia University College of Physicians and Surgeons, was referring to recent clinical trials that have cast doubt on the ability of estrogen to protect against heart disease or to reduce fracture.
Lead author of one of the studies, K. Arnold Chan, MD, ScD, assistant professor of medicine at the Channing Laboratory at Brigham and Women's Hospital and Harvard Medical School, seconds the cautionary note. He tells WebMD that he and his fellow researchers decided to look at statins after reading a study that found the drugs increased bone density in rats that were given high doses of statins. This increase in bone density strengthens the bone and leads to fewer fractures. He and his colleagues based their new study on medical records of women treated at six HMOs.


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Bruce Boudreau is a complex man. A man who has played nearly 20 years of professional hockey, won a Jack Adams award and has helped local businesses by appearing in their commercials. While taking photos for the Washington Capitals Examiner this past weekend, I got to know the man on a deeper level.
First, I met Happy-go-lucky-Bruce:
Then practice started and I met On-looker Bruce:
Uh-oh, "Why are you out of position?" Bruce showed up. Pleased to meet you.
"I heard that!" Bruce:
"I'll kick you out of Kettler!" Bruce:
"Go ahead. Make my day" Bruce:
"Naw. I'm just kidding with you" Bruce:
And since I know you're wondering: No, not all of these looks were directed at one individual player. Though if they were, I'm sure we could both guess who it'd be.


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I just finished watching "Kate and Leopold" which has definitely made my top favorites list. It's a chick flick from 2001 and considered to be a romantic-comedy, fantasy which tells the story of a Duke who travels through time from New York in 1876, to the present time, only to fall in love with a woman from […]
February 11, 2016
An 18th Century Modern Day Romance
February 9, 2016
When We Get It Ass Backwards
I have all these ideas, but they've never seemed GRAND enough, BIG enough or IMPORTANT enough to Make a difference, Make a change, Or make a living with… So, I haven't done them. At least not where blogging and being online are concerned. Instead, I've waited, trying to figure out how to grow them or make […]
February 7, 2016
Passion, Sensitivity and Vulnerability
"If you're a really passionate person, are there times when you wish you weren't?" There are times when I've disliked being a passionate person, because I saw it as a weakness. For, often times, with great passion comes great emotion and sensitivity too. That, in turn, can make a person more vulnerable. It also means […]
February 5, 2016
In these moments
When our hearts are conscious of their treasures… Only then are we truly alive.
February 1, 2016
Am I in need of a Branding Expert, Marketing Expert, PR Specialist, Life Coach, Editor, or perhaps… Just a Whiskey Scotch on the Rocks?
So, I have all the pieces to this wonderful jigsaw puzzle, I just don't know how to put it all together, and perhaps that's because I'm not sure of what the final masterpiece (picture) is supposed to look like. While the process seems amazingly complicated, my gut says that the outcome is rather simple, making […]
January 29, 2016
Our Latest Developments
There's something to be said for the unexplained absences we sometimes take. As much as I'd like to say that I was given a sabbatical, we'll call it a reinforced exploratory leave of absence instead and remember that sometimes, ignorance is bliss. Read All About It! So, believe it or not, our latest development includes […]
November 12, 2015
Beautiful Women
BEAUTIFUL women need to be PROTECTED gentlemen. I'm talking about those STRONG yet FRAGILE hearts, minds and souls of ladies everywhere For, they are ALL beautiful! She needs PROTECTION because plenty of people will LOVE her CHASE her DESIRE her RUN AFTER her and try to take ADVANTAGE of her For she has a good HEART […]
November 6, 2015
My Top 15 'Must Haves' For Him
So, I never really had a list of 'must haves' before, until I spent some time on various dating websites. It's taken a lot of years and painful lessons to realize that without them, my choices for whom to have personal relationships with would continue to be poor. Love really is blind, for I truly believed […]
October 21, 2015
What Makes Me Happy
THE HAPPINESS FACTOR What makes your eyes light up and your heart sing? What makes you smile and laugh out loud? These are just some of the things that bring me happiness: Quality time with people I love and care about My daughter's happiness and well-being Being transparent and vulnerable Genuine character and personality The sun […]
October 14, 2015
I've not done weekly challenges for awhile, but in light of recent events and activities, the current topic seems more than fitting. I have been so inspired this past week that I began writing multiple posts although, they've become rather intertwined by now. I'm going to keep putting them up anyways, because you don't seem […]


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I'm using one WP network installation with a few languages (WPML plugin). I basically need this:
to be the same page (translation actually). Different domains are handled by MU Domain Mapper plugin, and page name translations are handled by WPML. The only problem is the blog name, which can't be different. Is there a way I can make this work? I can't make it work with redirection because I need the link to stay in the same language.
Thanks in advance


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- Accessories(2467)
Results 1 - 20 of 2467 matches
Top RatedVic Firth Corpsmaster Marching Bass Mallets
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The wide motorcycle-style seat keeps you sitting tall and comfortable in the saddle. A very stable yet...$149.99Compare Compare Now site7prod445881
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Top RatedVic Firth Marching Snare Bag
Protect your marching snare with this durable, water-resistant gig bag! Attaches to marching snare drums with...$10.59 - $16.89Compare Compare Now site7prod449898
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Top RatedHercules Stands Single Guitar Stand with Folding Yoke
Fast height adjustment and weight-driven Auto Grab System (AGS) yoke sets this guitar stand apart from the...$48.99Compare Compare Now site7prod453081
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Top RatedHercules Stands GS525B Five-Instrument Guitar Rack
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Top RatedMusician's Gear Folding Music Stand
Fully collapsible, height adjustable, and extremely durable.$7.99Compare Compare Now site7prod451034
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Top RatedMusician's Gear Electric 10 Nickel Plated Steel Guitar...
10-13-17-26-36-46$2.29Compare Compare Now site7prod101811
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Top RatedVoodoo Lab Pedal Power 2+ Power Supply
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Top RatedRapco Horizon Stage Series 100' 16-Channel/4-Return Stage...
Features 22-gauge multipair wire; Neutrik connectors on box; Cannon XLR connectors on sends; 1/4" connectors...$359.99Compare Compare Now site7prod336684
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Are you looking for a nice low stress, free parking agency that appreciates you? My client, a Kirkland based independent agency, is looking for a solid commercial account manager who is versed in all lines of insurance. The book will be a mix of accounts ranging from small BOPs to package policies up to $100K in premium. You will support experienced producers with renewals/daily service work and ...
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