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Disadvantaged smokers are less likely to be successful when trying to stop smoking than more affluent smokers. In the UK, NHS Stop Smoking Services (SSS) provide a range of pharmacotherapy and behavioural support, delivered by advisors with a range of backgrounds. Whether the types of support provided and who provides it influence differences in quit rates amongst low SES smokers compared with high SES smokers has not previously been examined.
202,084 records of smokers in England who attended a NHS Stop Smoking Service between July 2010 and June 2011 were acquired. Smokers were followed-up by services at four weeks post quit date. Multilevel logistic regression models of CO validated quits were employed. Disadvantage was explored through the National Statistics Socio-Economic Classification (NS-SEC) and by eligibility for free prescriptions, an indicator of low income amongst adults aged between 19 and 59 in England.
Affluent smokers were more likely to quit than disadvantaged smokers (OR 1.38 (1.35 to 1.42) for clients who paid for prescriptions compared to those eligible for free prescriptions). 80% of service clients received one-to-one counselling but open group forms of behavioural therapy were more successful (main effect OR 1.26 (1.12 to 1.41)) except amongst some of the most disadvantaged clients (long-term unemployed and prisoners). Closed groups were little deployed and they were not significantly more successful than one-to-one behavioural therapy after controls. Who delivered treatment did make a difference for some clients, with all but the most affluent less likely to be successful if they had been treated by a nurse compared with other types of advisers, including smoking cessation specialists (main effect OR 0.73 (0.65 to 0.83)).
This study provides further evidence that disadvantaged smokers find quitting more difficult even when they have attended a smoking cessation programme. The findings suggest that open groups should be promoted, although they may not be as effective as other forms of behavioural therapy for the long-term unemployed or prisoners. Further research is required to explore why most groups of smokers who attended services staffed by nurses were less likely to quit than those who received treatment from other types of advisors.
The disease and mortality burden from smoking falls heaviest on low socio-economic status (SES) smokers (Kunst, Giskes, & Mackenbach, 2004; Mackenbach et al., 2008). While smoking rates have declined in the developed world, the decline has been slower or non-existent amongst low SES groups in these countries. This means that inequalities in smoking rates and inequalities in smoking-related conditions have increased (Barnett, 2000; Dube, Asman, Malarcher, & Caraballo, 2009; Federico, Kunst, Vannoni, Damiani, & Costa, 2004; Fernandez et al., 2001; Jarvis, 1994; Jefferis, Power, Graham, & Manor, 2004; La Vecchia, Decarli, & Pagano, 1986; Peretti-Watel, Seror, Constance, & Beck, 2009). The desire to quit smoking is equal across SES groups but success is not (Kotz, Fidler, & West, 2009; Reid, Hammond, Boudreau, Fong, & Siahpush, 2010). Disadvantaged smokers are less likely to quit than other smokers for a variety of reasons such as: reduced social support for quitting; lower motivation to quit; stronger addiction to tobacco; increased likelihood of not completing courses of pharmacotherapy or behavioural support sessions; psychological differences such as lack of self-efficacy and tobacco industry marketing (Hiscock, Bauld, Amos, Fidler, & Munafo, 2011). This pattern is true for those attempting to quit alone and those quitting with help from a smoking cessation programmes such as the UK's national network of services, known as NHS Stop Smoking Services (SSS) (Hiscock, Judge, & Bauld, 2011; Kotz et al., 2009; NICE, 2008).
NHS Stop Smoking Services were set up in 1999 to reduce smoking-related deaths particularly from cancer and coronary heart disease (NHS Executive, 1999) which predominantly occur amongst disadvantaged groups (Jha et al., 2006). SSS routinely collect self-reported outcomes at 4 weeks post quit date and biochemically validate this by conducting a breath test for levels of carbon monoxide (CO) (Murray et al., 2012). Previous studies have shown that the services are effective and cost effective (Bauld et al., 2012; Flack, Taylor, & Trueman, 2006; Godfrey, Parrott, Coleman, & Pound, 2005). The SSS provide a range of pharmacotherapy and behavioural support, delivered by advisors with a range of backgrounds. Whether the types of support provided and who provides treatment influences differences in quit rates between low SES and high SES smokers has not been examined and is explored in this paper.
NHS SSS provide support in the form of behavioural therapy either through one-to-one sessions, drop-ins or in groups typically involving weekly support over a period of at least 4 weeks after a quit date is set (NICE, 2008). Behavioural therapy and cognitive behavioural therapy are evidence-based treatments which aim to help people achieve specific aims or goals, such as smoking cessation, through focussing on the current situation rather than the past (Association for Behavioural and Cognitive Therapies, 2008; Guichenez et al., 2007). Compared to one-to-one treatment, group therapy offers the potential advantages of: receiving feedback from peers; modelling behaviour discussed by other group members; learning from the shared perspectives of group members; potentially increasing members' supportive social networks and reduced cost (Herkov, 2010; Paddock, Hunter, Watkins, & McCaffrey, 2011). However, whether better outcomes do occur in groups compared to one-to-one interventions requires more research (Cuijpers, van Straten, & Warmerdam, 2008; Tucker & Oei, 2007). There are two primary forms of group behavioural therapy: closed groups and open groups (Psychiatric Nursing, 2011).
Closed groups in the SSS involve structured, multi-session group courses with pre-arranged start and finish dates (Department of Health, 2007) starting with a minimum of eight clients (Department of Health, 2011) and are based on the scientifically validated 'Maudsley model' (Hajek, 1989; NHS Executive, 1999). Open groups deliver support in a flexible format where participants can choose when to attend; they have been used in a number of countries to provide support and treatment for a range of health problems or to facilitate behaviour change (Paddock et al., 2011; White, Bradley, Ferriter, & Hatzipetrou, 1998). Advantages of these open or rolling groups over closed groups, include: immediate starts (Morgan-Lopez, Saavedra, Hien, & Fals-Stewart, 2011; Ware & Bright, 2008); no fixed programme so clients can progress at their own pace and group leaders can be more responsive to individual client needs (Ware & Bright, 2008) and new clients learning from the experiences of those who have attended for longer (Ware & Bright, 2008). Thus, open groups have potential to be an effective form of behavioural therapy. There is however very little literature on the effectiveness of open groups compared with other forms of behavioural support (Bauld et al., 2012; Ware & Bright, 2008).
In 2010–2011, routine monitoring data from SSS in England suggested that from a total of 787, 527 clients, the majority (81%) received one-to-one structured support, 11% attended drop-in clinics, 3% attended drop-in rolling groups and 2% attended closed groups (NHS Information Centre, 2011). Telephone support, family or couple counselling and unclassified support were each received by 1% clients. However, outcomes at four weeks (post quit date) suggest that closed groups, despite being the least popular, are the most successful with an average quit rate of 60% for closed groups and 55% for rolling groups but only 49% for drop-ins and 48% for one-to-one support (NHS Information Centre, 2011). These patterns have also been found in longer term evaluations of the services (Bauld, Chesterman, Ferguson, & Judge, 2009; Bell et al., 2006; Brose et al., 2011) but there has been little attention paid to intervention type and disadvantage.
NHS SSS therapists (known as 'advisors') can be either specialists, who are employed only to work as smoking cessation advisors or can be people working in other health and social care roles such as: pharmacy employees; General Practitioners (GPs); nurses; Health Care Assistants (HCA); and midwives, who deliver stop smoking support as one part of their post. The type of therapist may influence uptake and effectiveness of treatment. Some potential clients are reluctant to access specialist services due to stigma or travel issues (Carter & Fairburn, 1995) and specialist staff may be more expensive to employ (Katon, Von Korff, Lin, & Simon, 2001). Furthermore, other health professionals, such as GPs, often encounter patients in routine practice with problems that could benefit from behavioural therapy (Leclerc, 1998). Evidence suggests that nurse conducted behavioural therapy can improve care and outcomes and it has been suggested that specialists should only handle complex cases (Katon et al., 2001).
Data on the type of SSS advisor is not collected routinely (NHS Information Centre, 2011) and there have not been any published recent evaluations (Bell et al., 2006). However there has been some work on the setting where the behavioural intervention takes place. A recent study of 24 English Services (Brose et al., 2011) found that the highest quit rates are in specialist clinics, these rates were significantly higher than primary care settings but not significantly higher than pharmacy or other settings. There is also evidence that inpatient interventions in hospitals are effective in facilitating quitting (Bell et al., 2006). In one study, a pharmacy intervention provided a low but still cost-effective quit rate (Bauld et al., 2012). Furthermore pharmacies have the potential to reach many smokers due to offering a range of locations and opening hours without the need for appointments.
SSS provide behavioural support in combination with one of three forms of pharmacotherapy — nicotine replacement therapy (NRT — sometimes used as combination therapy employing more than one product), bupropion (Zyban) or varenicline (Champix). In 2010–2011, the most widely used forms of pharmacotherapy provided by SSS were NRT (63%) and varenicline (31%) (NHS Information Centre, 2011). However, despite NRT being commonly used, the short-term (four week) quit rate for NRT (44%) was lower than varenicline (59%) and bupropion (52%) (Brose et al., 2011). Further evidence suggests that NRT is more effective when used in combination with behavioural support (NICE, 2008), but there is insufficient evidence to confirm whether NRT is more or less useful for disadvantaged or affluent smokers (Amos et al., 2011). However, previous research in the UK has shown that the use of smoking cessation programmes including behavioural support and pharmacotherapy can reduce inequalities if targeted towards disadvantaged groups (Chesterman, Judge, Bauld, & Ferguson, 2005).
The difference in success rates between low and high SES smokers begs the question of whether services could be optimised to help low SES smokers. Thus, the research questions explored in this paper are:
English SSS store their routine monitoring data on databases often managed by external agencies. These databases can include more detailed information than the summary reporting required by the NHS. One of these databases, used in just under half of SSS in England, was used for this study. Forty nine of about sixty SSS who used the 'Quit Manager' database (North51, 2010) at the time of the study allowed their data to be used for research purposes and clients consent to their data to be used for research so ethical approval was not needed for this specific analysis. Six months of client records were downloaded in both January 2011 and July 2011 (n = 202,084). Records with quit dates in December 2010 (n = 7304) and June 2011 (n = 12,177) were excluded so that all clients had the potential to be followed up at 4 weeks. Records were also excluded if the client's age (n = 115), gender (n = 46) or advisor (n = 5573) were unknown, if they were not aged between 19 and 59 (n = 40,023) and if they were pregnant (n = 6606). This left 132,586 quit attempts in the analysis. Final numbers and numbers of excluded cases do not tally as a client record could be excluded for more than one reason.
The main outcome variable was CO validated quit at 4 weeks post quit date (defined as self-report of not smoking in the past 2 weeks and having a CO reading of less than 10 ppm). Services are required to collect data on this short-term outcome by the UK government (Department of Health) and long-term quit rates can be estimated from this (Department of Health, 2011; Ferguson, Bauld, Chesterman, & Judge, 2005). In this dataset, the overall CO validation rate was 74% (Murray et al., 2012). An intention to treat approach was used, as is commonly the case in studies of smoking cessation, (West, Hajek, Stead, & Stapleton, 2005) so that clients lost to follow up were classified as continuing smokers. One stop smoking service had a markedly low CO validation rate (17% (Murray et al., 2012)) and was excluded from the analysis.
The measures of individual disadvantage collected by the SSS are eligibility for free prescriptions and NS-SEC (National Statistics Socio-Economic Classification based on occupation and economic status) (ONS, 2008). NS-SEC was devised by the UK National Statistics agency and is used in the main UK government surveys (NICE, 2008). All citizens should be able to be classified by NS-SEC either by their occupation or by their reason for not having an occupation (such as being retired or permanently sick). Traditionally there has been an occupational division between those with non manual (white collar/bourgeoisie/middle class) occupations and manual occupations (blue collar/proletariat/working class respectively) (Marx & Engels, 1848) and this is reflected in SSS targets for quits amongst clients with routine and manual occupations (Bell et al., 2006). More recently there has also been concern about the development of an underclass of non working people (Myrdal, 1963) currently manifesting itself in the "welfare scroungers" debate (de Castella, 2012). NS-SEC can be used to differentiate these three groups.
Clients were also defined as low SES or disadvantaged if they were exempt from paying for NHS prescriptions for medicines and high SES if they paid for prescriptions. Free prescriptions are available for those on low income (NHS Business Services Authority, 2008a,b; NHS choices, 2011). Exemption can also be granted certain for medical reasons, pregnancy or having had a baby in the previous 12 months (NHS choices, 2011). There are additional age related exemptions for those who are 60 or over, below 16 year olds, and 16 to 18 year olds in full time education (NHS choices, 2011). Thus, the analysis was confined to non-pregnant clients aged between 19 and 59 at their quit date.
A level of disadvantage was allocated to each SSS through the Index of Multiple Deprivation (IMD) (www.communities.gov.uk, 2011) which gives every census area a score based on the level of disadvantage experienced by its population on a variety of different measures. These scores have been aggregated to health administration areas which have the same boundaries as Stop Smoking Services. Thus we were also able to measure whether disadvantage in the localities in which each SSS operate affect the rates of quitting.
In the analysis, NS-SEC categories were routine and manual, intermediate, managerial and professional, retired or home carer, sick or disabled and unable to work, long-term unemployed or never worked, in prison and other. Eligibility for free prescription categories were free prescriptions, pays for prescriptions and unknown. Disadvantage in the health service administration area served by the SSS was measured as the rank of average IMD 2010 score for service local health administration area (1–30, 31 to 60, 61 to 90, 91 to 120, 121 or higher (high is the least disadvantaged)).
The following control variables were included: age at quit date quartiles (19 to 30, 31 to 39, 40 to 48 and 49 to 59), gender, ethnicity (Black, Asian, mixed or other; White; unknown), the month the quit date was set (tobacco control events, such as non smoking day occur at certain times of year and motivation varies with the seasons, for example, smokers may make quitting a new year's resolution and there may be a 'back to school' effect in September so the number of smokers setting quit dates with the SSS varies cyclically (Fox & Hampton, 2013); when quitters are more numerous, smokers may be more likely to be successful partly due to cohort effects/normalisation and because when there are more quitters, services are able to run more and larger groups), number of treatment episodes which refers to the number of quit dates set with the SSS (only episode, second episode, third episode, fourth or further episode) and medication (single NRT, combination NRT, bupropion only, varenicline only, mixed NRT/bupropion/varenicline, no medication or missing). These factors have previously been found to be associated with smoking cessation (Brose et al., 2011; Farren & Naidoo, 1996; King, Polednak, Bendel, Vilsaint, & Nahata, 2004; Quitline | Me Mutu, 2013).
The following stop smoking service intervention descriptors were included: intervention type (one-to-one, drop-in clinic, open (rolling) group, closed group, other or missing) and SSS advisor (smoking cessation specialist, GP, nurse, health care assistant (HCA), pharmacy employee and other/missing).
SPSS (version PASW 18.0) and Stata (StataCorp, 2010) were used for bivariate analysis. Co validated quit rates were calculated for all independent variables. Bivariate analysis however does not take into account other characteristics. Multilevel, multivariate logistic regression analysis was therefore conducted using MLwiN 2.24 (Rasbash, Charlton, Browne, Healy, & Cameron, 2009) with three levels: client record, advisor and SSS. At the time of the study SSS were provided by each health service administration area (termed Primary Care Trust (PCT)). A minority of neighbouring services shared advisors and these services were merged in the analysis so that the data had a completely nested structure.
Each fixed effect (independent variable that was not a level) was firstly added to the multilevel models separately ('one fixed effect' models), secondly all variables were added simultaneously firstly including NS-SEC to measure SES and secondly NS-SEC was removed and eligibility for free prescriptions was entered.
To determine whether some services were more appropriate for disadvantaged clients and other service types were more appropriate for more affluent clients, interactions were tested between low SES (as measured firstly by NS-SEC and secondly by eligibility for free prescriptions) and service type (measured by intervention type and advisor type).
Where an interaction term was found to be significant, cross-classified variables including most combinations of the categories of the two variables involved in the interaction were derived and included in the models (variables involved in the interaction were removed from the model). The reference group was rotated so that 'one-to-one' for each SES group became the reference category in turn. It was then possible to determine whether intervention type or advisor type differed significantly for each SES category. This technique has been used previously (Hiscock, Pearce, Blakely, & Witten, 2008).
Uptake rates and quit rates were tabulated for each intervention type and advisor type by free prescriptions and NS-SEC categories. Chi square tests were also undertaken.
Service uptake, quit rates and odds ratios of quitting by SES and service type are described in Table 1. In 'one fixed effect' multilevel modelling affluent clients (those with managerial, professional and intermediate occupations) were significantly more likely to quit than clients with routine and manual occupations. However, in the multivariate model, prisoners were also more likely to quit. Clients classified as retired or home carers, permanently sick or disabled, long-term unemployed or never worked were less likely to quit. Respondents who paid for prescriptions were more likely to quit.
In the bivariate model and in the model where SES was measured by free prescriptions, clients who attended groups (both open and closed) were more likely to quit than those who received one-to-one behavioural support. When NS-SEC was included in the analysis there was no longer a significant difference between closed groups and one-to-one.
Clients who saw GPs and nurses were less likely to quit than clients who saw smoking cessation specialists in multilevel models. Clients who saw pharmacy employees were less likely to quit than clients who saw specialists in the bivariate model but not the multivariate models. Thus, GPs and nurses were less effective than specialists in the main effects models, although the number of clients treated by GPs was very small.
Uptake of services and chances of quitting for the control variables are described in Table 2. Each age quartile covered about 10 years. Similar numbers of men and women accessed the services (48.5% and 51.5% respectively). The ethnicity of those accessing the services was primarily white (88.2%). Clients came to the services from both disadvantaged and more affluent areas. The largest numbers of clients accessed the services between January and March. The majority of individuals were attending the services for the first time (64.6%), only 6.8% were on their fourth or more episode. Single NRT (22%), Combination NRT (36.3%) and Champix (28.7%) were commonly used to support quit attempts. Overall there were 132 586 cases in the analyses (described in Tables 1 and 2) and the overall CO validated quit rate was 34%.
The odds ratios of quitting for the control variables in the multilevel multivariate models changed little when NS-SEC was substituted for free prescriptions as the measure of SES. The odds of a successful quit attempt significantly increased as age increased. Gender had no significant effect on the quit rate. Whites were significantly more likely to have a successful quit attempt than other ethnic groups. Area deprivation did not predict quitting. Compared with July, those quitting in November had a lower chance of success and those quitting in January, February, September and October had a greater chance of success. Clients on their fourth or more quit attempt were more likely to succeed than those on their first attempt. Compared to single NRT, use of any other type of medication increased an individual's chance of a successful quit.
There were three significant interaction terms when the interaction between NS-SEC and intervention type was tested (p < .05): long-term unemployed/never worked and open groups, prisoners and open groups and prisoners and drop-ins. These were explored using a cross classified variables. Socio-economic status patterns were more or less retained (Table 5 Section 1a): for most intervention types, clients with professional and managerial occupations were significantly more likely to quit than clients with routine and manual occupations. Retired/home carers, long-term sick and long-term unemployed clients were less likely to quit for most interventions. Only for prisoners did the intervention type change the quit rate from significantly higher to significantly lower than the reference.
When the reference category was rotated (Table 5 Section 1b), open groups were more effective than one-to-one (significantly so for clients with routine and manual occupations and clients with professional and managerial occupations) except for the long-term unemployed and prisoners. For unemployed clients and prisoners, there was a significant difference in the direction of the relationship. Open groups were less effective than one-to-one, significantly so for prisoners. There were no significant associations for closed groups.
When the interaction between NS-SEC and advisor type was tested, there was one significant interaction term (p < .05): professional/managerial occupation and nurse advisor. Socio-economic status patterns were more or less retained (Table 5 Section 2a): only clients with higher grade occupations were sometimes significantly more likely to quit than the reference group (clients with routine and manual occupations who saw specialists). Retired/home carers, long-term sick and long-term unemployed clients who saw various advisor types were often significantly less likely to quit than the reference group.
For all disaggregated NS-SEC categories when the reference group was rotated (Table 5 Section 2b), clients who saw nurses were less likely to quit and this relationship was significant or approached significance for all categories except for clients with professional or managerial occupations. For clients with professional or managerial occupations, there was little difference according to advisor type.
Neither the interaction between eligibility for free prescriptions and intervention type nor the interaction between eligibility for free prescriptions and advisor type was significant.
Smokers from all SES classifications accessed all intervention types. The largest number of quit attempts was made by clients with routine and manual occupations, over 36,000 (Table 4). More than 20,000 were made by clients with managerial and professional occupations with just 2000 made by the smallest NS-SEC category: prisoners. In terms of the types of behavioural support received, the vast majority of clients received one-to-one counselling (around 80% of quit attempts). The least common intervention type was closed groups for all NS-SEC categories (2% of quit attempts overall) except for prisoners. There were only about 2000 prisoners in the sample however.
More than 10,000 more quit attempts were made by clients who were eligible for free prescriptions than those who paid for prescriptions. Patterns were similar to NS-SEC.
Permanently sick clients were more likely to access the most successful intervention, open groups, than long-term unemployed clients (p < .001) and clients who paid for prescriptions were significantly more likely to access open groups that clients who were eligible for free prescriptions (p = .003).
Significantly more clients were seen by specialist advisors (56%) than GPs (3%) (Table 5), with the other advisor types falling in between these two categories. This pattern was true for all SES categories. There were similar uptake patterns when SES was measured by eligibility for free prescriptions.
The most effective intervention type across the sample as a whole was open groups (Table 1). It was not the case that open group support was markedly less frequent amongst disadvantaged NS-SEC groups (Table 3). The least effective advisor type was nurses (Table 1). It was not the case that disadvantaged groups were more likely to see nurses (Table 4).
The UK's Stop Smoking Services have played an important role in efforts to reduce tobacco use in the UK for almost 15 years (Bauld et al., 2012; Flack et al., 2006; Godfrey et al., 2005). The average impact of the services included in this analysis was 152 extra ex-smokers per 100,000 population between mid-2010 and mid-2011 (Murray et al., 2012). In general, quit rates in this study followed those reported in previous research: more affluent smokers, older clients and clients taking varenicline or combination therapy were most likely to quit (Brose et al., 2011; Ferguson et al., 2005). Overall, the effectiveness of different interventions offered by the services did not differ significantly for clients from more or less affluent groups. For most clients, the most effective form of behavioural support was open groups. In terms of advisor type, clients who saw nurses were generally less likely to quit than clients who were treated by other advisor types.
Examining in more detail any differences between intervention types in the study, the form of behavioural support with the most success was open, rolling groups. The exception was for the long-term unemployed and the very small number (n = 2000) of prisoners in the study, for whom open groups were less effective than one-to-one counselling. There are a number of possible explanations for this difference, including the fact that for the long-term unemployed, for example, engaging with interventions that require interpersonal skills may be challenging or uncomfortable (McQuaid, Green, & Danson, 2005; Niepel, 2010).
The professional background of the advisor delivering support made little difference to outcomes, with the exception of nurses who were found to be less effective than smoking cessation specialists when treating most groups of clients. Interestingly, clients who saw health care assistants (HCAs) had higher success rates despite these assistants working in the same settings (primary care premises) as nurses (model not shown OR main effect 1.27 (1.10 to 1.46)). These HCAs have fewer formal qualifications but may have more time to spend with clients. They may also be able to build rapport more effectively because they are more likely to be recruited from the same local communities as smokers themselves (Bosley & Dale, 2008; Lizarondo, Kumar, Hyde, & Skidmore, 2010; NHS Scotland, 2010; Petrova, Vail, Bosley, & Dale, 2010).
In addition, although clients supported by GPs can achieve high quit rates this association disappeared once the SSS where they worked was taken into account — only a very small number of SSS recorded having GPs as smoking cessation advisors. It is possible that the boundary was blurred between brief advice and more intense interventions in the reporting of these SSS.
Some differences in intervention effectiveness for SES groups were found when SES was measured by NS-SEC rather than free prescriptions. The advantage of NS-SEC is that it provides a more finely graded distinction between SES groups which may be necessary to tease out whether and where changes should be made to services. There was no evidence that disadvantaged smokers were less likely to quit because they were attending less effective services i.e. it was not the case that disadvantaged smokers were not accessing open groups or were predominantly receiving behavioural support from nurses.
This study only provides short-term outcomes because routine data, where follow up is conducted at four weeks, was analysed. The advantage of this short period was that less than 30% of cases were lost to follow up. In smoking cessation studies lost to follow up tends to be an indicator of relapse (West, 2006) so these cases could be retained in the analysis as non quitters avoiding selection bias. A particular limitation of routine data is that quality varies resulting in a lower level of accuracy than would be the case in a research study. Data on level of tobacco dependence and social support was limited to a few cases and could not be used in the analysis. Data on the advisor type was also poorly collected (it is not a national requirement for reporting) so further research is needed to corroborate our results on the relationship between who provides support and outcomes.
The naturalistic design has the advantage of real world observation but it meant that there was no control group so we cannot be certain whether using the services significantly increased quitting. Background quit rates (the chances of a smoker quitting with no help from the services) have however been estimated to be between 2% and 3% for 2006 (West, 2006) which is considerably lower than the 34% quit rate for this study.
We measured disadvantage by two proxies: NS-SEC and eligibility for free prescriptions. Both of these have weaknesses. Only personal NS-SEC was available which may not reflect the disadvantage of household members who are not the chief income earner. Secondly, NS-SEC can be difficult to classify. NS-SEC was recorded by advisors rather than researchers with expertise in classifying socio-economic status and the questions asked to ascertain NS-SEC were simpler than those used by government surveys. This may have caused some idiosyncrasies in the results — occasionally quit rates by intervention type for clients with routine and manual occupations were more similar to clients with professional and managerial occupations than to clients with intermediate occupations.
Treatment was free for all clients through the UK government funded National Health Service. In other countries more affluent clients might be asked to pay for treatment. Eligibility for free prescriptions can be determined by medical reasons as well as SES. The collection of data on medical conditions was not collected consistently or in enough detail for us to determine whether the free prescriptions were due to health or income reasons. We excluded pregnant women but data on whether women had a child under the age of one was not collected so we could not exclude such women. Eligibility for free prescriptions is only a measure of disadvantage for 19 to 59 year olds in England. Results for all age groups are presented elsewhere (Murray et al., 2012). In general, results were similar.
SSS level disadvantage did not significantly predict quitting. This may be because the health administration areas were too large or SSS disadvantage does not necessarily correlate with the disadvantage of individual clients. Ethnic minorities varied by health administration area and to increase the robustness of the analysis all ethnic minorities were combined, as the numbers were very small. In future research it would be helpful to analyse individual ethnic groups separately.
The therapy provided by SSS is not standardised and is delivered by a variety of advisor types. The UK's national centre for smoking cessation and training (NCSCT) is aware of this variation and has recently published on the techniques that the evidence suggests are most effective (Michie, Churchill, & West, 2011; West, Walia, Hyder, Shahab, & Michie, 2010).
It is likely that group dynamics affect the chances of successful smoking cessation for smokers who took part in groups (Paddock et al., 2011). Group dynamics are extremely complex to model particularly in an open group setting where members change from session to session (Morgan-Lopez et al., 2011; Paddock et al., 2011) and no attempt to assess these was included here. Thus standard errors may have been underestimated (Paddock et al., 2011). Different group dynamics may exist in groups with all low SES members, all high SES members or mixed membership. In future research focussing on socio-economic status and group dynamics may provide more insight into how to increase quit rates amongst more disadvantaged smokers taking part in open and closed groups.
Another concern with intervention types is that there are similarities between one-to-one and drop-ins, drop-ins and open groups, and open and closed groups. Thus these interventions may in practice lie on a continuum rather than be distinct entities. The same issues apply with age and SSS disadvantage. These continuous variables were divided into quartiles and quintiles to aid interpretation and allow the possibility of non linear effects.
There was significant variation between advisors and between health administration areas in the full multivariate model. Thus there must be more characteristics that can explain the variation which we were not able to model, which may have implications for the quit rates of low SES and high SES groups, such as differences in health administration areas' priorities, leadership, enthusiasm and cultures (Amos et al., 2011) and motivation, gender or rapport with clients for advisors (Hiscock, Moon, Pearce, Barnett, & Daley, 2012).
This study provides new insight into the types of behavioural support and smoking cessation service characteristics that are associated with biochemically validated quit rates amongst smokers from different socio-economic groups. As other studies have found, smokers who were more disadvantaged were less likely to be successful in their quit attempt than more affluent groups, even after accessing cessation services. With the exception of the most disadvantaged clients (the long-term unemployed and prisoners), smokers who attended open group therapy for smoking cessation were more successful than those who received one-to-one support. Clients were equally likely to quit if they received support to stop from staff trained as smoking cessation specialists, health care assistants or pharmacists, but less likely to quit if they were treated by nurses. Further research is required to explore in more detail how the background and training of those involved in delivering smoking cessation services may interact with client characteristics to affect outcomes.
Funding for this study was provided by National Institute of Health Research (NIHR) Health Technology Assessment Programme grant number 09/161/01. The NIHR Health Technology Assessment Programme had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. RH was funded by an Economic and Social Research Council UKCTCS (UK Centre for Tobacco Control Studies) fellowship (RES-590-28-0004) whilst working on this study.
RH undertook much of the analysis and wrote the majority of the first draft and revision of the paper. RH was also a co-applicant on the grant used to fund this study. SM assisted RH with the analysis and the results section of the paper and commented on subsequent drafts. LSB prepared the dataset and contributed to drafting of the paper. AMcE is the Director of the National Centre for Smoking Cessation and Training which holds the dataset used in the analysis and was a co-applicant on the grant. He also revised the paper. JL-B advised on the statistics used in the paper and contributed to the paper. FD is the project manager for the ELONS study which provided the grounds for this paper and contributed to the revision of the paper. LB is the Principal Investigator on the grant, had the original idea for the study and contributed to the paper.
AMcE receives a personal income from Cancer Research UK via University College London. He has received travel funding, honoraria and consultancy payments from manufacturers of smoking cessation products (Pfizer, GSK and Novartis). He also receives payment for providing training to smoking cessation specialists, receives royalties from books on smoking cessation and has a share in a patent of a nicotine delivery device. There are no other conflicts of interest.
We would like to thank North 51 and Stop Smoking Services from 49 PCTs for allowing the Quit Manager database to be used for research purposes and in particular Ian Baker from North 51. We would also like to acknowledge staff at the National Centre for Smoking Cessation and Training (NCSCT) including Michelle Spencer-Williams for contacting PCTs. We would also like to thank ELONS co-investigators for their comments on the paper.
The authors are members of the UK Centre for Tobacco Control Studies (UKCTCS), a UK Centre for Public Health Excellence. Funding from the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Medical Research Council and the National Institute of Health Research, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.

subset: commoncrawl


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Comfort Suites Brunswick
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Waterfront view ?
Beautiful park ! Many places to fish.
Not dog friendly.
Half campsites were on the beach and half on the river.
Riverside has one bathhouse / Air conditioned but not close to all the sites.
Large sites overall.
Rained the first day, flooded 95% of the riverside sites, ours (#54) was the worst with at least 4" of standing water.
No vacant dry spots. Refund issued returned home.
Will try again during dry season. (maybe)
Day 1 solo
... growing stack of stuff on the table to bring to Montana when I join the tour... There is no food in the house except cheese, bread, & cookies from Crust in Michigan, so I should be set!! ((Did I mention that, for whatever reason, I had an empty garbage bag in the air over my head & it got caught in the ceiling fan? I don't know where that scream came ...
Stop SEVEN Myrtle Beach state park SC
Travel day today, 5 1/2 - 6 hours. Went over a bridge that was named after Harriet Tubman. Kyler learned about her in school and memorized a poem about her and he was excited to be able to recite the whole poem, thank you miss Harris!! Stopped at Costco in savannah, gotta restock! The campground is beautiful, completely shaded and we have a 60 foot site. Can even start a fire... Yeah right. Hot and humid here. We were surprised. Haha. Looking forward to going to the ...
A Very Cross Wind...
... the road. Now Jeff has noted in the past, our motorhome is little more than a 13' by 33' fiberglass sail, and when the wind hits us sideways it can be a load of fun, and hit us it did. Our little home on wheels kept going to the right side of the road, and when we got to this very high and very long suspension bridge just outside of Jacksonville, it got a bit scary. Jeff said , "don't worry, all those big bridge cables ...
Spring Photo Shoot Kicks-Off In Georgia!
It's hard to believe it's time for another photo shoot! Our crew and models all arrived last night in Brunswick, GA to begin our 10 day trek for maurices Small Town Charm Campaign. The photo's will feature maurices Spring product that will be in store at the beginning of February. We'll also be traveling to Gulf Shores, AL this weekend and St. George, UT next week.
Brunswick is a small coastal town that boasts about ...


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Funny but sadly too true, thanks Karl!
BLACK BRA size 38
A Chinese guy goes into a Jewish-owned establishment to buy black bras, size 38. The Jewish store keeper, known for his skills as a businessman, says that black bras are rare and that he is finding it very difficult to buy them from his suppliers. Therefore he has to charge $50.00 for them.
The Chinese guy buys 25 bras.
He returns a few days later and this time orders fifty.
The Jewish owner tells him that they have become even harder to get and charges him $60.00 each.
The Chinese guy returns a month later and buys the store's remaining stock of 50, and this time for $75.00 each. The Jewish owner is somewhat puzzled by the large demand for black size 38 bras and asks the Chinese guy, "...please tell me - What do you do with all these black bras?"
The Chinese guy answers: "I cut them in half and sell them as skull caps to Jewish men for $200.00 each."
...and this is why the Chinese own us!
I swear, by my life and my love of it, that I will never live for the sake of another man, nor ask another man to live for mine. - Ayn Rand
Funny but sadly too true, thanks Karl!


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Hyundai testing facelifted Veloster Turbo in Germany
Love it or hate it, you have to admit that Hyundai went against the cookie-cutter norm when it unveiled the Veloster in 2011. And to many eyes, its oddball shape is still refreshingly original. But in the three and a half years since, Hyundai has moved its design language onwards, so it's about time the Korean automaker bring the quirky three-door (or novel four-door, depending on the angle from which you look at it) into the fold. And that's just what it appears to be doing in these latest spy shots.
Though it's hard to tell much from underneath the heavy camouflage, it's clear from these spy shots that this is indeed the Veloster, and given the center-exit dual exhaust tips, it seems to be the Turbo model and not the base naturally aspirated version. It seems to be wearing a bigger grille like the one Hyundai put on the latest Genesis, among others, and new bumpers front and back as well. The half-door on the right side does appear to be carrying over, it's wearing new wheels, and we're told there seems to be something afoot inside the cabin as well - likely revolving around an updated infotainment system.
Whether there are any consequential mechanical changes as well, we don't know. That said, development seems to be in a fairly advanced stage, so we wouldn't be surprised to see a refreshed Veloster on the show stand sometime later this year or early next at the latest.


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Date of Stay: April, 2016
Park is clean and access to the sites easy. Large pull thru sites and easy satellite TV access. Park staff is friendly.
Date of Stay: April, 2016
Telephoned and asked for a pull thru stating I didn't want to unhook for just one night. Told them I was a 45' foot coach towing a Jeep. It is impossible to get into a site without unhooking. Mud everywhere. Almost axel deep in mud getting in. Even if you could get in you would have to unhook to reach the electric. I am very dissatisfied and feel I have been misled. They have no business advertising for big rigs and pull thrus.
Date of Stay: June, 2010
Older park where not much has been done in a long time. Management is very accommodating and friendly. Plans to add spaces and add 50 amp service. Satellite dishes worked fine here. Gravel drives and grass parking. Easy in and out in a 45' motor home. Not much available this far up.
Date of Stay: April, 2010
Very unhappy with the way park is managed. People walk their dogs everywhere, including your site and vacant sites. They parked me in the back between a park employee, whose site looks as if he has lived there forever; and a lady with a 5th wheel with a small motor home in front, which she was remodeling! We had reservations for over 6 weeks prior. Very disappointing stay. This park did NOT meet our expectations and we will not stay here again.


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108 JOHNSON ST, Fairwater WI 53931 $11,900
Features of 108 JOHNSON ST Fairwater WI 53931
- Lots for Sale
- Status: Active
- Mailing City: Fair Water
- County: Fond Du Lac
- Subdivision: Grand Woods View
- School Dist: Markesan Sch Dist
- High School: Markesan
- Property Taxes: $199
- Property Tax Year: 2015
- Listing Company: Century 21 Properties Unlimited
Property Description for 108 JOHNSON ST Fairwater WI 53931
108 JOHNSON ST Fairwater WI 53931 - Affordable Building lot on a Cul-de-sac available in Fairwater`s Grand Woods View sub-division. Great opportunity to build your dream home on this ready to build on lot! Waste Available to Site = Laterals.
Land Features
- Waterfront/Access: N
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|Previous List Price
|Sold Price
|May 20 2016 12:20PM
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Buyer understands that the information which is contained on Data pages is obtained from a number of different sources and which has not been independently verified or confirmed by the various real estate brokers and agents who have been and are involved in this transaction. If any particular measurement or data element is important or material to buyer, Buyer assumes all responsibility and liability to research, verify and confirm said data element and measurement. REALTOR *MLS* Equal Housing Opportunity


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Introduction to Rock Climbing
This introduction to outdoor rock climbing is a great starting point for those with little or no experience of rock climbing or even making the transition from indoor to outdoor climbing. The primary focus is to let you experience what this sport entails by getting you to do as much climbing as possible on a range of different climbs.
Our climbing instructors are there to support and encourage you whilst sharing their knowledge and skills to help you develop in the time available. This course would even suit people who have never climbed indoor or outdoor before or just haven't climbed for many years and want to experience it again.
- Excellent staff ratios allowing more climbing time per person
- More people to ask questions
- Learn from each other
- Personal Climbing Equipment
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- Climbing Guide Books
- How to Belay and Lower off
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Suitable clothing to keep you warm and dry for the expected weather (check a forecast for this area or call us) carry a waterproof or windproof jacket. You will need sturdy footwear for the walk in and out of the crag, a packed lunch and drink. If you have climbing shoes please bring them or alternatively please call us to hire a pair for just £3.00.


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text:
Chinese professionals make their mark in Germany
In the first of a two-part series on China's growing influence in Europe, the newcomers to Germany come armed with MBAs and business cards
Related topics
On a recent Friday, a group of Chinese lawyers, auditors, managers and consultants, armed with business cards, schmoozed on a terrace overlooking a skyline of glass towers. The wine flowed, the hors d'oeuvres circulated and the seeds of potentially valuable relationships were planted.
The faces in the crowd included representatives from the audit, accounting and tax advisory firm Falk & Co, mergers and acquisitions advisers Keller & Coll, and insurer Ergo. They had gathered for talks on buying insurance, setting up limited companies and hiring staff. The event was organised by Steinbeis Consulting Centre China and the law firm Noerr.
Yet this scene did not play out in Shanghai, Hong Kong or Beijing. The location was an office in Frankfurt at No1 Boersenstrasse, next to the city's beating heart, the stock exchange, where securities have been traded for over 130 years - and where 23 mainland and Hong Kong companies have listed since 2007.
As Chinese firms acquire or merge with German ones or establish branches in the country, and as German firms hire staff from China to cater to that country's market, the number of Chinese white-collar workers in major German cities has grown. This is especially so in Frankfurt, Dusseldorf and Hamburg, respectively the country's financial, industrial and cargo hubs.
The small but growing crop of newcomers is nothing like the immigrants who worked in restaurants in the 1980s and 1990s. They wear fine leather shoes, banter in German, shuttle between Europe and China, and hold MBAs and accounting and legal qualifications.
"There has been a big rise in the number of businesspeople who are Chinese here," said Rainer Gehnen, executive director of the German-Chinese Business Association. "There have been so many investments coming from China to Germany, and they need locally experienced legal, tax and management consultants and advisers." Many service providers in Germany hire Chinese professionals to facilitate efficient communication with their Chinese business partners.
While Chinese companies that acquire German ones usually leave the core management unchanged, Chinese liaison managers are still required. "They help to bridge intercultural differences and align German operations with the Chinese owner's global strategy," says Gehnen.
He estimates this new class of Chinese worker has experienced double-digit growth every year for the past few years, corresponding to the general increase in Chinese direct investment in Germany.
Cord Eberspraecher, director of the Confucius Institute in Dusseldorf, said this group of Chinese were "much more self-confident about their own economic strength and what they have to offer".
"This has a lot to do with the companies they are working for," he said. "You can see it from the way they carry themselves."
The growing Chinese presence has been felt not only at the bourse, but in the appearance of more and more restaurants with names like Peking Ente, in the Putonghua heard on trams and trains, and in the news. Last year, China's Sany Heavy Industry agreed to buy German cement pump maker Putzmeister, and equipment manufacturer Weichai Power agreed to buy a stake in forklift maker Kion Group. According to the German Foreign Office, there are 900 Chinese companies in Germany.
For Germany, China is the second-biggest export market outside Europe, after the United States. For China, Germany is the top trading partner in Europe. Last year, German exports to China totalled €66.6 billion (HK$675 billion) and imports came to €77.3 billion.
According to the Central Registry of Foreigners in Germany, there were 86,435 Chinese nationals, including mainlanders and Hongkongers, in the country at the end of 2011. That represented a rise of 6.3 per cent compared to a year earlier and 40 per cent compared to a decade earlier. The most recent increase is unusual against recent years. From 2005 to 2010, the rate was 3.1 per cent at most.
The average age of the Chinese nationals in the country has remained steady at about 31 years old, with an even distribution of men and women.
There were also 102,000 immigrants or foreigners born in the country with a Chinese migration background in 2011.
More students come from China than anywhere else. In 2011, they totalled 22,828, more than double the number from Russia, the second-biggest country of origin.
Many of the Chinese professionals in Germany found jobs after graduating from universities in the country and have at least a working proficiency in the language and familiarity with the culture.
Yao Yuankai, China desk manager at Falk, is one example. The Qingdao native, 33, studied economics, finance and accounting at Frankfurt University, Munich University and Heidelberg University. He has grown adept at navigating cultural differences in his work.
"For Germans, things must be clear, ja or nein. The concept of a jein doesn't actually exist," he said. "Germans are direct about what they want, while Chinese clients won't tell you in very clear terms. You will know what the Chinese want in the end, but it requires a process."
Yao speaks German with his colleagues, keeps a collection of Goethe's works on his bedroom bookshelf, and readily expounds his views on Germany's welfare system, the strength of the country's industry and the hardiness of its women at the drop of a hat. At the same time, he can network Chinese style, dining with work acquaintances three times per week and going to the all-important karaoke gatherings.
And for that there is Melody KTV, whose interiors are decked out in gold wallpaper and chandeliers. Opened in 2008, it is one of two Asian-style karaoke venues in Frankfurt. On the Friday after the Steinbeis talks, this is where the real party starts and where, over beer and singing, relationships are forged.
Yao gets there late. Once there, he dives in, singing and yelling into the mike. When he leaves at 2am, he has downed six beers, but lets everyone else into taxis before leaving himself.
"For Germans, work is work, play is play. When their day is done, they go home to their families," Yao says over a lunch of Sichuan-style fish and dumplings the next day before going into the office. Not so for the Chinese. "For example, we'll play badminton together, but we won't talk business. We'll just play badminton, and we'll do this for a year or so. During this time, the other guy is determining what kind of a person you are, whether you're trustworthy."
As Chinese immigrants go, Yao is relatively new. The first generation arrived in the 19th century. They were merchants, students, diplomats and artists, said Barbara Yu-Demski, author of The Chinese in Berlin and director of the Confucius Institute in the capital. Following a break after the first world war, students from wealthy families and those who were interested in politics and the anti-imperialist movement arrived. Many left with the rise of the Nazis.
The 1980s and early 1990s saw the arrival of more students. Then those fleeing China came, followed in the late 1990s by businesspeople. Since then, the students have kept coming.
Those who arrived in the 1980s and 1990s have a different experience from those who came in the last decade due to what was happening in China. In the 1980s, Deng Xiaoping had just launched his economic reforms and Europe was flourishing. By contrast, those arriving now are coming from a booming economy to a Europe in austerity.
Shau Ying, who runs Shanghai Restaurant in Munich, which his sister opened in 1961, estimates 90 per cent of the Chinese in the country worked in restaurants in the early 1980s. Today Shau, chairman of the Federation of Chinese in Germany, believes that figure has dropped to about 60 per cent.
One Chinese woman, who arrived in 1987, remembers a more difficult time. "The cultural difference was too big," she said.
Things got especially hard when her husband finished his studies and his scholarship ended. "We didn't have much money and we didn't know how we were going to live," said the woman, 50, who declined to provide her full name. "If we were to go back to China, it would be very hard," she said.
The change of cuisine did not help and she missed steamed buns. Unable to find a bamboo steamer, she fashioned a makeshift one by hammering nails through the lid of a cookie tin. Today, steamers can be found at local Asian supermarkets.
Though the Chinese have been coming for decades, the relationship between them and the Germans is not always harmonious.
Eberspraecher says many stay confined to their Chinese working environments and have problems with the language.
He says there is a fear among Germans that the Chinese will take over local jobs, even though it is unfounded. "This comes from the past," he said. "In the 1980s, when the Chinese companies came to buy German ones, that meant a transfer of knowledge and technology away from Germany. Many Germans can't grasp that a Chinese takeover doesn't mean that any more."
Still, there are times when the cultures blend organically, for example one Sunday at a barbecue - or a Grille, a beloved German past-time - at the home of Xiu Haitao, founder and editor of the Chinesische Handelszeitung, a Frankfurt-based Chinese newspaper.
In between bites of lamb and steak, the guests, members of Frankfurt's Chinese community, filled up on noodles, marinated fungus and pickled turnip. After imbibing some German beer and award-winning wines from local vineyards, two men broke into song with German folk tunes. All the while, the two-year-old son of a German-Chinese couple ran around the house, speaking Putonghua.
The Chinese community continues to evolve. With the passage of time, another group has emerged: the children of the immigrants who came in the 1980s and 1990s. While the new arrivals are busy acclimatising to the land of beer, Bach and Bretzeln, this second generation is starting to explore its heritage.
Siyuan He, 24, has decided to do Chinese studies at the Free University in Berlin. During an internship at the magazine Tip-Berlin, she wrote about the Chinese community. "I want to learn about my roots," she says.
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Fenix LD01 and E01 Flashlight Set - $32.98
You can always have light ready-at-hand with the Fenix LD01 and E01 Flashlight Set. The triple-mode LD10 allows you to choose how much light you need based on how much run time you have. The amazing E01 is just three inches long and cranks out 10 lumens for 21 hours. - $32.98


text: CINCINNATI, Nov. 14, 2012 /PRNewswire/ -- d&a's Co-Founder and Chief Research Officer, Kobi Gershoni, accepted the Innovation Capability Award on behalf of d&a Visual Insights. According to P&G, this award "celebrates partnerships that have enabled successful execution of P&G's open innovation vision." (Photo: http://photos.prnewswire.com/prnh/20121114/NE13010) As part of P&G's Annual Connect+Develop (C+D) Partnership Celebration honoring their external innovators, P&G presented awards to its top C+D innovation partners. d&a Visual Insights represented one of seven partners, among hundreds, that P&G recognized. d&a is an ecosystem solutions company that applies intelligence methodologies, advanced technologies, and human insights to provide support for key decision makers across diverse industries. d&a and P&G established their partnership five years ago through P&G's Israeli innovation hub—the P&G Israel House of Innovation (IHI). Since then, d&a has continued to deliver decision support services to P&G through numerous global projects across various business units. Sophie Blum, Founder of P&G IHI and VP of Marketing (Central & Eastern Europe, Middle East, and Africa) for P&G, commented today: "d&a winning this P&G Partnership Award is an important recognition for the role of Israel as a source of innovation for P&G. P&G IHI celebrates this year its fifth anniversary with a track record of forming partnerships with Israeli startups and academia. d&a is a great example of Israeli entrepreneurship, out-of-the-box thinking, and strong willingness to collaborate on a global scale." For the past five years, d&a has partnered with P&G on over a dozen projects in which d&a has provided, and continues to provide, unique landscaping, mapping, and insight generation using intelligence-driven methodologies, data interrogation, visualization technologies, and subject matter expertise. Today, d&a and P&G continue to work together on many dynamic projects across the corporation's different business units. In partnership with client P&G, d&a is dedicated to ongoing decision support backed by intelligence.


text:
Tomato: Gold Nugget by Thompson and Morgan seeds a Cordon.
Early ripening trusses of golden-skinned, cherry-sized oval nuggets of a balanced acid/ sweet taste. Early fruits are almost seedless, thin skinned but resists splitting. Tomato Gold Nugget is best grown outdoors. Seeds are in the RHS Vegetable Collection.
Sowing Instructions
Sow seeds February to mid April, 12mm (1/2 inch) deep in pots or trays of good seed compost, at 20C (68F) under glass or in a propagator.
Growing instructions
When seedlings gain 2 true leaves, transplant into individual 7.5cm (3 inch) pots of compost and maintain a minimum temperature of 15C (59F). Pot on later into 10cm (4 inch) pots for stronger plants for planting out. Plant out end of May, or earlier if in a heated glasshouse, or when first flowers are showing. Allow 3 plants per growbag, 25cm (10 inch) pots or plant into the greenhouse soil. Outdoors plant out from early June, after hardening off and once frost risk has passed. Plants will require support if grown as cordons. Feed with tomato fertiliser once first fruits setting.
Prefers good quality compost and warm conditions. Harvest late July to October.
Cropping Time
100 Days
More Info
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16:49 26th October 2013
Burnley 2 QPR 0
DANNY Ings sent Burnley soaring three points clear at the top of the Championship with a stunning second half strike and a deadly penalty.
Ings struck his 12th goal of the campaign just after the hour mark, combining with strike partner Sam Vokes for the 20th goal of their prolific partnership.
It was no unlucky 13th for the England U21 striker either as he coolly stroked home a clinical spot kick two minutes from time after being upended in the box by Joey Barton.
And with the Clarets defence keeping former striker Charlie Austin under lock and key, a magnificent seventh straight league victory against previously unbeaten Rangers put daylight between the Clarets and their Championship rivals,
Sean Dyche made one change, with Keith Treacy replacing Scott Arfield, who picked up an untimely groin strain in training on Friday.
But it was the visitors who made the better start.
Rangers enjoyed plenty of possession and in the sixth minute Karl Henry met a cut back and forced Tom Heaton to block his drilled effort on the line.
It was Treacy who got the Clarets on the front foot minutes later, with a 60-yard run that was only ended with a last ditch challenge as he charged into the Rangers box.
Rangers then almost gifted Burnley the lead when, from Green's shot goal kick, Henry directed the ball directly into the path of Danny Ings, who was only denied when Geeen dived at his feet,
And as the Clarets built up a head of steam, Kieran Trippier forced Green into an error with a fierce 30 yard free kick that the former England goalkeeper fumbled and was thankful for a clearing header over his own goal from Richard Dunne.
It was quickly becoming an absorbing contest, with Burnley mixing it well with the Londoners.
And a flurry of cards only added to the electric atmosphere, with Joey Barton, David Jones, Karl Henry and Richard Dunne all going into the book for blatant fouls.
Treacy soon followed as the half turned scrappy, with only a Joey Barton drive from distance threatening the opening goal ahead of the break.
Burnley were out first for the restart, and straight on the front foot as Michael Kightly cut in side form the left and saw his low drive deflected wide
And when Trippier dumped the ball deep into the Rangers box 10 minutes into the half, panic spread as Vokes got to it first.
His cushioned header fell perfectly for the inrushing Dean Marney, who was only denied by a last-gasp Assou-Ekotto toe-poke.
But the Clarets were not to be denied - and in the 66th minute Turf Moor erupted.
Ings fed Vokes and sprinted into the space, where his Welsh strike partner delivered a terrific reverse pass.
That was all Ings needed and after taking a touch to compose himself, he beat Green with a sensational finish.
Rangers responded and immediately carved out their best opening of the day, but thankfully for Burnley it was the centre backs who combined.
Clint Hill rose to head a deep free kick square across the six-yard box for Richard Dunne, who skied his first time attempt.
But battling Burnley were a whisker away from doubling the lead in the 75th minute when Treacy whipped a ball into the corroder of uncertainty and Ings, at full stretch, just failed to get a connection.
But the game was up for Rangers in the 88th minute when Barton upended Ings in the area and the Clarets striker dusted himself down to send Green the wrong way.
What a day!
BURNLEY: Heaton, Mee, Duff, Shackell, Trippier, Treacy (
Stock 93)
, Marney (Edgar 84), Jones, Kightly, Vokes, Ings.
Subs: Cisak, Lafferty, Noble, Stanislas, Long
Booked: Jones 33, Treacy 44
QPR: Green, Simpson, Dunne, Hill, Barton, Kranjcar (Phillips 73), Henry (Jenas 68), Hoilett, O'Neill (Chevanton 73), Assou-Ekotto, Austin
Subs; Traore, Onyewu, Murphy, Faurlin
Booked: Barton 26, Hoilett 37, Dunne 39, Simpson 77
Ref: A Haines
Att: 16,047 (1,326)
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Oh God! I'm the first one!
I use to see Once Upon a saturday since the portuguese version. It's the best comics website I've know.
Congratulations again Carlos Ruas.
Now… I'm going to see USQ's feeds.
An example of how man is made in gods image.
Carlos, this is one of the best!


text:
IADIN, Buenos Aires, Argentina
Cardio-Respiratory Poligraphy (CRP) is useful for evaluating patients with suspected Obstructive Sleep Apnea (OSA) in specific situations. Outcome: To describe interobserver variability between an expert and an in-training scorers in the analysis of CRP carried out in patients with suspected OSA. To evaluate the effects of an specific training program in CRP scoring.
20 patients older than 18 years, with suspected OSA, studied with CRP level 3 (Stardust II, Respironics). Scoring was performed by an expert scorer -physician specialized in Sleep Medicine- (A) and an in-training technician with a short experience in scoring PSG (B). Standard criteria established by AASM were applied. Scorers were blinded of patients data and another scorer's results. After first analysis, in-training observer was submitted to an specific CRP scoring training under the supervision of two specialized physicians. 30 days after training program was completed, 20 CRP studies were scored again. Both observers were blinded of patients data and another scorer's results. OSA severity was established according to Respiratory Disturbance Index (RDI), normal < 5ev/h; mild 5–14.9; moderate 15–29.9, severe 30–49.9 and very severe > 50. Interobserver variability in the diagnostic result was valued as the percentage of agreement and kappa coefficient, a kappa value > 0.7 was considered acceptable. Pre and post-training RDI mean differences between scorers were compared.
13/20 males; age 48.1 ± 17.3 ys; BMI 28.6 ± 5. RDI mean difference between scorers was 4.82 ± 5.55 ev/h. When we compared diagnostic classification for every patient between observers the % of concordance was 55% and kappa 0.42. In the post-training evaluation the RDI mean difference fell down to 2.03 ± 2.40 ev/h (p = 0.02) whereas the % of concordance raised to 90% and kappa coeff to 0.87.
When we use CRP for diagnosing OSA the level of agreement between expert scorer and in-training technician is low, but substantially improve after an specific training.
An specific training in CRP scoring and interpretation is simple and very necessary.
Facundo Nogueira, No Financial Disclosure Information; No Product/Research Disclosure Information
Tuesday, November 3, 2009
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authn and authz issues with OUDfchagnon Mar 11, 2014 7:59 PM
I have an application that supports LDAP as a means of authentication and authorization. I would like to have it use our OUD-based identity store. This is not an open system; I have no control over the client's behaviour, so any tweaking I do to make it work must be done on the server side.
Authentication Issue:
If I just enter a username "firstname.lastname" (as is our convention), the application sends this string verbatim to OUD and fails.
[11/Mar/2014:14:49:34 -0400] CONNECT conn=67 from=xxx.xxx.xxx.xxx:44715 to=xxx.xxx.xxx.xxx:1636 protocol=LDAPS
[11/Mar/2014:14:49:34 -0400] BIND REQ conn=67 op=0 msgID=1 type=SIMPLE dn="firstname.lastname"
[11/Mar/2014:14:49:34 -0400] BIND RES conn=67 op=0 msgID=1 result=1 message="The provided value "firstname.lastname" could not be parsed as a valid distinguished name because it contained an RDN containing an empty attribute name" etime=23
This is predictable as the application is not smart enough to expand this username to something smart like "uid=firstname.lastname,ou=People,dc=example,dc=com". However, if I authenticate with this full qualified DN, authentication succeeds.
I don't don't expect my users to remember this ugly DN string. Is there anyway I can tweak the OUD side to accept these types of shortened aliases? Or am I verging on OVD territory here?
Authorization Issue:
The application is capable of mapping it's internal authorization levels to LDAP groups. The problem here is that it uses searches for memberOf (AD) or groupMembership (Novell) attributes in order to ascertain group membership, rather than the conventional memberUid or ismemberOf.
[11/Mar/2014:14:49:59 -0400] SEARCH REQ conn=71 op=1 msgID=2 base="uid=firstname.lastname,ou=People,dc=example,dc=com" scope=baseObject filter="(objectclass=user)" attrs="memberOf,groupMembership"
[11/Mar/2014:14:49:59 -0400] SEARCH RES conn=71 op=1 msgID=2 result=0 nentries=0 etime=0
The result of course is that group membership is not properly found, and thus authorizations are not assigned.
I understand that I can create a virtual attribute, based on ismemberof, but called memberof, which should be able to add support for this query but I cannot find a working recipe to properly add this functionality.
Has anyone done anything like this before?
Running OUD 220.127.116.11.0


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Press release: Mobile Health app wins BT Infinity Lab competition for SMEs with innovative ideas for public services
DC15-151 (31 March 2015)
London based company Babylon wins nationwide competition run by BT, TechHub and Cabinet Office
A company which has built a fully integrated mobile healthcare service has won a nationwide competition to find SMEs with ideas that could change lives run by BT, TechHub and the Cabinet Office.
Babylon, based in Bayswater, London, provides virtual consultations with highly qualified top doctors, along with cutting edge monitoring and diagnostics, one-tap appointment booking and prescription delivery, all via one easy to use app.
The company's owners walked away with the top prize of £15,000, along with six months support from BT to develop their business model and six months membership of TechHub's sold-out innovation space.
The BT Infinity Lab SME Award: Digital Innovation for the Public Sector was fiercely contested with entries from across the UK and Europe.
Seven shortlisted finalists were invited to BT Tower in London on March 26th where they presented their proposals to a panel of BT, Cabinet Office and TechHub industry experts.
Following their Dragon's Den style pitch, the panel privately discussed all the finalists before choosing their top three from a talented group of SMEs.
Babylon was announced as the winner on the night and the two runners-up were Hull-based Educater, which has designed a digital system to ensure every student with special needs and disability has equal opportunities in education and Hackney-based Fluency, which aims to change lives by teaching in-demand digital skills through their learning platform and filling the skills gap in the digital sector. Both received £7,500.
TechHub is BT's partner in the Infinity Lab competition and this was the fifth round in the series aimed at startups and SMEs.
Dr Ali Parsa, Babylon founder and CEO, said: "I love that we've won the BT Infinity Lab award, it's recognition of the impact we can make to change people's lives here in the UK and beyond."
Ian Dalton, president government services and health, BT Global Services, said: "We launched this competition to find SMEs with ideas that could change lives and I am delighted that Babylon was selected as the winner. Their innovative service has the potential to positively impact people's lives and BT will be helping turn their ideas into reality.
"BT has around900,000 SME customers, 63 per cent of our suppliers in the UK are SMEs and SMEs are at the heart of our open innovation model. We have a stake in ensuring that small businesses are given the support and mentoring they need to grow and to be successful. We want to help these businesses to grow, and to encourage new innovators to come forward."
Elizabeth Varley, TechHub Co-founder and CEO, said: "The quality and diversity of submissions was exceptional with a record number of entries."
Stephen Allott, Crown Representative for SMEs, Cabinet Office said: "We have introduced a range of measures to open up Government contracts to small businesses. SMEs in the tech sector have been particularly innovative in seizing the opportunities presented by our reforms and this initiative supports our work in this area."
About BT
BT is one of the world's leading providers of communications services and solutions, serving customers in more than 170 countries. Its principal activities include the provision of networked IT services globally; local, national and international telecommunications services to its customers for use at home, at work and on the move; broadband, TV and internet products and services; and converged fixed/mobile products and services.BT consists principally of five lines of business: BT Global Services, BT Business, BT Consumer, BT Wholesale and Openreach.
For the year ended 31 March 2014, BT Group's reported revenue was £18,287m with reported profit before taxation of £2,312m.
British Telecommunications plc (BT) is a wholly-owned subsidiary of BT Group plc and encompasses virtually all businesses and assets of the BT Group. T Group plc is listed on stock exchanges in London and New York.
For more information, visit www.btplc.com.
For further information
Alan Ball, Head of Global PR and Suzanne Masterton, Head of UK PR


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Every well-run home is teeming with tricks and shortcuts to keep it humming along. We're sharing our best quick tips — for cleaning, organizing and repairing stuff at home — to save you time and money. Click through for today's helpful hint, and links to tons more...
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