Counselor and stimulus control enhancements of a stage-matched expert system intervention for smokers in a managed care setting. Targeting smokers with low readiness to change with tailored and nontailored self-help materials. Feasibility of a telephone-based intervention for support persons to help smokers quit: a pilot study. A randomized trial of smoking cessation interventions in general practice in Italy. Proactive interventions for smoking cessation in general medical practice: a quasi-randomized controlled trial to examine the efficacy of computer-tailored letters and physician-delivered brief advice. A controlled trial of an expert system and self-help manual intervention based on the stages of change versus standard self-help materials in smoking cessation. Adoption, reach and effectiveness of computer-based, practitioner delivered and combined smoking interventions in general medical practices: a three-arm cluster randomized trial. The effectiveness of personalized smoking cessation strategies for callers to a Quitline service. Evaluation of a Dutch community-based smoking cessation intervention. Training pharmacists and pharmacy assistants in the stage-of-change model of smoking cessation: a randomised controlled trial in Scotland. The effectiveness of two smoking cessation programmes for use in general practice: a randomised clinical trial. A randomised controlled trial to evaluate the efficacy of a nurse-provided intervention for hospitalised smokers. Effects of stage-matched repeated individual counseling on smoking cessation: A randomized controlled trial for the high-risk strategy by lifestyle modification (HISLIM) study. Randomized trial of nurse-assisted strategies for smoking cessation in primary care. [Effectiveness of a programme of intensive tobacco counselling by nursing professionals]. Training support persons to help smokers quit: a pilot study. Interactive versus noninteractive interventions and dose-response relationships for stage-matched smoking cessation programs in a managed care setting. A randomized controlled trial of multiple tailored messages for smoking cessation among callers to the cancer information service. A randomized trial of self-help materials, personalized feedback, and telephone counseling with nonvolunteer smokers. A 2-year self-help smoking cessation manual intervention among middle-aged Finnish men: an application of the transtheoretical model. Reaching out, inviting back: using Interactive voice response (IVR) technology to recycle relapsed smokers back to Quitline treatment--a randomized controlled trial. A digital smoking cessation program delivered through internet and cell phone without nicotine replacement (happy ending): randomized controlled trial. Randomized controlled trial of a computer-based, tailored intervention to increase smoking cessation counseling by primary care physicians. Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: a randomised trial in Australian general practice. Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation. Effectiveness of a computer-tailored smoking cessation program: a randomized trial. The effectiveness of personally tailored computer-generated advice letters for smoking cessation. Evaluation of a minimal-contact smoking cessation intervention in an outpatient setting. Randomised trial of three approaches for marketing smoking cessation programmes to Australian general practitioners. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. [The effect of smoking cessation counseling at health checkup]. Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial. Comparing two web-based smoking cessation programs: randomized controlled trial. Evaluating the effectiveness of proactive telephone counselling for smoking cessation in a randomized controlled trial. Nurse-assisted counseling for smokers in primary care. Efficacy of resident training in smoking cessation: a randomized, controlled trial of a program based on application of behavioral theory and practice with standardized patients. A randomized controlled trial of Telephone Counseling with smokeless tobacco users: the ChewFree Minnesota study. Evaluating the effectiveness of a single telephone contact as an adjunct to a self-help intervention for smoking cessation in a randomized controlled trial. A theory-based video messaging mobile phone intervention for smoking cessation: randomized controlled trial.
Previous research has demonstrated the efficacy of an interactive expert system intervention for smoking cessation for a general population. The intervention provides individualized feedback that guides participants through the stages of change for cessation. Enhancing the expert system by adding proactive telephone counseling or a stimulus control computer designed to produce nicotine fading could produce preventive programs with greater population impacts.
                Four interventions were compared: (a) the interactive expert system intervention; (b) the expert system intervention plus counselor calls; (c) the expert system intervention plus the stimulus control computer; and (d) an assessment only condition. A 4 (intervention) x 4 (occasions) (0,6,12, and 18 months) design was used. Smokers were contacted at home via telephone or mail. The initial subject pool was the 24,178 members of a managed care company. Screening was completed for 19,236 members (79.6%), of whom 4,653 were smokers; 85.3% of the smokers were enrolled.
                Thirty-eight percent were in the precontemplation stage, 45% in the contemplation stage, and only 17% in the preparation stage. At 18 months, the expert system resulted in 23.2% point prevalence abstinence, which was 33% greater than that of assessment only. The counselor enhancement produced increased cessation at 12 months but not at 18 months. The stimulus control computer produced no improvement, resulting in 20% worse cessation rates than the assessment only condition.
                The enhanced conditions failed to outperform the expert system alone. The study also demonstrated the ability of the interactive expert system to produce significantly greater cessation in a population of smokers than assessment alone.
                Copyright 2000 American Health Foundation and Academic Press. Few smoking cessation self-help materials are available for smokers who are not planning to quit. However, computer-tailored interventions can be designed specifically for these smokers.
                In a large randomized field trial (N = 843), two different tailored smoking cessation self-help interventions (multiple tailoring and single tailoring) and one standardized smoking cessation self-help guide were compared with a no-information control group and with each other. The contents of the tailored interventions were adapted to individuals' self-reported stage of change, outcome expectations, self-efficacy levels, and smoking behavior.
                The primary outcome measure was forward stage transition. The standardized self-help guide had no effect. Among smokers who were not planning to quit within the next 5 years the multiple-tailored intervention was more effective than the single-tailored intervention. This pattern was supported by the cognitive changes caused by the interventions. Among smokers who were planning to quit within the next 5 years but not within the next 6 months, none of the self-help materials had any effect.
                The present results show that the self-help material currently available in the Netherlands, the standardized self-help guide, was not effective among smokers with low readiness to change. However, computer-generated tailored interventions seem a promising means of communicating information on smoking and smoking cessation to these smokers. Nonsmokers have a potentially supportive role in tobacco cessation efforts. The present study examined the feasibility, acceptability, and potential efficacy of a telephone-based intervention for nonsmoking support persons.
                A total of 59 support persons (mean age = 36 years, 92% female, 95% White) were randomly assigned to a control condition (N = 30; written materials only) or to a social cognitive theory-based intervention (N = 29; written materials and 5 weekly, 20- to 30-min telephone counseling sessions). Both support persons and smokers completed assessments separately by mail at baseline and at weeks 6 (end of treatment) and 26.
                Two thirds of the smokers reported low-moderate levels of motivation to quit at baseline as assessed by the contemplation ladder. Study retention rates were excellent, with 95% of both support persons and smokers completing the week 26 assessment. Moreover, 86% of support persons in the intervention group completed all five telephone sessions. Treatment acceptability was high for both support persons and smokers. Compared with the control condition, the intervention was associated with a significant increase in support person self-efficacy to help their smoker (p = .034) and outcome expectancies (p = .025) from baseline to week 6. However, the intervention was not associated with higher smoking abstinence rates or quit attempts.
                The program was successful in reaching smokers with lower levels of readiness to quit. The intervention was feasible and acceptable to both support persons and smokers. Although support persons and smokers can be engaged in this type of outreach program, refinements in the intervention approach are needed to improve the smoking outcomes. The purpose of this study was to examine the effectiveness of different practice-based approaches to assist patients of primary care physicians to quit smoking and sustain cessation. Forty-four nonsmoking general practitioners volunteered for the study. After a period of training, they randomized 923 smoking clients, unselected for motivation toward quitting, to four different intervention groups: (i) minimal intervention, consisting of one single counselling session and a brief handout on quitting techniques; (ii) repeated counselling including reinforcing sessions at Months 1, 3, 6, and 9; (iii) repeated counselling and use of nicotine gum; and (iv) repeated counselling and spirometry. Biochemically validated smoking status was assessed at six and 12 months after recruitment. The proportion of verified quitters at 12 months was 4.8 percent among subjects randomized to the minimal intervention group, compared to 5.5 percent, 7.5 percent, and 6.5 percent among those randomized to the three repeated-counselling groups. In no treatment group was the outcome significantly different from that for one-time counselling at the (P less than 0.05) level. Lack of power, contamination, and low attendance at reinforcing sessions should be taken into account in interpreting the results. To test the efficacy of (i) computer-generated tailored letters and (ii) practitioner-delivered brief advice for smoking cessation against an assessment-only condition; and to compare both interventions directly.
                Quasi-randomized controlled trial.
                A total of 34 randomly selected general practices from a German region (participation rate 87%).
                A total of 1499 consecutive patients aged 18-70 years with daily cigarette smoking (participation rate 80%).
                The tailored letters intervention group received up to three individualized personal letters. Brief advice was delivered during routine consultation by the practitioner after an onsite training session. Both interventions were based on the Transtheoretical Model of behaviour change.
                Self-reported point prevalence and prolonged abstinence at 6-, 12-, 18- and 24-month follow-ups.
                Among participants completing the last follow-up, 6-month prolonged abstinence was 18.3% in the tailored letters intervention group, 14.8% in the brief advice intervention group and 10.5% in the assessment-only control group. Assuming those lost to follow-up to be smokers, the rates were 10.2%, 9.7% and 6.7%, respectively. Analyses including all follow-ups confirmed statistically significant effects of both interventions compared to assessment only. Using complete case analysis, the tailored letters intervention was significantly more effective than brief advice for 24-hour [odds ratio (OR) = 1.4; P = 0.047] but not for 7-day point prevalence abstinence (OR = 1.4; P = 0.068) for prolonged abstinence, or for alternative assumptions about participants lost to follow-up.
                The study demonstrated long-term efficacy of low-cost interventions for smoking cessation in general practice. The interventions are suitable to reach entire populations of general practices and smoking patients. Computer-generated letters are a promising option to overcome barriers to provide smoking cessation counselling routinely. To examine the population impact and effectiveness of the Pro-Change smoking cessation course based on the Transtheoretical Model (TTM) compared to standard self-help smoking cessation literature.
                Randomized controlled trial.
                Sixty-five West Midlands general practices.
                Randomly sampled patients recorded as smokers by their general practitioners received an invitation letter and 2471 current smokers agreed.
                Responders were randomized to one of four interventions. The control group received standard self-help literature. In the Manual intervention group, participants received the Pro-Change system, a self-help workbook and three questionnaires at 3-monthly intervals, which generated individually tailored feedback. In the Phone intervention group, participants received the Manual intervention plus three telephone calls. In the Nurse intervention group, participants received the Manual intervention plus three visits to the practice nurse.
                Biochemically confirmed point prevalence of being quit and 6-month sustained abstinence, 12 months after study commencement.
                A total of 9.1% of registered current smokers participated, of whom 83.0% were not ready to quit. Less than half of participants returned questionnaires to generate second and third individualized feedback. Telephone calls reached 75% of those scheduled, but few participants visited the nurse. There were small differences between the three Pro-Change arms. The odds ratio (95% confidence intervals) for all Pro-Change arms combined versus the control arm were 1.50 (0.85-2.67) and 1.53 (0.76-3.10), for point prevalence and 6-month abstinence, respectively. This constitutes 2.1% of the TTM group versus 1.4% of the control group achieving confirmed 6-month sustained abstinence.
                There was no statistically significant benefit of the intervention apparent in this trial and the high relapse of quitters means that any population impact is small. Brief advice for smoking patients has not been sufficiently integrated in routine care. Computer-based interventions emerged as a time saving option that might help to exhaust the potential population impact of the general practice setting.
                151 practices were randomly assigned to one of three intervention programs consisting in the delivery of: (1) brief advice by the practitioner; (2) individually tailored computer-generated letters; or (3) a combination of both interventions. We assessed three dimensions of population impact: (1) adoption, i.e., the rate of practices participating in the program; (2) reach, measured as the number of interventions provided within 7 months; (3) effectiveness, measured as smoking abstinence at 12-months follow-up.
                Among the practices, 70% adopted the program with no significant differences across study groups. Treatment was provided to 3086 adult smokers. Negative binomial regression analysis revealed that the number of interventions provided was higher in practices allocated to the tailored letter and combination intervention groups by 215% (p<.01) and 127% (p=.02), respectively, compared to the brief advice intervention group. Among the patients who received the combination of both intervention, the odds of point abstinence from smoking was increased by 65% (p=.02) and 32% (p=.01) compared to the brief advice and tailored letters intervention respectively. Comparing the number of abstinent patients at follow-up revealed that the tailored letter and combination interventions were superior to the brief advice intervention.
                Computer-based interventions alone or in addition to conventional practitioner-delivered advice can foster the participation of general medical practices in tobacco control.
                Copyright © 2011 Elsevier Ireland Ltd. All rights reserved. To assess the effectiveness of a program of computer-generated tailored advice for callers to a telephone helpline, and to assess whether it enhanced a series of callback telephone counselling sessions in aiding smoking cessation.
                Randomized controlled trial comparing: (1) untailored self-help materials; (2) computer-generated tailored advice only, and (3) computer-generated tailored advice plus callback telephone counselling. Assessment surveys were conducted at baseline, 3, 6 and 12 months.
                Victoria, Australia.
                A total of 1578 smokers who called the Quitline service and agreed to participate.
                Smoking status at follow-up; duration of cessation, if quit; use of nicotine replacement therapy; and extent of participation in the callback service.
                At the 3-month follow-up, significantly more (chi2(2) = 16.9; P < 0.001) participants in the computer-generated tailored advice plus telephone counselling condition were not smoking (21%) than in either the computer-generated advice only (12%) or the control condition (12%). Proportions reporting not smoking at the 12-month follow-up were 26%, 23% and 22%, respectively (NS) for point prevalence, and for 9 months sustained abstinence; 8.2, 6.0, and 5.0 (NS). In the telephone counselling group, those receiving callbacks were more likely than those who did not to have sustained abstinence at 12 months (10.2 compared with 4.0, P < 0.05). Logistic regression on 3-month data showed significant independent effects on cessation of telephone counselling and use of NRT, but not of computer-generated tailored advice.
                Computer-generated tailored advice did not enhance telephone counselling, nor have any independent effect on cessation. This may be due to poor timing of the computer-generated tailored advice and poor integration of the two modes of advice. Until 1990, smoking cessation interventions in the Netherlands were limited. The utility and effectiveness of community-based smoking cessation programs have not been examined.
                In a treatment city (Den Bosch) a multicomponent community-based smoking cessation intervention was implemented in which local mass media and general practitioners draw smokers' attention to a local quit line. Telephone counselors advised applicants on their choice between self-help and group treatment and optional telephone counseling. Another Dutch city (Apeldoorn) served as a control. Population samples of smokers (n = 547 and n = 546) were interviewed three times at approximately 7-month intervals. Self-help manual requesters (n = 84) and group participants (n = 83) were interviewed before and 6 months after treatment.
                Treatment modalities were successful; 13% of self-help manual requesters and 22% of group participants were abstinent after 6 months. On a population level the intervention resulted in significantly higher recall of self-help manual and group program in the treatment city. A modest intervention effect on prevalence of abstinence was found at the community level.
                Treatment modalities were effective within their participants, but the intervention effectiveness on a community level was limited. No significant difference was found between quit rates after 14 months (7% in treatment city and 9% in control city). Several system failures could be identified. However, probably the intervention effect was seriously confounded by two national governmental publicity campaigns introducing and reinforcing a mandatory smoking ban and a series of national campaigns initiated by the united Dutch tobacco producers opposing the ban. To evaluate a training workshop for community pharmacy personnel to improve their counselling in smoking cessation based on the stage-of-change model.
                A randomised controlled trial of community pharmacies and pharmacy customers.
                All 76 non-city community pharmacies registered in Grampian, Scotland, were invited to participate. Sixty-two pharmacies (82%) were recruited.
                All the intervention pharmacy personnel were invited to attend the training; 40 pharmacists and 54 assistants attended. A total of 492 customers who smoked (224 intervention, 268 controls) were recruited during the 12-month recruitment period (overall recruitment rate 63%).
                The perceptions of customers and pharmacy personnel of the pharmacy support and self-reported smoking cessation rates for the two groups of customers at one, four, and nine months.
                The intervention customer respondents were significantly more likely to have discussed stopping smoking with pharmacy personnel, 85% (113) compared with 62% (99) of the controls (p < 0.001). The former also rated their discussion more highly; 34% (45) of the intervention customers compared with 16% (25) of the controls rated it as "very useful" (p = 0.048). Assuming non-responders had lapsed, one-month point prevalence of abstinence was claimed by 30% of intervention customers and 24% of controls (p = 0.12); four months' continuous abstinence was claimed by 16% of intervention customers and 11% of controls (p = 0.094); and nine months' continuous abstinence was claimed by 12% of intervention customers and 7% of controls (p = 0.089). These trends in outcome were not affected by potential confounders (sex, age, socioeconomic status, nicotine dependence, and type of nicotine replacement product used) or adjustment for clustering.
                The intervention was associated with increased and more highly rated counselling, and a trend toward higher smoking cessation rates, indicating that community pharmacy personnel have the potential to make a significant contribution to national smoking cessation targets. To evaluate a structured, behavioural change, smoking cessation intervention designed for use within general practice.
                Randomised controlled clinical trial.
                General practices in Newcastle, Australia.
                311 Patients identified as smokers by a screening question were enrolled in the study. Of these, 101 were assigned to a structured behavioural change programme, 104 to a simple advice programme adapted from previous research, and 106 to a control group. No significant differences were found between groups for demographic and smoking related variables before the study.
                Patients in the simple advice group received a brief statement of advice from the general practitioner as well as three pamphlets; those in the structured intervention group were given strategies which included attitude and behavioural change programmes as well as techniques to aid compliance. The amount of smoking in all groups was assessed by self reports with validation by measurement of salivary cotinine concentrations.
                Significant increase in cessation rates.
                Significant differences between controls and the structured behavioural change group were found at the one month follow up, but only for self reported abstinence. The simple advice programme did not produce any significant differences over the control group. General practitioner evaluation of the structured programme highlighted difficulties in relation to the duration of the intervention. Overall the structured programme in its present form did not appear to be an effective programme for use within general practice. Does the provision of a nurse-based intervention lead to smoking cessation in hospital patients?
                At tertiary teaching hospital in Newcastle, Australia, 4,779 eligible (aged 18-80, admitted for at least 24 hours, and able to provide informed consent) and consenting (73.4%) in-patients were recruited into a larger cross-sectional survey. 1,422 (29.7%) smokers (in the last 12 months) were randomly assigned to control (n = 711) or intervention group (n = 711). The brief nurse-delivered intervention incorporated: tailored information, assessment of withdrawal, offer of nicotine replacement therapy, booklets, and a discharge letter. Self-reported cessation at 12 months was validated with CO and salivary cotinine.
                There were no significant differences between groups in self-reported abstinence at three or 12 months post intervention, based on an intention to treat analysis. At three months, self-reported abstinence was 27.3% (I) and 27.5% (C); at 12 months was 18.5% (I) and 20.6% (C). There were no differences in validation of self-report between intervention and control groups at 12 months.
                This brief nurse-provided in-patient intervention did not significantly increase the smoking cessation rates compared with the control group at either three or 12-month follow-up.
                A systematic total quality improvement model of accountable outcome-focused treatment, incorporating assertive physician-led pharmacotherapy, routine assessment and recording of nicotine dependence (ICD 10 coding), in- and outpatient services and engagement from multidisciplinary teams of health professionals may be required to improve treatment modalities for this chronic addictive disorder. The purpose of this study was to evaluate the effects of stage-matched repeated individual behavioral counseling as an intervention for the cessation of smoking.
                We conducted a multisite randomized controlled trial that enrolled smokers unselected for their readiness to quit. There were 979 smokers with hypertension or hypercholesterolemia recruited from 72 study sites and randomly allocated to the intervention or control group. Smokers in the intervention group received stage-matched individual counseling consisting of a 40 minute initial session and four 20-30 minute follow-up sessions. Smokers in the control group received individual behavioral counseling for hypertension or hypercholesterolemia.
                The point prevalence abstinence rate at 6 months, validated by carbon monoxide testing, in the intervention group (13.6%) was 5.4 times higher (p<0.001) than that in the control group (2.5%). When the data were analyzed based on the baseline stage of change, there were significant differences in the abstinence rates at 6 months in smokers versus controls with each stage of change except in immotives. The odds ratio was 6.4 (p<0.001) in precontemplators, 6.7 (p<0.001) in contemplators, and 6.2 (p<0.01) in preparators. There was a positive, consistent effect of the intervention regardless of study site (worksite or community) or the presence of hypertension or hypercholesterolemia.
                We showed the effects of an intervention with repeated individual behavioral counseling on the cessation of smoking in smokers unselected for their readiness to quit. This result suggests that stage-matched individual counseling, based on the transtheoretical model, is effective in smokers with a lower motivation to quit as well as those ready to quit. Brief advice to stop smoking from general practitioners (GPs) has been repeatedly shown to increase smoking cessation by a small, but measurable amount. Some studies have suggested that adding more intensive interventions to brief advice may increase its effectiveness, but it is unclear whether this is true in general practice.
                To determine whether brief advice from a doctor together with counselling and follow-up from a trained practice nurse is more effective than brief advice alone in helping people to stop smoking.
                The design was a randomized controlled trial. Four hundred and ninety-seven general practice patients aged older than 18 years and smoking at least one cigarette per day in six general practices in Oxfordshire, Berkshire, and Buckinghamshire were randomized to one of two interventions: brief verbal or written advice from a GP plus extended counselling and follow-up from a trained practice nurse; brief advice from a GP alone. The primary outcome was sustained abstinence from smoking at three and 12 months. A secondary outcome was forward movement in the stages of change cycle.
                The proportion showing sustained abstinence was 3.6% in the extended counselling group, and 4.4% in the brief advice group (difference = -0.8%; 95% confidence interval = -4.3% to 2.6%). Seventy-four (30%) of those randomized to extended counselling actually took up this offer. No significant progression in stages of change was detected between the two groups.
                In unselected general practice patients who smoke, brief advice from a GP combined with intensive intervention and follow-up by a practice nurse is no more effective than brief advice alone. To determine the effectiveness of a systematic intensive tobacco counselling programme conducted by nursing professionals.
                Randomised clinical trial with control.
                Primary care nursing and medical consultations.
                Smokers requesting help in our centre's medical clinics during the recruitment period, up to the sample size required (125). Inclusion criteria were: aged between 18 and 70, people who smoked during the preceding month any number of cigarettes a day, and a score over 7 on the Richmond test.
                The patients recruited were randomised, according to the clinic from which they came, to the group that received brief counselling from the doctor (control group) or to the group that received brief counselling plus nursing follow-up (intervention group). Follow-up visits were programmed in this latter group for up to 3 months after giving up smoking.
                Abstinence at 12 and 24 months.
                The effectiveness of the intervention considered as the rate of abstinence at 12 months was 13.8% (95% CI, 6.5-24.7) in the control group and 6.7% (95% CI, 1.8-16.2) in the intervention group, with no significant differences between the two.
                In smokers seen in primary care, the effectiveness of a programme of intensive tobacco counselling by nursing staff is no more effective than the doctor's brief, one-off counselling. Brief counselling has a better cost-effectiveness relationship than intensive counselling. Evaluate the feasibility, acceptability, and potential efficacy of a skills-training intervention for adults interested in helping someone to stop smoking (i.e., support persons).
                Sixty adult support persons (77% female) were directly recruited from the community and randomly assigned to this intervention (manual plus five weekly group-based sessions) or a control condition (one-page leaflet). All intervention and outcome assessments occurred through the support persons. Assessments occurred at weeks 0 (baseline), 6 (end of treatment), 12, and 24. The study was conducted from 1998 to 2001; data collection occurred from 1999 to 2000. Outcomes were ratings of treatment acceptability, recruitment and retention rates, supportive behaviors provided to the smoker, and smoking behavior change in the smoker as reported by the support person.
                Support persons were recruited in a timely manner and study retention rates were high. Support persons in skills training showed significant increases in their supportive behavior scores compared with control subjects at weeks 6 and 12. Although not statistically significant, the skills-training intervention was associated with more quit attempts, greater improvement in stage of change, and higher 7-day point prevalence abstinence rates in the smokers than the control condition.
                A skills training intervention for support persons is feasible and acceptable. Further studies are needed to test the efficacy of this approach for smoking cessation. This study compared interactive and noninteractive smoking cessation interventions for a population of smokers who were all members of 1 division of a managed care company. In addition, it examined whether a dose-response relationship existed. Screening was completed for 19,236 members who were contacted by telephone or mail. Of the 4,653 who were identified as smokers, 85.3% were enrolled. A 2 Intervention (interactive or noninteractive) x 4 Contacts (1, 2, 3, or 6 contacts) x 4 Occasions (0, 6, 12, and 18 months) design was used. The interactive intervention was stage-matched expert-system reports plus manuals; the noninteractive intervention was stage-matched manuals. Contact occurred in 1 of 4 series (1, 2, 3 or 6 contacts) at 3-month intervals. The expert system outperformed the stage-matched manuals, but there was no clear dose-response relationship for either intervention. Self-help materials computer-tailored to the specific needs of smokers have shown promise as a high-reach, low-cost intervention for smoking cessation. Adding tailored cessation materials to telephone-based cessation counseling may be a way of generating greater efficacy in promoting and maintaining cessation. The objective of this study is to assess the efficacy of adding different types of behavioral smoking cessation materials to brief telephone-based cessation counseling.A total of 1,978 smokers calling the National Cancer Institute's (NCI's) Cancer Information Service (CIS) for help in quitting smoking initially received brief cognitive-behavioral cessation counseling from a CIS information specialist. Following a baseline interview administered by the information specialist, subjects were randomly assigned to one of four conditions, each delivered by U.S. mail: a single, untailored smoking cessation guide (SU); a single, tailored smoking cessation guide (ST); a series of four (multiple) printed materials tailored only to baseline data (MT); and a series of four (multiple) printed materials tailored to baseline as well as retailored using 5-month interim progress data (MRT). The primary outcome measure was 7-day point prevalence abstinence rates assessed using a computer-assisted telephone interview (CATI) at 12-month follow-up.At 12-month follow-up, using intent-to-treat, imputed, and per-protocol analyses, no differences were found among the four experimental conditions (linear trend), or when the ST, MT, and MRT groups were compared with the control (SU) group. Participants in the two multiple message group conditions combined (MT + MRT), however, had significantly higher abstinence rates than participants in the two single message group conditions combined (SU + ST). Moreover, among subjects who reported quitting at the 5-month follow-up, participants receiving the MRT materials reported higher abstinence rates at 12 months than the other three groups combined (SU + ST + MT). The results of this study support the effectiveness, over and above a single telecounseling interaction, of multiple tailored print material contacts on cessation. These effects, however may be due to tailoring, or the longitudinal nature of the two multiple tailored conditions, or both. The strongest evidence for tailoring occurred in the MRT condition for relapse prevention, suggesting that print materials tailored to interim progress may be especially effective in this context. The qualities of specific psychosocial and communication elements in tailored materials should receive attention in future research. The incremental effects of (a) a self-help booklet alone, (b) self-help booklet with computer-generated personalized feedback, and (c) self-help booklet, personalized feedback, and outreach telephone counseling were evaluated in a population-based, nonvolunteer sample of smokers. Smokers (N = 1,137) were identified through a telephone survey of a random sample of 5,903 enrollees in a health maintenance organization and randomized to a no-treatment control group or 1 of the 3 intervention conditions. Smoking status was ascertained 3, 12, and 21 months postrandomization. Cotinine validation of self-reported cessation was obtained at the 12-month follow-up. Overall, the telephone counseling significantly increased smoking cessation at the 3-month follow-up, but not at 12 or 21 months. Among smokers who were precontemplative at baseline, telephone counseling significantly increased prevalent abstinence at 3 and 12 months and continuous abstinence at 21 months (defined as self-reported abstinence at 3, 12, and 21 months). A 2-year self-help manual smoking cessation intervention was conducted among a panel of middle-aged Finnish men (n = 265) who were recruited proactively in a longitudinal cardiovascular risk factor surveillance study.
                Intervention utilized the stages of change concept of the transtheoretical model. The stages were assessed in the treatment condition at baseline of the cessation study and after that by mail every sixth month. Assessments were followed by an immediate mailing of a stage-based self-help manual matching the stage of change at that time. A usual care group was assessed annually but received no treatment.
                A significant time x intervention effect (P < 0.05) and time x baseline stage effect (P < 0.001) on quit rates were observed in the panel data over the 2-year period. An analysis of changes in the stages of change also revealed an accelerated cessation process in the treatment condition.
                We conclude that mailed stage-matched self-help smoking cessation manuals were able to accelerate the smoking cessation process but manuals alone may not constitute a sufficient long-term intervention. The effects of differential exposure to intervention, subject characteristics, measurement reactivity, and secular trends are discussed as potential confounds. Tobacco dependence is a chronic, relapsing condition that typically requires multiple quit attempts and extended treatment. When offered the opportunity, relapsed smokers are interested in recycling back into treatment for a new, assisted quit attempt. This manuscript presents the results of a randomized controlled trial testing the efficacy of interactive voice response (IVR) in recycling low income smokers who had previously used quitline (QL) support back to QL support for a new quit attempt.
                A sample of 2985 previous QL callers were randomized to either receive IVR screening for current smoking (control group) or IVR screening plus an IVR intervention. The IVR intervention consists of automated questions to identify and address barriers to re-cycling in QL support, followed by an offer to be transferred to the QL and reinitiate treatment. Re-enrollment in QL services for both groups was documented.
                The IVR system successfully reached 715 (23.9%) former QL participants. Of those, 27% (194/715) reported to the IVR system that they had quit smoking and were therefore excluded from the study and analysis. The trial's final sample was composed of 521 current smokers. The re-enrollment rate was 3.3% for the control group and 28.2% for the intervention group (p < .001). Logistic regression results indicated an 11.2 times higher odds for re-enrollment of the intervention group than the control group (p < .001). Results did not vary by gender, race, ethnicity, or level of education, however recycled smokers were older (Mean = 45.2; SD = 11.7) than smokers who declined a new treatment cycle (Mean = 41.8; SD = 13.2); (p = 0.013). The main barriers reported for not engaging in a new treatment cycle were low self-efficacy and lack of interest in quitting. After delivering IVR messages targeting these reported barriers, 32% of the smokers reporting low self-efficacy and 4.8% of those reporting lack of interest in quitting re-engaged in a new QL treatment cycle.
                Proactive IVR outreach is a promising tool to engage low income, relapsed smokers back into a new cycle of treatment. Integration of IVR intervention for recycling smokers with previous QL treatment has the potential to decrease tobacco-related disparities.
                ClinicalTrials.gov Identifier: NCT01260597. Happy Ending (HE) is an intense 1-year smoking cessation program delivered via the Internet and cell phone. HE consists of more than 400 contacts by email, Web pages, interactive voice response, and short message service technology. HE includes a craving helpline and a relapse prevention system, providing just-in-time therapy. All the components of the program are fully automated.
                The objectives were to describe the rationale for the design of HE, to assess the 12-month efficacy of HE in a sample of smokers willing to attempt to quit without the use of nicotine replacement therapy, and to explore the potential effect of HE on coping planning and self-efficacy (prior to quitting) and whether coping planning and self-efficacy mediate treatment effect.
                A two-arm randomized controlled trial was used. Subjects were recruited via Internet advertisements and randomly assigned to condition. Inclusion criteria were willingness to quit on a prescribed day without using nicotine replacement and being aged 18 years or older. The intervention group received HE, and the control group received a 44-page self-help booklet. Abstinence was defined as "not even a puff of smoke, for the last seven days" and was assessed by means of Internet surveys or telephone interviews 1, 3, 6, and 12 months postcessation. The main outcome was repeated point abstinence (ie, abstinence at all four time points). Coping planning and self-efficacy were measured at baseline and at the end of the preparation phase (ie, after 2 weeks of treatment, but prior to cessation day).
                A total of 290 participants received either the HE intervention (n=144) or the control booklet (n=146). Using intent-to-treat analysis, participants in the intervention group reported clinically and statistically significantly higher repeated point abstinence rates than control participants (20% versus 7%, odds ratio [OR] = 3.43, 95% CI = 1.60-7.34, P = .002). Although no differences were observed at baseline, by the end of the preparation phase, significantly higher levels of coping planning (t(261) = 3.07, P = .002) and precessation self-efficacy (t(261) = 2.63, P = .01) were observed in the intervention group compared with the control group. However, neither coping planning nor self-efficacy mediated long-term treatment effect. For point abstinence 1 month after quitting, however, coping planning and self-efficacy showed a partial mediation of the treatment effect.
                This 12-month trial documents a long-term treatment effect of a fully automated smoking cessation intervention without the use of nicotine replacement therapy. The study adds to the promise of using digital media in supporting behavior change. The primary care visit represents an important venue for intervening with a large population of smokers. However, physician adherence to the Smoking Cessation Clinical Guideline (5As) remains low. We evaluated the effectiveness of a computer-tailored intervention designed to increase smoking cessation counseling by primary care physicians.
                Physicians and their patients were randomized to either intervention or control conditions. In addition to brief smoking cessation training, intervention physicians and patients received a one-page report that characterized the patients' smoking habit and history and offered tailored recommendations. Physician performance of the 5As was assessed via patient exit interviews. Quit rates and smoking behaviors were assessed 6 months postintervention via patient phone interviews. Intervention effects were tested in a sample of 70 physicians and 518 of their patients. Results were analyzed via generalized and mixed linear modeling controlling for clustering.
                Intervention physicians exceeded controls on "Assess" (OR 5.06; 95% CI 3.22, 7.95), "Advise" (OR 2.79; 95% CI 1.70, 4.59), "Assist-set goals" (OR 4.31; 95% CI 2.59, 7.16), "Assist-provide written materials" (OR 5.14; 95% CI 2.60, 10.14), "Assist-provide referral" (OR 6.48; 95% CI 3.11, 13.49), "Assist-discuss medication" (OR 4.72;95% CI 2.90, 7.68), and "Arrange" (OR 8.14; 95% CI 3.98, 16.68), all p values being < 0.0001. Intervention patients were 1.77 (CI 0.94, 3.34,p = 0.078) times more likely than controls to be abstinent (12 versus 8%), a difference that approached, but did not reach statistical significance, and surpassed controls on number of days quit (18.4 versus 12.2, p < .05) but not on number of quit attempts.
                The use of a brief computer-tailored report improved physicians' implementation of the 5As and had a modest effect on patients' smoking behaviors 6 months postintervention. GPs often lack time to provide intensive cessation advice for patients who smoke. This study aimed to determine the effectiveness of opportunistic referral of smokers by their GP for telephone cessation counselling by a trained nurse.
                Adult smokers (n = 318) attending 30 GPs in South Western Sydney, Australia were randomly allocated to usual care or referral to a telephone-based program comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse. Self-reported point prevalence abstinence at six and 12 months was compared between groups. Characteristics of patients who accepted and completed the intervention were investigated.
                Of 169 smokers randomised to the intervention, 76 (45%) consented to referral. Compared with smokers in 'pre-contemplation', those further along the stage-of-change continuum were significantly more likely to consent (p = 0.003). Those further along the continuum also were significantly more likely to complete all four calls of the intervention (OR 2.6, 95% CI: 0.8-8.1 and OR 8.6, 95% CI: 1.7-44.4 for 'contemplation' and 'preparation' respectively). At six months, there was no significant difference between groups in point prevalence abstinence (intention to treat) (9% versus 8%, p = 0.7). There was no evidence of differential intervention effectiveness by baseline stage-of-change (p = 0.6) or patient sex (p = 0.5). At 12 months, point prevalence abstinence in the intervention and control groups was 8% and 6% respectively (p = 0.6).
                Acceptance of opportunistic referral for nurse delivered telephone cessation advice was low. This trial did not demonstrate improved quit rates following the intervention. Future research efforts might better focus support for those patients who are motivated to quit. AUSTRALIAN CLINICAL TRIALS REGISTRY NUMBER: ACTRN012607000091404. A stage-matched expert system intervention was evaluated on 4144 smokers in a two-arm randomized control trial with four follow-ups over 24 months. Smokers were recruited by random digit-dial calls, and 80.0% of the eligible smokers were enrolled. Individualized and interactive expert system computer reports were sent at 0, 3, and 6 months. The reports provided feedback on 15 variables relevant for progressing through the stages. The primary outcomes were point prevalence and prolonged abstinence rates. At 24 months, the expert system resulted in 25.6% point prevalence and 12% prolonged abstinence, which were 30% and 56% greater than the control condition. Abstinence rates at each 6-month follow-up were significantly greater in the Expert System (ES) condition than in the comparison condition with the absolute difference increasing at each follow-up. A proactive home-based stage-matched expert system smoking cessation program can produce both high participation rates and relatively high abstinence rates. From a public health perspective, prevention of cancer and cardiovascular diseases requires effective smoking cessation programs that can be used on a large scale.
                To test the effectiveness of a new computer-tailored smoking cessation program vs no intervention.
                Randomized controlled trial, in the French-speaking part of Switzerland, September 20, 1998, to December 31, 1999. Potential participants were randomly selected from a general population register and recruited by mail. Daily cigarette smokers who wished to participate (N = 2934) were randomized to either the program or no intervention. A mean of 1.5 times per 6 months, participants in the active arm received by mail a computer-tailored counseling letter based on their answers to a questionnaire and stage-matched booklets. The counseling letters were tailored to the participants' stage of change (categorized as precontemplation [no intention of quitting smoking in the next 6 months], contemplation [seriously considers quitting in the next 6 months], or preparation [has decided to quit in the next 30 days]), level of tobacco dependence, self-efficacy, and personal characteristics. The outcome measure was self-reported abstinence (no puff of tobacco smoke in the past 4 weeks) 7 months after entry into the program.
                Abstinence was 2.6 times greater in the intervention group than in the control group (5.8% vs 2.2%, P<.001). The program was effective in "precontemplators" who were not motivated to quit smoking at baseline (intervention vs control, 3.8% vs 0.8%; P =.001) and was effective regardless of perceived difficulty in quitting smoking at baseline.
                The program was effective in increasing smoking cessation rates. Because it can reach a large number of smokers, this program can substantially contribute to disease prevention at a population level. To assess the effectiveness of a new computer-generated tailored advice programme designed to be used by smokers and recent quitters having problems staying stopped.
                Randomized trial comparing a series of questionnaire assessments leading to tailored computer-generated advice letters mailed at strategically relevant times, to a no extra treatment control sent standardized printed self-help materials.
                Victoria, Australia.
                A total of 1058 smokers or recent quitters recruited from callers to the Quitline.
                Smoking status and sustained abstinence at 12-month follow-up, plus extent of participation in the intervention.
                Using a conservative analysis (missing data coded as a treatment failure), 6-month sustained abstinence was reported by significantly more participants in the computer-generated tailored advice (20%) than the standard printed materials condition (12%) at 12-month follow-up OR 1.82 (1.31-2.55)). Group differences in point prevalence abstinence (28% intervention, 25% control) were not significant. Among participants in the tailored advice condition, 6-month sustained abstinence was associated with the number of advice letters received.
                The provision of a series of tailored, computer-generated advice letters resulted in greater rates of sustained cessation than for controls. A dose-response relationship was found, with increased compliance with the intervention associated with improved cessation outcomes. The programme appears to have much of its effect by preventing relapse. We examined the ability of a provider-initiated, minimal-contact intervention to modify the smoking behavior of ambulatory clinic patients. Smokers at two outpatient sites were assigned to one of three groups: provider intervention only (PI); provider intervention plus self-help manual (PI/M); and usual care (control) group (C). The physician message emphasized the patient's personal susceptibility, the physician's concern, and the patient's ability to quit (self-efficacy). The nurse consultation concentrated on benefits and barriers associated with stopping, and on strategies for cessation. Telephone interviews were conducted with the 250 participants within a few days of their clinic visit and again at one and six months. Both PI and PI/M proved to be superior to usual care in motivating attempts to quit at both one-month and six-month follow-ups, and logistic regression analyses indicated that participants receiving the self-help manual in addition to the health provider message were between two and three times more likely to quit smoking during the study period than were participants in either of the other study groups. To compare three approaches for marketing a quit smoking intervention kit to general practitioners.
                Randomised trial of (a) personal delivery and presentation by an educational facilitator with a follow up visit six weeks later; (b) delivery to the receptionist by a friendly volunteer courier with a follow up phone call six weeks later, or (c) postal delivery with a follow up letter six weeks later.
                Melbourne, Australia.
                264 randomly selected general practitioners.
                A research assistant visited each doctor four months after delivery and measured use of components of the kit. A questionnaire measuring perceptions of aspects of the kit and its delivery was completed by doctors. Costs of each approach were calculated.
                Doctors receiving the educational facilitator approach were significantly more likely than those receiving the other two approaches to have seen the kit, to rate the method of delivery as engendering motivation to try the kit, to have used one of the "intensive intervention" components from the kit, to report that they found the kit less complicated, and to report greater knowledge of how to use the kit. There were no significant differences in use of "minimal intervention" components of the kit, ratings of overall acceptability of delivery, perceptions of cultural and structural barriers to using the kit, and ratings of the overall acceptability of the kit. The cost of the educational facilitator approach ($A142/doctor) was 24 times that of the mailed approach. The volunteer courier approach ($A14) was twice the cost of the mailed approach.
                Educational facilitators and volunteer couriers do not seem to be cost effective strategies for distributing smoking interventions. Smokers (N = 756) were randomly assigned by stage of change to (a) standardized self-help manuals (ALA+ condition), (b) individualized manuals matched to stage (TTT condition), (c) interactive expert-system computer reports plus individualized manuals (ITT condition), or (d) a personalized condition with 4 counselor calls, stage manuals, and computer reports (PITT condition). Over 18 months, the ITT group's results more than doubled those of the ALA+ group on abstinence measures. The ALA+ and TTT conditions were equivalent over 12 months, but at 18 months the TTT condition was more effective. The ITT condition was the best or comparable with the best treatment at all follow-ups for smokers at all stages of change. Results suggest that an effective expert system has been developed, and discussion focuses on delivering this system to entire populations of smokers. Smoking cessation counseling is an important element of tobacco control in the workplace, but it is not easy to persuade workers to stop smoking. We performed a controlled intervention trial to evaluate the effectiveness of a new cessation program developed by Nakamura et al., which consisted of one brief individual counseling session and 4 follow-up telephone calls. Two hundred and twenty-eight smokers who visited our center for an annual health checkup were randomly divided into two group: 117 were assigned to the intervention group, and 111 were controls. Smoking status questionnaires were administered to assess the smoking habit of each subject and to evaluate their stages of change toward smoking cessation before the counseling session. Stage-matched cessation counseling was then provided to the intervention group by nurses who had completed training courses for this program. During the counseling session, carbon monoxide in expired air and nicotine metabolites in urine were measured to enhance self-perception of smoking. Only those clients who set a quit date during their counseling sessions received follow-up telephone calls. It was easy to implement this program (15 to 20 minutes long) during a health checkup. No significant differences were observed in the baseline characteristics of the two groups. The cross-sectional smoking cessation rates at 6 months and 1 year of follow-up were 6.2 times higher in the intervention group than in the control group. The continuous smoking cessation rate at 1 year of follow-up was 7.6 times higher in the intervention group than in the control group. In the intervention group, the lower level of nicotine metabolites in urine and higher smoking stage were related to cessation success, but other baseline characteristics were similar in those who quit smoking and those who did not. The effectiveness and easy applicability of this cessation program was proved in the present study. Further examinations in various settings are expected to clarify the effectiveness of this program. To evaluate the effectiveness of two teaching interventions to increase residents' performance of smoking cessation counseling.
                Randomized controlled factorial trial.
                Eleven residency programs, in internal medicine (six), family medicine (three), and pediatrics (two). Programs were located in three university medical centers and four university-affiliated community hospitals.
                261 residents who saw ambulatory care patients at least one half-day per week, and 937 returning patients aged 17 to 75 years who reported having smoked five or more cigarettes in the preceding seven days. Of the 937, 843 were eligible for follow-up, and 659 (78%) were interviewed by phone at six months.
                Two interventions (tutorial and prompt) and four groups. The tutorial was a two-hour educational program in minimal-contact smoking cessation counseling for residents. The prompt was a chart-based reminder to assist physician counseling. One group of residents received the tutorial; one, the prompt; and one, both. A fourth group received no intervention.
                Six months after the intervention, physician self-reports showed that residents in the tutorial + prompt and tutorial-only groups had used more counseling techniques (1.5-1.9) than had prompt-only or control residents (0.9). Residents in all three intervention groups advised more patients to quit smoking (76-79%) than did control group residents (69%). The tutorial had more effect on counseling practices than did the prompt. Physician confidence, perceived preparedness, and perceived success followed similar patterns. Exit interviews with 937 patients corroborated physician self-reports of counseling practices. Six months later, self-reported and biochemically verified patient quitting rates for residents in the three intervention groups (self-reported: 5.3-8.2%; biochemically verified: 3.4-5.7%) were higher than those for residents in the control group (self-reported: 5.2%; biochemically verified: 1.7%), though the differences were not statistically significant.
                A simple and feasible educational intervention can increase residents' smoking cessation counseling. Smoking cessation remains a significant public health problem. Innovative interventions that use the Internet have begun to emerge that offer great promise in reaching large numbers of participants and encouraging widespread behavior change. To date, the relatively few controlled trials of Web-based smoking cessation programs have been limited by short follow-up intervals.
                We describe the 6-month follow-up results of a randomized controlled trial in which participants recruited online were randomly assigned to either a Web-based smoking cessation program (Quit Smoking Network; QSN) or a Web-based exercise enhancement program (Active Lives) adapted somewhat to encourage smoking cessation.
                The study was a two-arm randomized controlled trial that compared two Web-based smoking cessation programs: (1) the QSN intervention condition presented cognitive-behavioral strategies, and (2) the Active Lives control condition provided participants with guidance in developing a physical activity program to assist them with quitting. The QSN condition provided smoking cessation information and behavior change strategies while the Active Lives condition provided participants with physical activity recommendations and goal setting. The QSN condition was designed to be more engaging (eg, it included multimedia components) and to present much greater content than is typically found in smoking cessation programs.
                Contrary to our hypotheses, no between-condition differences in smoking abstinence were found at 3- and 6-month follow-up assessments. While participants in the QSN intervention condition spent more time than controls visiting the online program, the median number of 1.0 visit in each condition and the substantial attrition (60.8% at the 6-month follow-up) indicate that participants were not as engaged as we had expected.
                Contrary to our hypothesis, our test of two Web-based smoking cessation conditions, an intervention and an attention placebo control, failed to show differences at 3- and 6-month assessments. We explored possible reasons for this finding, including limited engagement of participants and simplifying program content and architecture. Future research needs to address methods to improve participant engagement in online smoking cessation programs. Possible approaches in this regard can include new informed consent procedures that better explain the roles and responsibilities of being a research participant, new program designs that add more vitality (changing content from visit to visit), and new types of reminders pushed out to participants to encourage return visits. Simplifying program content through a combination of enhanced tailoring and information architecture also merits further research attention. To evaluate the effectiveness of repeated-contact proactive telephone counselling for smoking cessation in a UK setting.
                Randomized controlled trial.
                The Quitline, an established national telephone counselling service available throughout the UK.
                A total of 1,457 callers to the Quitline in 2000 and 2001 were allocated randomly to a Control group to receive usual care or to a Repeated Contact group to be offered five proactive calls in addition to usual care. MEASUREMENTS Prolonged abstinence and 24-hour point-prevalent abstinence 6 and 12 months after recruitment, quit attempts and 24-hour periods of abstinence in non-quitters.
                No significant differences were found between the Repeated Contact and Control groups on prolonged or point-prevalent abstinence. On an intention-to-treat basis, 9.5% of the Control group were abstinent for longer than 6 months at the 12-month follow-up, compared with 9.3% of the Repeated Contact group; 18.9% and 20.2%, respectively, were point-prevalent abstinent at the 6-month follow-up. Significantly more non-quitters in the Control group made a quit attempt in the first 6 months following recruitment than in the Repeated Contact group (62.6%/56.1%, P < 0.05). CONCLUSIONS Proactive telephone counselling did not significantly increase abstinence rates, and appeared to decrease quit attempts, in callers to the Quitline. A non-structured, client-led counselling protocol and insufficient pre-quit motivational counselling could account for the lack of effect. Physician-delivered advice to stop smoking is effective, but time demands often reduce the number of smokers who receive assistance. We evaluated three nurse-assisted interventions designed to minimize physician burden and increase counseling in primary care settings.
                Randomized controlled trial with a 12-month follow-up.
                Internal medicine and family practice offices in a health maintenance organization.
                Smokers (n = 3161) who were patients of participating physicians or other medical care providers (n = 60).
                Medical care providers delivered a 30-second stop-smoking prompt to 2707 smokers and referred them to an on-site nurse smoking counselor. The nurse randomly provided a two-page pamphlet (advice control) or one of three nurse-assisted interventions: 1) self-quit training; 2) referral to a group cessation program; or 3) a combination of self-quit training and referral. Each nurse-delivered intervention included a 10-minute video, written materials, and a follow-up phone call.
                Physicians delivered brief advice to 86% of identified smokers during the 1-year program. The proportion of participants reporting abstinence after both 3 and 12 months of follow-up nearly doubled (P = 0.01) for the nurse-assisted self-quit (7.1%), group-referral (7.6%), and combination (6.9%) interventions, compared to brief physician advice alone (3.9%) (P < 0.05). Saliva cotinine tests confirmed these effects (P < 0.004), although quit rates were lower (3.4%, 4.7%, 4.3%, and 2.3%, respectively) because roughly one half of quitters chose not to provide a saliva sample and were counted as smokers.
                Involving nurses in counseling smokers reduces physician burden, makes counseling more likely, and significantly increases cessation rates compared with brief physician advice alone. New educational programs must be developed to improve physicians' skills and effectiveness in counseling patients about smoking cessation.
                To assess the efficacy of an educational program based on behavioral theory, active learning methods, and practice with standardized patients in helping patients abstain from smoking and changing physicians' counseling practices.
                Cluster randomized, controlled trial.
                Two general internal medicine clinics in Switzerland.
                35 residents and 251 consecutive smoking patients.
                A training program administered over two half-days, during which physicians learned to provide counseling that matched smokers' motivation to quit and practiced these skills with standardized patients acting as smokers at different stages of change. The control intervention was a didactic session on management of dyslipidemia.
                Self-reported abstinence from smoking at 1 year of follow-up, which was validated by exhaled carbon monoxide testing at one clinic; score of overall quality of counseling based on use of 14 counseling strategies; patient willingness to quit; and daily cigarette consumption.
                At 1 year of follow-up, abstinence from smoking was significantly higher in the intervention group than in the control group (13% vs. 5%; P = 0.005); this corresponded to a cluster-adjusted odds ratio of 2.8 (95% CI, 1.4 to 5.5). Residents who received the study training provided better counseling than did those who received the control training (mean score, 4.0 vs. 2.7; P = 0.002). Smokers' willingness to quit was also higher in the intervention group (94% vs. 80%; P = 0.007). A nonsignificant trend toward lower daily cigarette consumption in the intervention group was observed.
                A training program in smoking cessation administered to physicians that was based on behavioral theory and practice with standardized patients significantly increased the quality of physicians' counseling, smokers' motivation to quit, and rates of abstinence from smoking at 1 year. Although a considerable body of evidence supports telephone quit lines for smoking cessation, much less is known about the effectiveness of proactive Telephone Counseling with smokeless tobacco (ST) users. We conducted a randomized controlled trial comparing Telephone Counseling with the distribution of a self-help manual for ST cessation. We recruited 406 adult ST users throughout the state of Minnesota and randomized them to receive either: (a) a self-help manual (Manual only) or (b) a self-help manual plus proactive telephone-based cessation counseling (Telephone Counseling). The telephone-based treatment included up to four calls in support of quitting, and personalized various cognitive and behavioral strategies that are generally considered effective in tobacco cessation (such as setting a quit date, examining patterns of use, developing stress reduction skills, avoiding known triggers to use). Participants were surveyed by phone at 3 and 6 months to assess both point prevalence and continued abstinence. Prolonged abstinence from all tobacco was 6.8% and 30.9% (p < .001) at 3 months and 9.8% and 30.9% (p < .001) at 6 months in Manual only and Telephone Counseling, respectively. We found older age, lower dependency, and increased readiness predicted quitting success. Proactive telephone-based counseling is an effective strategy for improving cessation rates among ST users. Future research should determine the components contributing to the intervention success. This study evaluated the effects of including a single brief prequit telephone counseling session in a self-help program for smoking cessation conducted through the mail, by comparison with the effects of the self-help program alone. Volunteer participants from northwestern Spain (N = 228) were randomly assigned to one of two groups: (a) the self-help-only group (n = 110, mean age = 37.4 years, pretreatment cigarette consumption = 26.5 cigarettes/day) or (b) the telephone-support group (n = 118, mean age = 36.8 years, pretreatment cigarette consumption = 27.7 cigarettes/day). Using a conservative data analysis method (missing data considered as treatment failures), we found that the point-prevalence abstinence rate was significantly higher in the telephone-support group than in the self-help-only group at the end of treatment (44.9% vs. 21.8%) and at the 3-month follow-up (39.0% vs. 26.4%). Likewise, sustained abstinence was significantly higher in the telephone-support group at the 3-month follow-up (33.9% vs. 13.6%), the 6-month follow-up (25.4% vs. 12.7%), and the 12-month follow-up (21.2% vs. 9.1%). The results of this randomized controlled trial indicate that both treatments are an effective aid for smoking cessation, and that a single brief telephone call before the quit date is a low-cost and effective procedure for improving abstinence rates in a mailed self-help program. Advances in technology allowed the development of a novel smoking cessation program delivered by video messages sent to mobile phones. This social cognitive theory-based intervention (called "STUB IT") used observational learning via short video diary messages from role models going through the quitting process to teach behavioral change techniques.
                The objective of our study was to assess the effectiveness of a multimedia mobile phone intervention for smoking cessation.
                A randomized controlled trial was conducted with 6-month follow-up. Participants had to be 16 years of age or over, be current daily smokers, be ready to quit, and have a video message-capable phone. Recruitment targeted younger adults predominantly through radio and online advertising. Registration and data collection were completed online, prompted by text messages. The intervention group received an automated package of video and text messages over 6 months that was tailored to self-selected quit date, role model, and timing of messages. Extra messages were available on demand to beat cravings and address lapses. The control group also set a quit date and received a general health video message sent to their phone every 2 weeks.
                The target sample size was not achieved due to difficulty recruiting young adult quitters. Of the 226 randomized participants, 47% (107/226) were female and 24% (54/226) were Maori (indigenous population of New Zealand). Their mean age was 27 years (SD 8.7), and there was a high level of nicotine addiction. Continuous abstinence at 6 months was 26.4% (29/110) in the intervention group and 27.6% (32/116) in the control group (P = .8). Feedback from participants indicated that the support provided by the video role models was important and appreciated.
                This study was not able to demonstrate a statistically significant effect of the complex video messaging mobile phone intervention compared with simple general health video messages via mobile phone. However, there was sufficient positive feedback about the ease of use of this novel intervention, and the support obtained by observing the role model video messages, to warrant further investigation.
                Australian New Zealand Clinical Trials Registry Number: ACTRN12606000476538; http://www.anzctr.org.au/trial_view.aspx?ID=81688 (Archived by WebCite at http://www.webcitation.org/5umMU4sZi).
Based on four trials using direct comparisons, stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents. Thirty-one trials of stage-based self help or counselling interventions versus any control condition demonstrated levels of effectiveness which were comparable with their non-stage-based counterparts. Providing these forms of practical support to those trying to quit appears to be more productive than not intervening. However, the additional value of adapting the intervention to the smoker's stage of change is uncertain. The evidence is not clear for other types of staged intervention, including telephone counselling, interactive computer programmes and training of physicians or lay supporters. The evidence does not support the restriction of quitting advice and encouragement only to those smokers perceived to be in the preparation and action stages.