Non-UK purchasers will have to pay a small fee for post and packing. For European countries the c... more Non-UK purchasers will have to pay a small fee for post and packing. For European countries the cost is £2 per monograph and for the rest of the world £3 per monograph.
To evaluate the relative cost-effectiveness of nicotine replacement therapy (NRT) and bupropion S... more To evaluate the relative cost-effectiveness of nicotine replacement therapy (NRT) and bupropion SR for smoking cessation, the authors reviewed published studies and developed a decision analytic model from the UK National Health Services perspective. Irrespective of the methods or assumptions involved, the results of published studies consistently indicated that NRT for smoking cessation is cost-effective. No published studies have evaluated the relative cost-effectiveness of bupropion SR for smoking cessation. The results of the decision analyses indicated that, as compared with ad-vice or counseling alone, the incremental cost per life-years saved is about $1,441~$3,455 for NRT, $920~$2,150 for bupropion SR, and $1,282~$2,836 for NRT plus bupropion SR. The cost-effectiveness of adding NRT and bupropion SR to advice or counseling for smoking cessation is better than many other accepted health care interventions.
Objectives: To evaluate the effectiveness in helping pregnant women stop smoking of two intervent... more Objectives: To evaluate the effectiveness in helping pregnant women stop smoking of two interventions (Pro-Change for a healthy pregnancy) based on the transtheoretical model of behaviour change (TTM) compared to current standard care. Design: Cluster randomised trial. Setting: Antenatal clinics in West Midlands, UK general practices. Participants: 918 pregnant smokers Interventions: 100 general practices were randomised into the three trial arms. Midwives in these practices delivered three interventions: A (standard care), B (TTM based self help manuals), and C (TTM based self help manuals plus sessions with an interactive computer program giving individualised smoking cessation advice). Main outcome measures: Biochemically confirmed smoking cessation for 10 weeks previously, and point prevalence abstinence, both measured at 30 weeks of pregnancy and 10 days after delivery. Results: There were small differences between the TTM arms. Combining the two arms, the odds ratios at 30 weeks were 2.09 (95% confidence interval (CI) 0.90 to 4.85) for 10 week sustained abstinence and 2.92 (95% CI 1.42 to 6.03) for point prevalence abstinence relative to controls. At 10 days after delivery, the odds ratios were 2.81 (95% CI 1.11 to 7.13) and 1.85 (95% CI 1.00 to 3.41) for 10 week and point prevalence abstinence respectively. Conclusions: While there is a small borderline significant increase in quitting in the combined intervention arms compared with the controls, the effect of the intervention is small. At 30 weeks gestation and at 10 days postnatal, only about 3% of the intervention groups achieved sustained cessation, with numbers needed to treat of 67 (30 weeks of gestation) and 53 (10 weeks postnatal) for one additional woman to achieve sustained confirmed cessation. Given also that the intervention was resource intensive, it is of doubtful benefit.
Aim To examine the population impact and effectiveness of the Pro-Change smoking cessation course... more Aim 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. Design Randomized controlled trial. Setting Sixty-five West Midlands general practices. Participants Randomly sampled patients recorded as smokers by their general practitioners received an invitation letter and 2471 current smokers agreed. Interventions 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. Measurements Biochemically confirmed point prevalence of being quit and 6month sustained abstinence, 12 months after study commencement. Findings 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 6month abstinence, respectively. This constitutes 2.1% of the TTM group versus 1.4% of the control group achieving confirmed 6-month sustained abstinence. Conclusions 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.
Background: There is insufficient and conflicting evidence about whether more intensive behaviour... more Background: There is insufficient and conflicting evidence about whether more intensive behavioural support is more effective than basic behavioural support for smoking cessation and whether primary care nurses can deliver effective behavioural support. Methods: A randomised controlled trial was performed in 26 UK general practices. 925 smokers of >10 cigarettes per day were randomly allocated to basic or weekly support. All participants were seen before quitting, telephoned around quit day, and seen 1 and 4 weeks after the initial appointment (basic support). Participants receiving weekly support had an additional telephone call at 10 days and 3 weeks after the initial appointment and an additional visit at 2 weeks to motivate adherence to nicotine replacement and renew quit attempts. 15 mg/16 h nicotine patches were given to all participants. The outcome was assessed by intention to treat analyses of the percentage confirmed sustained abstinence at 4, 12, 26 and 52 weeks after quit day. Results: Of the 469 and 456 participants in the basic and weekly arms, the numbers (%) who quit and the percentage difference were 105 (22.4%) vs 102 (22.4%), 0.1% (95% CI 25.3% to 5.5%) at 4 weeks, 66 (14.1%) vs 52 (11.4%), 22.6% (95% CI 26.9% to 1.7%) at 12 weeks, 50 (10.7%) vs 40 (8.8%), 21.9% (95% CI 25.7% to 2.0%) at 26 weeks and 36 (7.7%) vs 30 (6.6%), 21.1% (95% CI 24.4% to 2.3%) at 52 weeks. Conclusions: The absolute quit rates achieved are those expected from nicotine replacement alone, implying that neither basic nor weekly support were effective. Primary care smoking cessation treatment should provide pharmacotherapy with sufficient support only to ensure it is used appropriately, and those in need of support should be referred to specialists.
A Parsons, research fellow, 1 A Daley, senior lecturer, NIHR career scientist, 2 R Begh, research... more A Parsons, research fellow, 1 A Daley, senior lecturer, NIHR career scientist, 2 R Begh, research associate, 1 P Aveyard, clinical reader, NIHR career scientist 1 ABSTRACT Objective To systematically review the evidence that smoking cessation after diagnosis of a primary lung tumour affects prognosis.
Background: There is insufficient and conflicting evidence about whether more intensive behaviour... more Background: There is insufficient and conflicting evidence about whether more intensive behavioural support is more effective than basic behavioural support for smoking cessation and whether primary care nurses can deliver effective behavioural support. Methods: A randomised controlled trial was performed in 26 UK general practices. 925 smokers of >10 cigarettes per day were randomly allocated to basic or weekly support. All participants were seen before quitting, telephoned around quit day, and seen 1 and 4 weeks after the initial appointment (basic support). Participants receiving weekly support had an additional telephone call at 10 days and 3 weeks after the initial appointment and an additional visit at 2 weeks to motivate adherence to nicotine replacement and renew quit attempts. 15 mg/16 h nicotine patches were given to all participants. The outcome was assessed by intention to treat analyses of the percentage confirmed sustained abstinence at 4, 12, 26 and 52 weeks after quit day. Results: Of the 469 and 456 participants in the basic and weekly arms, the numbers (%) who quit and the percentage difference were 105 (22.4%) vs 102 (22.4%), 0.1% (95% CI 25.3% to 5.5%) at 4 weeks, 66 (14.1%) vs 52 (11.4%), 22.6% (95% CI 26.9% to 1.7%) at 12 weeks, 50 (10.7%) vs 40 (8.8%), 21.9% (95% CI 25.7% to 2.0%) at 26 weeks and 36 (7.7%) vs 30 (6.6%), 21.1% (95% CI 24.4% to 2.3%) at 52 weeks. Conclusions: The absolute quit rates achieved are those expected from nicotine replacement alone, implying that neither basic nor weekly support were effective. Primary care smoking cessation treatment should provide pharmacotherapy with sufficient support only to ensure it is used appropriately, and those in need of support should be referred to specialists.
Objective: To discover the importance of social sources of tobacco to young people as opposed to ... more Objective: To discover the importance of social sources of tobacco to young people as opposed to commercial sources; to describe the peer market for cigarettes in schools and the consequences for young people of their involvement in it.Study design: Cross sectional questionnaire survey, one-to-one interviews, and focus groups.Setting: Seven schools in Birmingham, UK.Subjects: All students in two randomly selected classes from each school completed the questionnaire, and never smokers, occasional smokers, and regular smokers were interviewed.Results: Two thirds of occasional smokers and one quarter of regular smokers obtained cigarettes socially, mostly for free. A few smokers regularly bought their cigarettes from others. Among friendship groups, both smokers and non-smokers were involved in the exchange of cigarettes, often for money, which is a common activity. A few young people use the selling of cigarettes to fund their own smoking. Some young people, smokers and non-smokers, are involved in semi-commercial selling of cigarettes. All school students are aware of where to purchase cigarettes from non-friends, which is only used “in emergency” because of the high price. One school had a strong punishment policy for students caught with cigarettes. In this school, more people bought singles from the peer market and the price was higher.Conclusions: The passing and selling of cigarettes in school is a common activity, which from the young persons perspective, ensures that all share cross counter purchases. A few people are prepared to use the peer market for monetary gain and it appears to be responsive to external conditions. The peer market might mean that efforts to control illegal sales of cigarettes are not as effective as hoped.
Objective To test the efficacy of nortriptyline plus nicotine replacement therapy compared with p... more Objective To test the efficacy of nortriptyline plus nicotine replacement therapy compared with placebo plus nicotine replacement therapy for smoking cessation. Design Pragmatic randomised controlled trial. Setting National Health Service stop smoking service clinics. Participants 901 people trying to stop smoking. Interventions Participants chose their nicotine replacement product, including combinations of nicotine replacement therapy, and received behavioural support. Nortriptyline was started one to two weeks before quit day, with the dose increased from 25 mg to 75 mg daily for eight weeks and reduced if not tolerated. Main outcome measures Primary outcome was prolonged confirmed abstinence at six months. Secondary outcomes were prolonged abstinence at 12 months, drug use, severity of side effects, nicotine withdrawal symptoms, and urges to smoke. Results 72 of 445 (16%) people using nortriptyline and 55 of 456 (12%) using placebo achieved prolonged abstinence at six months (relative risk 1.34, 95% confidence interval 0.97 to 1.86). At 12 months the corresponding values were 49 (11%) for nortriptyline and 40 (9%) for placebo (1.26, 0.84 to 1.87). 337 (79%) people in the nortriptyline arm and 325 (75%) in the placebo arm were taking combination treatment on quit day, median 75 mg per day in both groups. More people in the nortriptyline arm than in the placebo arm took lower doses. The nortriptyline arm had noticeably higher severity ratings for dry mouth and constipation than the placebo arm, with slightly higher ratings for sweating and feeling shaky. Both groups had similar urges to smoke, but nortriptyline reduced depression and anxiety. Overall, withdrawal symptom scores did not differ. Conclusions Nortriptyline and nicotine replacement therapy are both effective for smoking cessation but the effect of the combination is less than either alone and evidence is lacking that combination treatment is more effective than either alone. Trial registration Current Controlled Trials ISRCTN57852484.
School nurses: policies, working practices, roles and value perceptions Background. In the UK, sc... more School nurses: policies, working practices, roles and value perceptions Background. In the UK, school nursing has recently been at the forefront of policy change, with school nurses being considered pivotal to child-centred public health practice. There is very little literature on this topic and, in particular, little that is written from a practitioner perspective. Aim. This paper reports a survey that examines the work of school nurses compared with the expectations of their first line managers and policy-makers in government, in order to discover any potential practical or ideological areas of conflict. Methods. We first applied a theoretical framework of sensitizing concepts to the historical, political, cultural and contextual background of school nursing. Following this, 46 school nurses in the West Midlands region of the UK were randomly selected and asked to complete a questionnaire about their personal characteristics, experience, training and working practices. The 38 nurses who completed this were then interviewed. Job descriptions for school nurses and governmental job expectations were obtained from various official sources and compared with the self-reported practices of school nurses. Findings. All the nurses met the work criteria of their local employers, except in respect of health needs assessment activities, which two nurses had not yet attempted. All 38 also carried out a range of additional work activities, including providing sexual health services and parental support clinics. They also had a diverse range of skills and qualifications relevant to supporting the needs of their local communities. Qualitative data from interviews provided a useful insight into nurses' feelings of being valued by their clients and by local and national employers, and feelings of professional undervaluing by their peers. They felt positive about role changes in the last few years, and that they supported the child-centred public health role advocated by public policy.
The stages of change model underpins the British Gov-Background. The transtheoretical model (TTM)... more The stages of change model underpins the British Gov-Background. The transtheoretical model (TTM) and ernment's creation of a network of smoking cessation computer technology are promising technologies for clinics . However, as it is often used, the stages of changing health behavior, but there is little evidence change model represents little more than a commonof their effectiveness among adolescents.
This paper outlines a novel explanatory frame for understanding how schools may intervene in orde... more This paper outlines a novel explanatory frame for understanding how schools may intervene in order to promote pupils' health. The new theory is synthesised from an Aristotelian interpretation of human functioning and a theory of cultural transmission. In keeping with recent influential theoretical developments, it is proposed that health has its roots in human functioning. It follows from this concept that the promotion of pupils' health is facilitated by the promotion of pupil functioning and the primary mechanisms through which schools promote pupil functioning and, hence, health, are through the influences of school organisation, curriculum development and pedagogic practice on pupil development. According to the new theory, good human functioning is dependent on the realisation of a number of identified essential human capacities and the meeting of identified fundamental human needs. Two essential capacities, the capacity for practical reasoning and the capacity for affiliation with other humans, plan and organise the other essential capacities. The realisation of these two capacities should, it is argued, be the primary focus of health promoting schools. Additionally, health promoting schools should ensure that fundamental human needs concerning non-useful pain and information about the body are met. A number of testable hypotheses are generated from the new theory. Comparisons with existing interpretations of health promoting schools indicate there are similarities in the actions schools should take to promote health. However, the new theory can, uniquely, be used to predict which pupils will enjoy the best health at school and in adulthood. Additionally, according to the new theory, schools do not need designated health education classes or teaching staff with specialist health education roles in order to be health promoting. It is concluded that the new theory may have a number of advantages over existing theories at both the policy and intervention levels. r
Journal of Epidemiology and Community Health, 2007
Objective: To determine whether value-added education is associated with lower risk of substance ... more Objective: To determine whether value-added education is associated with lower risk of substance use among adolescents: early initiation of alcohol use (regular monthly alcohol consumption in grade 7), heavy alcohol use (.10 units per week) and regular illicit drug use. Design: Cross-sectional self-reported survey of alcohol and drug use. Analysis used two-level logistic modelling to relate schools providing value-added education with pupils' substance use. The value-added education measure was derived from educational and parenting theories proposing that schools providing appropriate support and control enhance pupil functioning. It was operationalised by comparing observed and expected examination success and truancy rates among schools. Expected examination success and truancy rates were based on schools' sociodemographic profiles. Participants: Data were collected across 15 West Midlands English school districts and included 25 789 pupils in grades 7, 9 and 11 from 166 UK secondary schools. Results: Value-added education was associated with reduced risk of early alcohol initiation (OR (95% CI) 0.87 (0.78 to 0.95)) heavy alcohol consumption (OR 0.91 (0.85 to 0.96)) and illicit drug use (OR 0.90 (0.82 to 0.98)) after adjusting for gender, grade, ethnicity, housing tenure, eligibility for free school meal, drinking with parents and neighbourhood deprivation. Conclusions: The prevalence of substance use in school is influenced by the school culture. Understanding the mechanism through which the school can add value to the educational experience of pupils may lead to effective prevention programmes.
Objectives. To examine whether, as predicted by the transtheoretical model (TTM), stage-matched i... more Objectives. To examine whether, as predicted by the transtheoretical model (TTM), stage-matched interventions will be more effective than stage-mismatched interventions.
Bjog-an International Journal of Obstetrics and Gynaecology, 2002
Objective To examine whether routinely measured variables explained the increased risk of preterm... more Objective To examine whether routinely measured variables explained the increased risk of preterm delivery in some UK ethnic groups. Design Cross sectional study of deliveries recorded in the Child Health Record System.
Aims To evaluate the effect on quitting smoking at 18 months postpartum of smoking cessation int... more Aims To evaluate the effect on quitting smoking at 18 months postpartum of smoking cessation interventions based on the Transtheoretical Model (TTM) delivered in pregnancy compared to current standard care. It has been claimed that TTM-based interventions will continue to create quitters after the end of the intervention period.Design Cluster randomized trial.Setting Antenatal clinics in general practices in the West Midlands, UK.Participants A total of 918 pregnant smokers originally enrolled in the trial, of which 393 women were followed-up at 18 months postpartum.Interventions One hundred general practices were randomized into the three trial arms. Midwives in these practices delivered three interventions: A (standard care), B (TTM-based self-help manuals) and C (TTM-based self-help manuals plus sessions with an interactive computer program giving individualized smoking cessation advice).Measurements Self-reported continuous and point prevalence abstinence since pregnancy.Findings When combined together, there was a slight and not significant benefit for both TTM arms compared to the control, with an odds ratio (OR) 95% confidence interval (CI) of 1.20 (0.29–4.88) for continuous abstinence. For point prevalence abstinence, the OR (95%CI) was 1.15 (0.66–2.03). Seven of the 54 (13%) women who had quit at the end of pregnancy were still quit 18 months later, and there was no evidence that the TTM-based interventions were superior in preventing relapse.Conclusions The TTM-based interventions may have shown some evidence of a short-term benefit for quitting in pregnancy but no benefit relative to standard care when followed-up in the longer-term.
The objectives of this review were to examine whether smoking prevalence varies between schools i... more The objectives of this review were to examine whether smoking prevalence varies between schools independently of health promotion programmes and pupil composition, to show which school characteristics are responsible for this variation, and to examine the methodological adequacy of such studies. Searches for published studies were performed on medical, educational and social science databases, relevant articles' reference lists, and citation searches. Any study was included that described inter-school variation in smoking prevalence, or related such variation to school characteristics. A model relating pupil smoking to school, neighbourhood, and pupil characteristics unlikely and likely to be influenced by school was used to examine the adequacy of control of confounding by pupil composition. Data from studies were combined qualitatively considering methodological adequacy to examine the relation of smoking prevalence to school characteristics. Theoretical frameworks underpinning the choice of school characteristics and postulated relationships between these characteristics and smoking prevalence were described. There were large variations in smoking prevalence between ostensibly similar schools. Evidence that pupil composition did not cause this was weak, because all studies had methodological problems, including under control of relevant pupil compositional factors and over control of factors likely to represent the mechanism through which schools influence pupils' smoking. There was little evidence that elements of tobacco control policy other than bans and enforcement deterred smoking. Academic practice and school ethos were related to smoking. Academically selective schools did not influence smoking, once pupil composition was controlled. There was one study on neighbourhood influences, which were unrelated to smoking. Studies frequently offered little or no theoretical justification for associating school characteristics with smoking. Some aspects of school influence pupils' smoking, probably independently of pupil composition. However, under-control and over-control of confounding and lack of theoretical underpinning precludes definitive conclusions on how particular school characteristics influence pupils' smoking. r
Non-UK purchasers will have to pay a small fee for post and packing. For European countries the c... more Non-UK purchasers will have to pay a small fee for post and packing. For European countries the cost is £2 per monograph and for the rest of the world £3 per monograph.
To evaluate the relative cost-effectiveness of nicotine replacement therapy (NRT) and bupropion S... more To evaluate the relative cost-effectiveness of nicotine replacement therapy (NRT) and bupropion SR for smoking cessation, the authors reviewed published studies and developed a decision analytic model from the UK National Health Services perspective. Irrespective of the methods or assumptions involved, the results of published studies consistently indicated that NRT for smoking cessation is cost-effective. No published studies have evaluated the relative cost-effectiveness of bupropion SR for smoking cessation. The results of the decision analyses indicated that, as compared with ad-vice or counseling alone, the incremental cost per life-years saved is about $1,441~$3,455 for NRT, $920~$2,150 for bupropion SR, and $1,282~$2,836 for NRT plus bupropion SR. The cost-effectiveness of adding NRT and bupropion SR to advice or counseling for smoking cessation is better than many other accepted health care interventions.
Objectives: To evaluate the effectiveness in helping pregnant women stop smoking of two intervent... more Objectives: To evaluate the effectiveness in helping pregnant women stop smoking of two interventions (Pro-Change for a healthy pregnancy) based on the transtheoretical model of behaviour change (TTM) compared to current standard care. Design: Cluster randomised trial. Setting: Antenatal clinics in West Midlands, UK general practices. Participants: 918 pregnant smokers Interventions: 100 general practices were randomised into the three trial arms. Midwives in these practices delivered three interventions: A (standard care), B (TTM based self help manuals), and C (TTM based self help manuals plus sessions with an interactive computer program giving individualised smoking cessation advice). Main outcome measures: Biochemically confirmed smoking cessation for 10 weeks previously, and point prevalence abstinence, both measured at 30 weeks of pregnancy and 10 days after delivery. Results: There were small differences between the TTM arms. Combining the two arms, the odds ratios at 30 weeks were 2.09 (95% confidence interval (CI) 0.90 to 4.85) for 10 week sustained abstinence and 2.92 (95% CI 1.42 to 6.03) for point prevalence abstinence relative to controls. At 10 days after delivery, the odds ratios were 2.81 (95% CI 1.11 to 7.13) and 1.85 (95% CI 1.00 to 3.41) for 10 week and point prevalence abstinence respectively. Conclusions: While there is a small borderline significant increase in quitting in the combined intervention arms compared with the controls, the effect of the intervention is small. At 30 weeks gestation and at 10 days postnatal, only about 3% of the intervention groups achieved sustained cessation, with numbers needed to treat of 67 (30 weeks of gestation) and 53 (10 weeks postnatal) for one additional woman to achieve sustained confirmed cessation. Given also that the intervention was resource intensive, it is of doubtful benefit.
Aim To examine the population impact and effectiveness of the Pro-Change smoking cessation course... more Aim 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. Design Randomized controlled trial. Setting Sixty-five West Midlands general practices. Participants Randomly sampled patients recorded as smokers by their general practitioners received an invitation letter and 2471 current smokers agreed. Interventions 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. Measurements Biochemically confirmed point prevalence of being quit and 6month sustained abstinence, 12 months after study commencement. Findings 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 6month abstinence, respectively. This constitutes 2.1% of the TTM group versus 1.4% of the control group achieving confirmed 6-month sustained abstinence. Conclusions 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.
Background: There is insufficient and conflicting evidence about whether more intensive behaviour... more Background: There is insufficient and conflicting evidence about whether more intensive behavioural support is more effective than basic behavioural support for smoking cessation and whether primary care nurses can deliver effective behavioural support. Methods: A randomised controlled trial was performed in 26 UK general practices. 925 smokers of >10 cigarettes per day were randomly allocated to basic or weekly support. All participants were seen before quitting, telephoned around quit day, and seen 1 and 4 weeks after the initial appointment (basic support). Participants receiving weekly support had an additional telephone call at 10 days and 3 weeks after the initial appointment and an additional visit at 2 weeks to motivate adherence to nicotine replacement and renew quit attempts. 15 mg/16 h nicotine patches were given to all participants. The outcome was assessed by intention to treat analyses of the percentage confirmed sustained abstinence at 4, 12, 26 and 52 weeks after quit day. Results: Of the 469 and 456 participants in the basic and weekly arms, the numbers (%) who quit and the percentage difference were 105 (22.4%) vs 102 (22.4%), 0.1% (95% CI 25.3% to 5.5%) at 4 weeks, 66 (14.1%) vs 52 (11.4%), 22.6% (95% CI 26.9% to 1.7%) at 12 weeks, 50 (10.7%) vs 40 (8.8%), 21.9% (95% CI 25.7% to 2.0%) at 26 weeks and 36 (7.7%) vs 30 (6.6%), 21.1% (95% CI 24.4% to 2.3%) at 52 weeks. Conclusions: The absolute quit rates achieved are those expected from nicotine replacement alone, implying that neither basic nor weekly support were effective. Primary care smoking cessation treatment should provide pharmacotherapy with sufficient support only to ensure it is used appropriately, and those in need of support should be referred to specialists.
A Parsons, research fellow, 1 A Daley, senior lecturer, NIHR career scientist, 2 R Begh, research... more A Parsons, research fellow, 1 A Daley, senior lecturer, NIHR career scientist, 2 R Begh, research associate, 1 P Aveyard, clinical reader, NIHR career scientist 1 ABSTRACT Objective To systematically review the evidence that smoking cessation after diagnosis of a primary lung tumour affects prognosis.
Background: There is insufficient and conflicting evidence about whether more intensive behaviour... more Background: There is insufficient and conflicting evidence about whether more intensive behavioural support is more effective than basic behavioural support for smoking cessation and whether primary care nurses can deliver effective behavioural support. Methods: A randomised controlled trial was performed in 26 UK general practices. 925 smokers of >10 cigarettes per day were randomly allocated to basic or weekly support. All participants were seen before quitting, telephoned around quit day, and seen 1 and 4 weeks after the initial appointment (basic support). Participants receiving weekly support had an additional telephone call at 10 days and 3 weeks after the initial appointment and an additional visit at 2 weeks to motivate adherence to nicotine replacement and renew quit attempts. 15 mg/16 h nicotine patches were given to all participants. The outcome was assessed by intention to treat analyses of the percentage confirmed sustained abstinence at 4, 12, 26 and 52 weeks after quit day. Results: Of the 469 and 456 participants in the basic and weekly arms, the numbers (%) who quit and the percentage difference were 105 (22.4%) vs 102 (22.4%), 0.1% (95% CI 25.3% to 5.5%) at 4 weeks, 66 (14.1%) vs 52 (11.4%), 22.6% (95% CI 26.9% to 1.7%) at 12 weeks, 50 (10.7%) vs 40 (8.8%), 21.9% (95% CI 25.7% to 2.0%) at 26 weeks and 36 (7.7%) vs 30 (6.6%), 21.1% (95% CI 24.4% to 2.3%) at 52 weeks. Conclusions: The absolute quit rates achieved are those expected from nicotine replacement alone, implying that neither basic nor weekly support were effective. Primary care smoking cessation treatment should provide pharmacotherapy with sufficient support only to ensure it is used appropriately, and those in need of support should be referred to specialists.
Objective: To discover the importance of social sources of tobacco to young people as opposed to ... more Objective: To discover the importance of social sources of tobacco to young people as opposed to commercial sources; to describe the peer market for cigarettes in schools and the consequences for young people of their involvement in it.Study design: Cross sectional questionnaire survey, one-to-one interviews, and focus groups.Setting: Seven schools in Birmingham, UK.Subjects: All students in two randomly selected classes from each school completed the questionnaire, and never smokers, occasional smokers, and regular smokers were interviewed.Results: Two thirds of occasional smokers and one quarter of regular smokers obtained cigarettes socially, mostly for free. A few smokers regularly bought their cigarettes from others. Among friendship groups, both smokers and non-smokers were involved in the exchange of cigarettes, often for money, which is a common activity. A few young people use the selling of cigarettes to fund their own smoking. Some young people, smokers and non-smokers, are involved in semi-commercial selling of cigarettes. All school students are aware of where to purchase cigarettes from non-friends, which is only used “in emergency” because of the high price. One school had a strong punishment policy for students caught with cigarettes. In this school, more people bought singles from the peer market and the price was higher.Conclusions: The passing and selling of cigarettes in school is a common activity, which from the young persons perspective, ensures that all share cross counter purchases. A few people are prepared to use the peer market for monetary gain and it appears to be responsive to external conditions. The peer market might mean that efforts to control illegal sales of cigarettes are not as effective as hoped.
Objective To test the efficacy of nortriptyline plus nicotine replacement therapy compared with p... more Objective To test the efficacy of nortriptyline plus nicotine replacement therapy compared with placebo plus nicotine replacement therapy for smoking cessation. Design Pragmatic randomised controlled trial. Setting National Health Service stop smoking service clinics. Participants 901 people trying to stop smoking. Interventions Participants chose their nicotine replacement product, including combinations of nicotine replacement therapy, and received behavioural support. Nortriptyline was started one to two weeks before quit day, with the dose increased from 25 mg to 75 mg daily for eight weeks and reduced if not tolerated. Main outcome measures Primary outcome was prolonged confirmed abstinence at six months. Secondary outcomes were prolonged abstinence at 12 months, drug use, severity of side effects, nicotine withdrawal symptoms, and urges to smoke. Results 72 of 445 (16%) people using nortriptyline and 55 of 456 (12%) using placebo achieved prolonged abstinence at six months (relative risk 1.34, 95% confidence interval 0.97 to 1.86). At 12 months the corresponding values were 49 (11%) for nortriptyline and 40 (9%) for placebo (1.26, 0.84 to 1.87). 337 (79%) people in the nortriptyline arm and 325 (75%) in the placebo arm were taking combination treatment on quit day, median 75 mg per day in both groups. More people in the nortriptyline arm than in the placebo arm took lower doses. The nortriptyline arm had noticeably higher severity ratings for dry mouth and constipation than the placebo arm, with slightly higher ratings for sweating and feeling shaky. Both groups had similar urges to smoke, but nortriptyline reduced depression and anxiety. Overall, withdrawal symptom scores did not differ. Conclusions Nortriptyline and nicotine replacement therapy are both effective for smoking cessation but the effect of the combination is less than either alone and evidence is lacking that combination treatment is more effective than either alone. Trial registration Current Controlled Trials ISRCTN57852484.
School nurses: policies, working practices, roles and value perceptions Background. In the UK, sc... more School nurses: policies, working practices, roles and value perceptions Background. In the UK, school nursing has recently been at the forefront of policy change, with school nurses being considered pivotal to child-centred public health practice. There is very little literature on this topic and, in particular, little that is written from a practitioner perspective. Aim. This paper reports a survey that examines the work of school nurses compared with the expectations of their first line managers and policy-makers in government, in order to discover any potential practical or ideological areas of conflict. Methods. We first applied a theoretical framework of sensitizing concepts to the historical, political, cultural and contextual background of school nursing. Following this, 46 school nurses in the West Midlands region of the UK were randomly selected and asked to complete a questionnaire about their personal characteristics, experience, training and working practices. The 38 nurses who completed this were then interviewed. Job descriptions for school nurses and governmental job expectations were obtained from various official sources and compared with the self-reported practices of school nurses. Findings. All the nurses met the work criteria of their local employers, except in respect of health needs assessment activities, which two nurses had not yet attempted. All 38 also carried out a range of additional work activities, including providing sexual health services and parental support clinics. They also had a diverse range of skills and qualifications relevant to supporting the needs of their local communities. Qualitative data from interviews provided a useful insight into nurses' feelings of being valued by their clients and by local and national employers, and feelings of professional undervaluing by their peers. They felt positive about role changes in the last few years, and that they supported the child-centred public health role advocated by public policy.
The stages of change model underpins the British Gov-Background. The transtheoretical model (TTM)... more The stages of change model underpins the British Gov-Background. The transtheoretical model (TTM) and ernment's creation of a network of smoking cessation computer technology are promising technologies for clinics . However, as it is often used, the stages of changing health behavior, but there is little evidence change model represents little more than a commonof their effectiveness among adolescents.
This paper outlines a novel explanatory frame for understanding how schools may intervene in orde... more This paper outlines a novel explanatory frame for understanding how schools may intervene in order to promote pupils' health. The new theory is synthesised from an Aristotelian interpretation of human functioning and a theory of cultural transmission. In keeping with recent influential theoretical developments, it is proposed that health has its roots in human functioning. It follows from this concept that the promotion of pupils' health is facilitated by the promotion of pupil functioning and the primary mechanisms through which schools promote pupil functioning and, hence, health, are through the influences of school organisation, curriculum development and pedagogic practice on pupil development. According to the new theory, good human functioning is dependent on the realisation of a number of identified essential human capacities and the meeting of identified fundamental human needs. Two essential capacities, the capacity for practical reasoning and the capacity for affiliation with other humans, plan and organise the other essential capacities. The realisation of these two capacities should, it is argued, be the primary focus of health promoting schools. Additionally, health promoting schools should ensure that fundamental human needs concerning non-useful pain and information about the body are met. A number of testable hypotheses are generated from the new theory. Comparisons with existing interpretations of health promoting schools indicate there are similarities in the actions schools should take to promote health. However, the new theory can, uniquely, be used to predict which pupils will enjoy the best health at school and in adulthood. Additionally, according to the new theory, schools do not need designated health education classes or teaching staff with specialist health education roles in order to be health promoting. It is concluded that the new theory may have a number of advantages over existing theories at both the policy and intervention levels. r
Journal of Epidemiology and Community Health, 2007
Objective: To determine whether value-added education is associated with lower risk of substance ... more Objective: To determine whether value-added education is associated with lower risk of substance use among adolescents: early initiation of alcohol use (regular monthly alcohol consumption in grade 7), heavy alcohol use (.10 units per week) and regular illicit drug use. Design: Cross-sectional self-reported survey of alcohol and drug use. Analysis used two-level logistic modelling to relate schools providing value-added education with pupils' substance use. The value-added education measure was derived from educational and parenting theories proposing that schools providing appropriate support and control enhance pupil functioning. It was operationalised by comparing observed and expected examination success and truancy rates among schools. Expected examination success and truancy rates were based on schools' sociodemographic profiles. Participants: Data were collected across 15 West Midlands English school districts and included 25 789 pupils in grades 7, 9 and 11 from 166 UK secondary schools. Results: Value-added education was associated with reduced risk of early alcohol initiation (OR (95% CI) 0.87 (0.78 to 0.95)) heavy alcohol consumption (OR 0.91 (0.85 to 0.96)) and illicit drug use (OR 0.90 (0.82 to 0.98)) after adjusting for gender, grade, ethnicity, housing tenure, eligibility for free school meal, drinking with parents and neighbourhood deprivation. Conclusions: The prevalence of substance use in school is influenced by the school culture. Understanding the mechanism through which the school can add value to the educational experience of pupils may lead to effective prevention programmes.
Objectives. To examine whether, as predicted by the transtheoretical model (TTM), stage-matched i... more Objectives. To examine whether, as predicted by the transtheoretical model (TTM), stage-matched interventions will be more effective than stage-mismatched interventions.
Bjog-an International Journal of Obstetrics and Gynaecology, 2002
Objective To examine whether routinely measured variables explained the increased risk of preterm... more Objective To examine whether routinely measured variables explained the increased risk of preterm delivery in some UK ethnic groups. Design Cross sectional study of deliveries recorded in the Child Health Record System.
Aims To evaluate the effect on quitting smoking at 18 months postpartum of smoking cessation int... more Aims To evaluate the effect on quitting smoking at 18 months postpartum of smoking cessation interventions based on the Transtheoretical Model (TTM) delivered in pregnancy compared to current standard care. It has been claimed that TTM-based interventions will continue to create quitters after the end of the intervention period.Design Cluster randomized trial.Setting Antenatal clinics in general practices in the West Midlands, UK.Participants A total of 918 pregnant smokers originally enrolled in the trial, of which 393 women were followed-up at 18 months postpartum.Interventions One hundred general practices were randomized into the three trial arms. Midwives in these practices delivered three interventions: A (standard care), B (TTM-based self-help manuals) and C (TTM-based self-help manuals plus sessions with an interactive computer program giving individualized smoking cessation advice).Measurements Self-reported continuous and point prevalence abstinence since pregnancy.Findings When combined together, there was a slight and not significant benefit for both TTM arms compared to the control, with an odds ratio (OR) 95% confidence interval (CI) of 1.20 (0.29–4.88) for continuous abstinence. For point prevalence abstinence, the OR (95%CI) was 1.15 (0.66–2.03). Seven of the 54 (13%) women who had quit at the end of pregnancy were still quit 18 months later, and there was no evidence that the TTM-based interventions were superior in preventing relapse.Conclusions The TTM-based interventions may have shown some evidence of a short-term benefit for quitting in pregnancy but no benefit relative to standard care when followed-up in the longer-term.
The objectives of this review were to examine whether smoking prevalence varies between schools i... more The objectives of this review were to examine whether smoking prevalence varies between schools independently of health promotion programmes and pupil composition, to show which school characteristics are responsible for this variation, and to examine the methodological adequacy of such studies. Searches for published studies were performed on medical, educational and social science databases, relevant articles' reference lists, and citation searches. Any study was included that described inter-school variation in smoking prevalence, or related such variation to school characteristics. A model relating pupil smoking to school, neighbourhood, and pupil characteristics unlikely and likely to be influenced by school was used to examine the adequacy of control of confounding by pupil composition. Data from studies were combined qualitatively considering methodological adequacy to examine the relation of smoking prevalence to school characteristics. Theoretical frameworks underpinning the choice of school characteristics and postulated relationships between these characteristics and smoking prevalence were described. There were large variations in smoking prevalence between ostensibly similar schools. Evidence that pupil composition did not cause this was weak, because all studies had methodological problems, including under control of relevant pupil compositional factors and over control of factors likely to represent the mechanism through which schools influence pupils' smoking. There was little evidence that elements of tobacco control policy other than bans and enforcement deterred smoking. Academic practice and school ethos were related to smoking. Academically selective schools did not influence smoking, once pupil composition was controlled. There was one study on neighbourhood influences, which were unrelated to smoking. Studies frequently offered little or no theoretical justification for associating school characteristics with smoking. Some aspects of school influence pupils' smoking, probably independently of pupil composition. However, under-control and over-control of confounding and lack of theoretical underpinning precludes definitive conclusions on how particular school characteristics influence pupils' smoking. r
Uploads
Papers by Paul Aveyard