While tobacco use remains a leading preventable risk factor for mortality and morbidity in Canada (Patra, Rehm, Baliunas & Popova, 2007), the overall smoking prevalence rate of Canadians has decreased substantially from close to 50% of the population in 1965 to 16.1% of the population in 2012 (Canadian Tobacco Use Monitoring Survey (CTUMS) 2012; Reid, Hammond, Rynard & Burkhalter, 2014). However, up to 85% of individuals with a mental illness continue to use tobacco products (Harris, Parle & Gagne, 2007), contributing to an inequitable distribution of negative health outcomes for this population. Individuals with severe mental illness die an estimated twenty-five years earlier than the general population, with sixty per cent of these deaths due to cardiovascular, pulmonary and infectious disease (Parks, Svendsen, Singer, & Foti, 2006). A recent study that examined specific tobacco-attributable deaths in these populations found that tobacco accounted for 53% of deaths in individuals with schizophrenia, 50% of all deaths for those diagnosed with a depressive disorder, and 48% of all deaths for those with a diagnosis of bipolar disorder (Callaghan et al., 2014). This research project is intended to increase our understanding of what constitutes an effective intervention for smoking cessation and smoking reduction in a population of individuals with severe mental illness who are homeless or vulnerably housed, living in a large urban setting. Two areas of inquiry were proposed. The first inquiry examined data collected as part of a needs assessment to determine the overall prevalence rate of smoking and related behaviours for a population of individuals with severe mental illness receiving services from a community mental health agency. We found that the tobacco use prevalence was 72%, and 62% of smokers had high or very high levels of nicotine dependence; however almost half of respondents (47%) were interested in quitting or reducing tobacco within the next 6 months. Smokers were found to be over 9 times more likely to have a co-occurring substance use disorder (OR=9.44, 95%CI[6.33,14.08]). The second inquiry was a pilot study conducting a randomized controlled trial design to evaluate smoking cessation and smoking reduction outcomes for two groups of individuals (n=61) with severe mental illness receiving different smoking cessation interventions. Clients randomly assigned to the routine Smoking Cessation group (SC-R) received up to 24 weeks of no-cost Nicotine Replacement Therapy (NRT) and clients assigned to the Smoking Cessation Plus group (SC+) received up to 24 weeks of no-cost Nicotine Replacement Therapy (NRT) plus two initial individual sessions of motivational interviewing followed by weekly psychosocial group interventions for up to 24 weeks. Primary outcomes were levels of tobacco use at the 3-month and 6-month follow-up. The 7-day point prevalence abstinence rate measured at 3 months was 21.9% (n=7) for the SC+ group and 13.8% (n=4) for the SC-R group (OR=1.75,95%CI[.46,6.74]). At 6 months, the 7-day point prevalence abstinence rate was 12.5% (n=4) for the SC+ group and 6.9% (n=2) for the SC-R group (OR=1.93, 95%CI[.33,11.41]). Secondary outcomes included change in reported quality of life, physical health and mental health status functioning over the course of the study. We found that there were no statistically significant differences in the smoking quit or smoking reduction rates between the two treatment groups. At the 3-month time point the overall quit rate for both groups combined was 18% (n=11) and at the 6-month time point the quit rate was 10% (n=6). Reduction in the number of daily cigarettes smoked was statistically significant over time (F [1.68, 98.90] = 55.13, p < .001, η p 2 = 0.48) for both groups, as was the overall reduction of the FTND score (F [2, 94] = 17.98, p < .001, η p 2 = 0.28). This research demonstrates that collecting vital tobacco prevalence and dependency information is a straightforward and important task for community mental health agencies. Individuals with mental illness have both the interest and ability to quit or reduce their use of tobacco. Practitioners need to be aware of alternative smoking practices that may contribute to understanding tobacco use patterns and dependence in this population. Other factors such as co-morbid substance use disorder and level of community functioning may influence smoking status and, consequently, how treatment is provided. The findings of the pilot trial demonstrate the feasibility of conducting smoking cessation research with the population. Findings also suggest that a larger definitive trial is warranted to examine the effectiveness of the SC+ intervention. This research adds to the limited but growing knowledge base of how to address tobacco use and provide treatment to this vulnerable group, and will contribute to advances in population health by informing effective interventions with the attendant implications for program and policy development.

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No. of bitstreams: 1 henriquetavieiravankeulen.pdf: 2640042 bytes, checksum: d345a0bc1ee637ebbc9b770acd474c42 (MD5) Previous issue date: 2015-03-20 / CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / A presente dissertação foi apresentada em dois artigos que contemplaram os seguintes objetivos: (i) avaliar a concentração sérica do metabólito de óxido nítrico (NO) em mulheres tabagistas e não tabagistas com excesso de peso e correlacionar o NO com variáveis antropométricas e com o número de cigarros/dia (artigo 1), e (ii) comparar a concentração sérica de NO em tabagistas no início e após 4 meses de tratamento para abstinência tabágica e correlacionar o NO com os marcadores inflamatórios (artigo 2). Foi realizado um estudo de intervenção, que avaliou os participantes do Centro Interdisciplinar de Pesquisa e Intervenção em Tabagismo do Hospital Universitário da Universidade Federal de Juiz de Fora (CIPIT-HU/UFJF) no início do tratamento para abstinência e aqueles que se mantiveram até o término da pesquisa após 4 meses, tanto homens quanto mulheres. Dos 159 indivíduos que iniciaram o tratamento, 86 foram incluídos no estudo. Artigo1: Para a realização da 1a fase da pesquisa, foram avaliados os exames bioquímicos, dados antropométricos e número de cigarros/dia de 20 mulheres tabagistas com sobrepeso, entre 20 e 72 anos que utilizaram o tratamento de reposição de nicotina (TRN) e foram convidadas 18 mulheres também com sobrepeso, não tabagistas, pareadas por idade, de outro projeto denominado Saúde na Balança que funcionava no mesmo local. Foram avaliados os exames bioquímicos e dados antropométricos dessas mulheres para serem comparadas às mulheres tabagistas. Os resultados apresentaram diminuição dos níveis séricos de NO em todas as participantes da pesquisa indicando que ambos os grupos podem estar sofrendo diminuição de biodisponibilidade de NO, o que pode estar relacionado com o aumento de fatores de risco para doenças relacionadas com o tabagismo e com o sobrepeso. Portanto, parece que a associação do tabagismo com o sobrepeso interfere nos níveis finais de nitrito. Artigo 2: Para a continuidade da pesquisa foram analisados os níveis séricos de NO, citocinas (IL-1, IL-6, IL-8, IL-10, IL-12 e TNF-α) e índice HOMA-IR no início e ao final do tratamento daqueles indivíduos que se mantiveram após 4 meses de tratamento (30 sujeitos, do sexo feminino e masculino – 25 abstinentes e 5 ainda fumantes). Foi observada uma redução significativa (p=0,001) do valor mediano de NO inicial de 18,80 (3,55 – 80,01) μmol/L para o NO final 8,10 (2,85 – 14,97) μmol/L após 4 meses de tratamento. Na comparação entre os dados do NO no início e no final do tratamento, os participantes que não conseguiram se manter abstinentes (9,18 ± 3,85 μmol/L) e os abstinentes (7,58 ± 3,03 μmol/L) não apresentaram diferença estatisticamente significativa (p= 0,304). Ainda considerando o status tabágico após 4 meses de tratamento (abstinente x fumante), não foram encontradas diferenças estatísticas dos valores das citocinas analisadas, mas acredita-se que essa resposta faça parte de um processo adaptativo do organismo pela redução do uso da nicotina. Dos 86 sujeitos que iniciaram o tratamento e foram incluídos nesta pesquisa, somente 25 indivíduos conseguiram se manter abstinentes, mas os 5 sujeitos que não conseguiram se abster, diminuíram o consumo de cigarros/dia. O IMC que no início já era, em média, indicativo de sobrepeso (27,84 ± 5,58Kg/m2), teve um acréscimo no seu valor final (28,63 ± 5,70Kg/m2), apresentando um aumento estatisticamente significativo (p= 0,018), potencializando o risco de sobrepeso e obesidade. Além disso, o tempo determinado para o tratamento pode ter sido insuficiente para se perceber uma melhora no estado geral dos participantes e, ainda, a utilização da TRN durante todo o tratamento pode ter sido determinante para os resultados encontrados. / This work was presented in two articles which contemplated the following objectives: (i) to evaluate the serum concentration of nitric oxide metabolites (NO) in smokers and nonsmokers overweight women and correlate with anthropometric variables NO and the number of cigarettes / day (Article 1), and (ii) to compare the serum concentration of NO in smokers at baseline and after 4 months of treatment for smoking cessation and correlate NO with inflammatory markers (Article 2). We conducted an intervention study which evaluated the participants of the Interdisciplinary Center for Research and Intervention in University Hospital Tobacco, Federal University of Juiz de Fora (CIPIT-HU/UFJF) at the beginning of treatment for abstinence and those who remained until the end of the study after four months, both men and women. Of the 159 individuals who began treatment, 86 were included in the study. Article1: To carry out the first phase of the study, we evaluated the biochemical, anthropometric data and number of cigarettes/day of 20 women smokers overweight, ranging from 20 to 72 who used the treatment of nicotine replacement therapy (NRT) and 18 also overweight women, nonsmokers and matched by age, were invited to another project called Health in the Balance that worked in the same place. We evaluated the biochemical and anthropometric data of these women to be compared to female smokers. The results showed decreased serum levels of NO in all study participants indicating that both groups may be experiencing decreased bioavailability of NO, which may be associated with increased risk factors for diseases related to smoking and the overweight. Therefore, it seems that the association of smoking with overweight interferes in the final levels of nitrite. Article 2: To continue the research we analyzed the serum levels of NO, cytokines (IL-1, IL-6, IL-8, IL-10, IL-12 and TNF-α) and HOMA-IR index at the beginning and the end of the treatment of those individuals who remained after 4 months of treatment (30 subjects, female and male - 25 abstinent and 5 still smoking). A significant reduction was observed (p = 0.001) of the initial NO median value of 18.80 (3.55 to 80.01) μmol/L for NO end 8.10 (2.85 to 14.97) μmol/L after 4 months of treatment. Comparing the data of NO at the beginning and end of treatment, participants who failed to keep abstinent (9.18 ± 3.85 μmol/L) and abstinent (7.58 ± 3.03 μmol/L) do not show statistical significant difference (p = 0.304). Still considering the smoking status after 4 months of treatment (abstinent x smokers), there were no statistical differences of the values of the analyzed cytokines, but it is believed that this response is part of an adaptive process in the body by reducing the use of nicotine. Of the 86 patients who started treatment and were included in this survey, only 25 individuals managed to remain abstinent but the 5 subjects who could not refrain decreased consumption of cigarettes/ day. BMI which earlier was already on average overweight sign (27.84 ± 5,58Kg/m2), had an increase in its final value (28.63 ± 5,70Kg/m2), with a statistically significant increase (p = 0.018), enhancing the risk of overweight and obesity. In addition, the time allotted for the treatment may have been insufficient to realize an improvement in the general condition of the participants and also the use of NRT during the treatment may have been decisive for the results.

Research indicates that tobacco cessation rates are at least doubled when smokers receive assistance from a clinician; receiving tobacco cessation advice from multiple types of clinicians increases quit rates even further.¹ To address a decades-long deficiency in the tobacco cessation training of health professionals in general, a shared curriculum, Rx for Change: Clinician-Assisted Tobacco Cessation, was developed in 1999 as a collaboration of the schools of pharmacy in California.^2,3 Between 2003 and 2005, pharmacy faculty members (n=191) participated in national train-the-trainer workshops designed to equip faculty with the necessary knowledge and skills to implement the Rx for Change curriculum at their academic institutions.⁴ <div><br></div><div> The studies that comprise this dissertation are a logical extension of this national initiative, applying a mixed-methods approach to: (a) evaluate the long-term impact of training pharmacy faculty using the Rx for Change program, (b) delineate recommendations for developing and disseminating shared curricula for health-care programs, and (c) evaluate utilization of the Rx for Change website, which hosts faculty resources and curricular files for download. In combination, these (along with a previously-conducted qualitative study) provide a comprehensive “view” of the long-term impact of this unique shared curriculum. </div><div><br></div><div>Results from the three studies provided evidence for: (1) reach to the majority of pharmacy institutions, (2) a high level of adoption of the Rx for Change in health professional schools, (3) a positive impact on faculty trainees’ careers and their level of confidence for teaching, precepting clinical students, and assisting tobacco users, (4) implementation of the Rx for Change curriculum with a variety of teaching methodologies, and (5) continuity of use within the core curriculum of pharmacy institutions. Seven key factors were found to have contributed to the success of the Rx for Change program, and thus the following are recommended for future shared curriculum developers: (1) appeal to attendees, (2) relate content to clinical practice, (3) deliver live training (in-person), (4) develop high quality materials delivered by experts, (5) meet accreditation standards, (6) provide support for teaching, and (7) demonstrate effectiveness. Data from the website analysis provided evidence for interprofessional reach of the Rx for Change website to educators, learners, and professionals.<br></div>

Context: Tobacco use among medical students is of public health concern, given their role as future role models for healthy lifestyles. This study sought to determine the prevalence and determinants of tobacco use and nicotine dependence in medical students in Pretoria. In particular, this study explored the role of sense of coherence – a measure of stress-coping ability – on tobacco use patterns among medical students. Furthermore, we examined the students’ knowledge of smoking cessation approaches, their perceptions with regard to the availability and adequacy of tobacco control curricula, and their perception of their role as ”role models” for their patients. Methods: This cross-sectional analytical study, involving undergraduate medical students in their 2nd and 6th year of study at the universities of Pretoria and Limpopo (MEDUNSA), was conducted during August and September 2008. Consenting participants completed a self-administered questionnaire (N=722). Information obtained included: demographic characteristics of respondents, alcohol use, past and current use of various tobacco products, perception of availability and adequacy of training in tobacco control (TC), support for various TC legislation and perception of the role of doctors in smoking cessation. A six-item Antonovsky’s sense of coherence scale (SOC) was also included to measure respondents’ ability to cope with stress. Nicotine dependence was measured using the diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). Data analysis included chi-square statistics, t-test and multiple logistic regression analysis. Level of significance was set at p<0.05. Results: Prevalence of cigarette smoking in medical students was 17.3%. Cigarette smoking was significantly higher among the 6th (21.5%) than among the 2nd year (14.1%) students and was also significantly higher among males (20.4%) than among females (14.4%). In a bivariate analysis, problem drinkers were more likely to be smokers (37.5%) as compared to non-problem drinkers (13%). Compared to non-smokes, smokers were more likely to have a lower SOC [Mean(sd); 26.8 (8.8) vs 28.8 (7.4); p=0.019] and were less likely to attach importance to being seen as a role model by patients. Only 21.9% felt their training curriculum contained TC issues and of these a little over half felt the TC content was inadequate. After controlling for potential confounders, the factors that were independently associated with the current smoking status were, having lower support for TC legislation (OR=0.49; 95% CI= (0.41-0.59) and attaching less importance to being seen as a role model by patients (0.62; 0.41-0.91). Other factors associated with cigarette use included: being a 6th year student (OR=2.17; 95% CI; 1.32-3.58), having a drinking problem (2.17; 1.28-3.68), reporting exposure to others smoking at home (3.29; 1.91-5.66) and having received previous formal training in cessation (0.55; 0.32-0.95). Younger age (0.86; 0.77- 0.97), lower SOC (0.94; 0.90-0.99), and lower level of support for TC legislation (0.56; 0.40-0.79) were independently associated with nicotine dependence. Conclusions: This study’s findings suggest that tobacco use is prevalent among medical students and tobacco use is strongly associated with alcohol abuse. In addition to offering tobacco cessation services to these students, these findings highlight the need to institute a curriculum on tobacco control that includes not only teaching cessation counselling skills to medical students, but that also encourages them to become advocates for TC legislation and to recognise themselves as important role models in the society. Copyright / Dissertation (MMed)--University of Pretoria, 2009. / School of Health Systems and Public Health (SHSPH) / MMed / Unrestricted

No description available.

Aus der Einleitung: "Nahezu jeder zweite Deutsche war oder ist akutell regelmäßiger Raucher. Fast ein Viertel - in manchen Altersstufen sogar mehr - aller Adoleszenten und Erwachsenen sind nikotinabhängig oder stark gesundheitsgefährdete "starke Raucher" mit mehr als 20 Zigaretten pro Tag. Fast alle regelmäßigen Raucher wissen zwischenzeitlich, daß Rauchen gefährlich und gesundheitsschädlich ist; jeder zweite Raucher bezeichnet sich sogar selbst als "abhängig. 90% haben bereits mindestens einmal über zumindest einige Tage versucht aufzuhören - ohne Erfolg. [...]"

Im Rahmen der Smoking and Nicotine Dependence Awareness and Screening (SNICAS) Studie wurde neben strukturellen Bedingungen und Variablen auf Ärzteseite (z.B. Qualifikation, Einstellungen zum Rauchen und zur Raucherentwöhnung, spezielle Vorerfahrungen und Therapiepräferenzen, perzipierte Barrieren) daher auch die Aufhörmotivation und die Erfahrungen mit Aufhörversuchen auf Seiten der Patienten untersucht.

Recent advance in health and technology has made mobile apps a viable approach to delivering behavioral interventions in areas including physical activity encouragement, smoking cessation, substance abuse prevention, and mental health management. Due to the chronic nature of most of the disorders and heterogeneity among mobile users, delivery of the interventions needs to be sequential and tailored to individual needs. We operationalize the sequential decision making via a policy that takes a mobile user's past usage pattern and health status as input and outputs an app/intervention recommendation with the goal of optimizing the cumulative rewards of interest in an indefinite horizon setting. There is a plethora of reinforcement learning methods on the development of optimal policies in this case. However, the vast majority of the literature focuses on studying the convergence of the algorithms with infinite amount of data in computer science domain. Their performances in health applications with limited amount of data and high noise are yet to be explored. Technically the nature of sequential decision making results in an objective function that is non-smooth (not even a Lipschitz) and non-convex in the model parameters. This poses theoretical challenges to the characterization of the asymptotic properties of the optimizer of the objective function, as well as computational challenges for optimization. This problem is especially exacerbated with the presence of high dimensional data in mobile health applications. In this dissertation we propose a regularized greedy gradient Q-learning (RGGQ) method to tackle this estimation problem. The optimal policy is estimated via an algorithm which synthesizes the PGM and the GGQ algorithms in the presence of an L₁ regularization, and its asymptotic properties are established. The theoretical framework initiated in this work can be applied to tackle other non-smooth high dimensional problems in reinforcement learning.

Background: Tobacco dependence is among the strongest of addictions and smoking is a significant risk factor for a large number of diseases as well as premature death. New treatment options for tobacco dependence have emerged with the implementation of eHealth approach, especially those provided remotely. In the field of addictology we are mainly talking about applications for smoking cessation, which can be an attractive option for those who want to quit smoking, but their effectiveness needs to be further examined. Aims: The main objective of this study is to describe user experience of tobacco smokers using the online intervention Endre. Partial aims were to find how users rated the visual interface of the intervention, the user-friendliness and what method of cessation they would choose for their future atempts to quit. Material and methods: Data collection was carried out using a quantitative method of probability selection, namely a simple intentional (criteria) selection through an online questionnaire tool sent by e-mail to selected participants of the ongoing RCT study. The research group consisted of 105 respondents, of whom 60 were women and 45 men. To evaluate the collected data, MS excel was used, where frequency analyzes, summary statistics and testing of statistical hypotheses were...

Background: There is robust preclinical literature and preliminary clinical findings supporting the use of N-Acetylcysteine (NAC) to treat substance use disorders, including tobacco use disorder (TUD). However, randomized controlled trials have yielded mixed results and NAC's efficacy for TUD has not been established. The goals of this study were to assess the efficacy of NAC in promoting early and end-of-treatment abstinence and preventing relapse among adult smokers. Methods: This randomized, double-blinded clinical trial enrolled adult, daily smokers (N = 114; ages 23–64; 51 % female; 65 % White; 29 % Black/African American; 7% Hispanic/Latinx), who were randomized 1:1 to receive NAC (n = 59) or placebo (n = 55) (1200 mg b.i.d.) for eight weeks. Participants received brief cessation counseling and incentives for abstinence during the first three days of the quit attempt. Primary outcomes: (i) carbon monoxide (CO)-confirmed abstinence during the first three days of the quit attempt. Secondary outcomes: (ii) time to relapse; (iii) biologically confirmed abstinence at Week 8. Results: No differences were found between NAC and placebo groups on measures of early abstinence (3-day quit attempt; 11 % for NAC vs. 15 % for placebo; all p > 0.11), time to relapse (p = 0.19), and end-of-treatment abstinence (7% for NAC vs. 11 % for placebo; all p > 0.40]. Conclusions: Results indicate that NAC is a well-tolerated pharmacotherapy but is unlikely to be efficacious as a monotherapy for TUD in adults. Considered in the collective context of other research, NAC may potentially be more useful in a younger population, as a combination pharmacotherapy, or in the presence of more intensive psychosocial treatment.