published_or_final_version / Nursing Studies / Master / Master of Philosophy

published_or_final_version / Nursing Studies / Doctoral / Doctor of Philosophy

Smoking during pregnancy remains a significant public health issue despite knowledge about the adverse maternal and fetal health effects. This research had six purposes: identifying effective smoking cessation strategies for low income pregnant women; identifying characteristics of Kentucky women who smoke during pregnancy; estimating the role of smoking on birth outcomes in Kentucky; exploring the impact of tobacco reduction on birth outcomes; identifying the characteristics of women participating in the Giving Infants and Families Tobacco-free Starts (GIFTS) pilot program; and evaluating the impact of GIFTS on smoking status and birth outcomes. Seven randomized controlled trials targeting low income women with smoking cessation interventions identified social support and incentives as promising strategies. Only one study focused on women living in rural settings. Live birth certificate data from 2004-2008 revealed that 26% of Kentucky women reported smoking during pregnancy. Continuing to smoke approximately doubled the odds for low birth weight (LBW) [Estimated Odds Ratio 1.95 (95% Confidence Interval 1.87-2.03)] and no breastfeeding initiation (NBI) [1.93 (1.87-1.98)] versus no pre-pregnancy smoking. Continuers also had higher odds for preterm birth (PTB) [1.25 (1.20-1.29)] and neonatal intensive care unit admissions (NICU) [1.20 (1.14-1.26)]. Reducers and quitters had increased odds of LBW and NBI. The probability of quitting relative to the probability of continuing was increased for women aged less than 25, non-White, Hispanic, graduate degree, obese and "other" payor source for the delivery. The GIFTS program targeted pregnant women receiving local health department services who reported recent or current tobacco use. Significantly increased odds of participation were identified for women reporting 1-5 [2.05 (1.06-3.94) ], 6-10 [2.06 (1.10-3.83)] and ≥11 [2.17 (1.12-4.20)] cigarettes per day compared to those reporting no cigarettes. Women with one [1.55 (1.07-2.24)] or two [1.83 (1.21-2.76)] previous quit attempts also had increased odds for participation compared to those with no quit attempts. GIFTS participants were significantly less likely to have preterm infants (p=.0369) than a matched comparison group. No significant differences were found on tobacco cessation, tobacco reduction or cessation, LBW, NICU, or NBI. This research has implications for future cessation efforts as well as policy development.

Cigarette smoking is the leading cause of preventable disease and is the cause of nearly 1 in 5 deaths in the United States. The prevalence of smoking has had a leveling off effect after many years of significant decline. Certain subgroups of the population, such as those with low income and certain illnesses, continue to smoke at disproportionately high rates. Reasons for these disparities in smoking rates are complex. Developing a better understanding of the issues related to persistent smoking particularly for those with medical illness and limited access to cessation resources can help focus interventions to help these high risk smokers quit. This dissertation includes a systematic review of the literature associated with hardcore smoking; an analysis of the reliability and validity of a self-efficacy instrument in a sample of low-SES, medically ill smokers; and the results of a cross-sectional, non-experimental study exploring the relationship between smoking-related factors and planning to quit in a sample of medically ill smokers. A sample of 70 current and recent smokers was surveyed at a free clinic. Quitting self-efficacy was measured using an instrument not previously tested in a rural, medically ill sample. Modifications to the survey were made based on qualitative interviews with smokers and a single question measuring self-efficacy was also tested. There was a high correlation among the self-efficacy measures (Spearman’s rho .99, p < .001) and between the longer instrument and the single question (Spearman’s rho .65, p < .001). Each measure demonstrated acceptable reliability and validity. In the study exploring potential factors associated with planning to quit, the number of prior quit attempts and confidence to quit explained 43% of the variance in those planning versus not planning to quit. Providing interventions focused on increasing confidence and experience with quit attempts can be effective in promoting a plan to quit in this group of smokers who, because of their medical illness, can benefit significantly from cessation. Research is needed to explore cessation outcomes when employing these targeted interventions with medically ill smokers in rural areas.

Bakgrunn: Røyking blir fortsatt betraktet som den viktigste forebyggbare årsak til død i ge land. Praktiserende leger er nøkkelpersoner innen tobakksforebygging. Enkel rådgiving, som minimal intervensjon, gitt av allmennleger øker andelen røykfrie pasienter signifikant. Kan en oppsøkende intervensjon gjennomført av en likemann være en egnet metode for å få leger til å ta opp tobakksbruk oftere og på en bedre måte, og kan denne undersøkelsen påvise dette? Hensikt: Hensikten med denne studien er: 1) Vurdere om primærlegene i Agder har endret praksis i perioden 2001-2004 med hensyn til hvor ofte og hvordan de tar opp tobakksbruk med sine pasienter og eventuelle hindringer for dette. 2) Undersøke om oppsøkende intervensjon er en egnet metode for å få leger til å endre praksis ved at de bidrar mer og bedre med individuell røykeintervensjon. Metode: Randomisert kontrollert studie for å undersøke om oppsøkende intervensjon er en egnet metode for å få leger til å endre praksis. Denne studien er sett i lys av en sammenliknende analyse av legenes røykeintervensjon og hindringer for dette i perioden 2001-2004. Resultat: Allmennlegene i Agder har endret praksis i perioden 2001 til 2004. Legene tar oftere opp tobakksbruk uten av pasientene har røykerelaterte symptomer, og det er færre hindringer både for å spørre om røykevaner og for å tilby hjelp til røykeslutt. Studien kan ikke bekrefte at oppsøkende intervensjonen er en egnet metode for å få leger til endre praksis ved at de bidrar mer og bedre med individuell røykeintervensjon. Konklusjon: I perioden 2001-2004 har det vært en signifikant endring i legenes røykeintervensjon og hindringer for dette. Studien kan ikke påvise at legene som fikk opplæringen ”Røykeslutt i praksis” bidrar mer med individuell røykeintervensjon enn kontrollgruppen, og det er heller ikke signifikante forkjeller på hindringer for en slik intervensjon / Background: Cigarette smoking is still considered the leading preventable cause of death in the western world. Physicians constitutes a key personnel in tobacco prevention. Brief advising, such as minimal intervention, performed by general practitioners, GPs, increases the number of smoke free patients significantly. The potential effect of outreach visits performed by a peer educator is a question to be studied. Objective: The objective of this study is: 1) Assesswhether the primary physicians in Agder, during the period 2001 to 2004, have changed their professional practice as tohow often and in which way they discuss smoking habits with their patients and possible barriers to stop them. 2) The study also seeks to determine whether outreach visits constitute an effective method to make GPs change their professional practice by contributing more and better to individual smoking cessation. Method: Randomised controlled study to determine whether outreach visits constitute an effective method to make GPs change their practice. This study is also viewed in the light of a comparative analysis of doctors’ attitude to tobacco prevention over the period 2001-2004. Result: During the period 2001-2004 the GPs in Agder have changed their professional practice. They discuss more frequently tobacco use with patients without smoke-related symptoms, and there are fewer barriers that keep them from asking about smoking habits and from offering assistance with smoking cessation. The effect of outreach visits in improving professional practice cannot be ascertained through this study. Conclusion: During the period 2001-2004 there has been a significant change in the GPs intervention work and fewer barriers to stop them. The GPs who received training through the program “Røykeslutt i praksis” do not contribute to individual smoke intervention any more than the control group. We were unable to detect any significant differences regarding barriers to such intervention / <p>ISBN 91-7997-153-9</p>

The purpose of this study was to examine the genetic and environmental influences on lifetime quit attempt in three US adolescent and young adult twin samples (N total = 6,322). The study utilized a common-contingent-causal (CCC) model to estimate these factors for lifetime quit attempts, after accounting for the factors for lifetime cigarette use and cigarettes per day. The study also examined age and sex differences, as well as the degree of relationship between these smoking phenotypes. The results demonstrated significant genetic influences for lifetime quit attempts in adolescents and young adults. No sex differences were observed for the contributions of genetic and environmental factors for lifetime quit attempts. Furthermore, separate liabilities for lifetime quit attempts and lifetime cigarette use were found for most age groups. Study findings have important implications for promoting quit attempts in adolescents and young adults.

Bakgrund: Inom primärvården möter läkare och distriktssköterskor dagligen patienter som söker hjälp för symtom som är direkt relaterade till rökning. Att arbeta sjukdomsförebyggande genom livsstilsförändringar är en viktig del av distriktssköterskans ansvarsområde. Enligt Socialstyrelsens (2011) nationella riktlinjer finns tydliga rekommendationer för hur distriktssköterskor ska gå till väga med patienter som söker hjälp för att sluta röka. Syfte: Syftet var att belysa distriktssköterskans erfarenheter av arbetet med rökavvänjning för patienter samt vilka arbetsmetoder de använder för detta. Metod: En kvalitativ metod användes och 14 semistrukturerade intervjuer utfördes med distriktssköterskor som arbetar med rökavvänjning inom primärvård i ett län i södra Sverige. Vid dataanalysen användes manifest kvalitativ innehållsanalys. Resultat: Analysen av data resulterade i två kategorier: Distriktsköterskans tillvägagångssätt och Faktorer som påverkar rökavvänjning med fem underkategorier under vardera kategori. Resultatet i studien visar att distriktssköterskornas arbetsmetoder vid rökavvänjning består av Motiverande samtal MI (Motivational Interviewing) och kvalificerade rådgivande samtal med patienter. Distriktssköterskornas erfarenhet är att dessa två arbetsmetoder är de mest effektiva att använda för att kunna finna ut hur beslutsam samt hur motiverad patient är till rökstopp och hur de tillsammans kan planera vägen dit. Distriktssköterskornas erfarenhet av rökavvänjningsarbetet är att det ger positiv energi när patienten lyckas bli rökfri.  Det ger också ny energi till att fortsätta med motivationsarbetet. En generell svaghet som konstaterats är bristerna i uppföljning av om patienternas rökfrihet varit varaktig efter avslutad behandling. Slutsats:  Motiverande samtal i kombination med nikotinersättningsmedel beskrevs av distriktssköterskorna som betydelsefullt i strävan efter att stödja patienter till rökfrihet. Stöd av kollegor i form av nätverksträffar, utbildning inom samtalsmetod samt arbetslivserfarenhet var viktiga delar för distriktssköterskorna och underlättade för dem i arbete med att försöka stödja patienter till varaktig rökfrihet. / Background: In primary care physicians and district nurses faces on a daily basis patients seeking help for symptoms that are directly related to smoking. Working disease prevention through lifestyle changes is an important part of the district nurse's responsibility. According to the National Board of Health (2011) National guidelines there are clear recommendations for district nurses to proceed with patients seeking help to quit smoking. Objective: The objective was to highlight the district nurse practice and experience of working with smoking cessation for patients in primary care. Method: A qualitative method was used, and 14 semi-structured interviews were conducted with district nurses in Southern Sweden. The data was analyzed according to the method manifest qualitative content analysis. Results: The analysis of the data resulted in two categories: The primary nurse approaches and factors affecting smoking cessationwith five sub-categories in each category. The results of the study show that the district nurses working methods consists of Motivational Interviewing, MI and qualified advisory conversations with patients and smoking cessation. District nurses common experience that these two methods are the two most effective to use to find out how determined and how motivated the patient is to quit smoking and how they together can plan the way to quit smoking. District nurses experience from smoking cessation is that it gives them positive feedback when they manage to get the patient non-smoking and it gives positive energy to continue with the motivational work. An identified general weakness are shortcomings in monitoring whether patients' abstinence has been sustained after the treatment is finished.  Conclusion: Motivational interviewing and nicotine replacement medicine was described by the district nurses as important in the quest for supporting patients to quit smoking. Support of colleagues, training in communication technique in the form of network meetings and work were important parts of the districts nurses and facilitating them in their work is often very difficult and important task to try to support patients to smoke.

Background: Tobacco smoke exposure (TSE) is unequivocally harmful to children's health, yet up to 48% of children who visit the pediatric emergency department (PED) and urgent care setting are exposed to tobacco smoke. The incorporation of clinical decision support systems (CDSS) into the electronic health records (EHR) of PED patients may improve the rates of screening and brief TSE intervention of caregivers and result in decreased TSE in children. Objective: We propose a study that will be the first to develop and evaluate the integration of a CDSS for Registered Nurses (RNs) into the EHR of pediatric patients to facilitate the identification of caregivers who smoke and the delivery of TSE interventions to caregivers in the urgent care setting. Methods: We will conduct a two-phase project to develop, refine, and integrate an evidence-based CDSS into the pediatric urgent care setting. RNs will provide input on program content, function, and design. In Phase I, we will develop a CDSS with prompts to: (1) ASK about child TSE and caregiver smoking, (2) use a software program, Research Electronic Data Capture (REDCap), to ADVISE caregivers to reduce their child's TSE via total smoking home and car bans and quitting smoking, and (3) ASSESS their interest in quitting and ASSIST caregivers to quit by directly connecting them to their choice of free cessation resources (eg, Quitline, SmokefreeTXT, or SmokefreeGOV) during the urgent care visit. We will create reports to provide feedback to RNs on their TSE counseling behaviors. In Phase II, we will conduct a 3-month feasibility trial to test the results of implementing our CDSS on changes in RNs' TSE-related behaviors, and child and caregiver outcomes. Results: This trial is currently underway with funding support from the National Institutes of Health/National Cancer Institute. We have completed Phase I. The CDSS has been developed with input from our advisory panel and RNs, and pilot tested. We are nearing completion of Phase II, in which we are conducting the feasibility trial, analyzing data, and disseminating results. Conclusions: This project will develop, iteratively refine, integrate, and pilot test the use of an innovative CDSS to prompt RNs to provide TSE reduction and smoking cessation counseling to caregivers who smoke. If successful, this approach will create a sustainable and disseminable model for prompting pediatric practitioners to apply tobacco-related guideline recommendations. This systems-based approach has the potential to reach at least 12 million smokers a year and significantly reduce TSE-related pediatric illnesses and related costs.

Research has revealed a variety of negative health consequences for older adults who stop driving, and with the "graying of America," this will be a frequently encountered issue for healthcare providers. The purpose of this study was to determine if there are differences in quality of life and depressive symptoms between former drivers who made the decision to stop driving voluntarily and former drivers who made the decision involuntarily (either in a resistant or in a reluctant manner). In this cross-sectional cohort comparison study, community dwelling older adults were asked to complete questionnaires of depression (using the Geriatric Depression Scale), and quality of life (QOL) (using the Short Form Health Survey-36 questionnaire). Descriptive statistics include data for each individual group separately; separate analysis of variance (ANOVA) was used to analyze the data to determine if differences in QOL and depression exist between the groups. Results: the small sample (n=18) was predominantly comprised of women (15/18), most were widowed, and the age of participants was 81 years. No differences were detected between the three group means for the GDS, F(2, 15) = .782 (p = .47). Results for the SF-36 revealed differences between the group means in the mental health component summary was F(2,13) = 4.209, (p = .039). Conclusions: There are few differences between involuntary and voluntary former drivers demographics, but differences may exist between involuntary and voluntary former drivers' quality of life.

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal.