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Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Homoeopathy, Durban University of Technology, 2011. / ‘Cigarette smoking is a modern day epidemic that poses a substantial health burden’, it has been proven that smokers die on average fourteen years earlier than non smokers as a direct result of their smoking. An abundance of evidence indicates that the health risks associated with cigarette smoking can however be reversed with a sufficient period of abstinence. Thus achieving life-long abstinence must be a health priority for both developing and developed countries (Caponnetto &, Polosa, 2008). Over 80% of smokers express a desire to stop smoking and 35% of them try to stop each year. However, less than 5% are successful in un-aided attempts to quit (American Psychiatric Association, 1995). The greatest challenge facing smokers who wish to quit are nicotine withdrawal symptoms; these include dysphoric or depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate and increased appetite or weight gain (American Psychiatric Association, 1995). The aim of this double blind placebo controlled quantitative study was to determine the effectiveness of a homoeopathic complex (Caladium seguinum 30 CH, Nux vomica 30 CH and Staphysagria delphinium 30 CH); a tautopathic preparation and the combined effect thereof, in the treatment of nicotine withdrawal syndrome as determined by the Tolerance Dependence Questionnaire, Smoking History and Perceptions of Treatment Questionnaire. Methodology Forty participants recruited by means of convenience sampling were randomly and equally divided into one of four treatment groups, namely tautopathic group, homoeopathic group, combined tautopathic and homoeopathic group and placebo group. The duration of the study was 2 weeks and two consultations with each participant were conducted. The respective interventions were administered in oral spray format; participants were asked to spray their respective preparations directly into their mouth three times daily and to repeat the dose whenever they had a craving for a cigarette. iv Measurements in the form of the Tolerance Dependence Questionnaire (Appendix D), Perceptions of Treatment Questionnaire (Appendix H), and Smoking History (Appendix G) were used to quantify response to treatment. Non-parametric statistical analysis was conducted to analyse the data. Results All four research groups experienced a statistically significant reduction in the amount of cigarettes smoked, favourable perceptions of their response to treatment and improved tolerance. Statistically however when the groups were compared with each other they were similar with respect to their tolerance to nicotine, perception of response to treatment and reduction in amount smoked. Although interventions were statistically similar in terms of effectiveness, the data does suggest that Tautopathy as an intervention warrants exploration. The Tautopathic group achieved the highest reduction in the number of cigarettes smoked when comparing medians (11 less smoked per day), achieved the highest percentage of participants who experienced reduced cravings, and the highest percentage of participants who would continue using the intervention (90% respectively) as well as improvements in 6/9 variables of the Tolerance Dependence Questionnaire. Conclusions The study concludes that each of the four subject groups (including placebo) proved to be successful in aiding the participant to cease smoking. The results showed a significantly positive perception of the participants to the interventions used. The influence of the placebo effect however was very evident in this study; in addition other factors such as the unique method of administration of the medication (oral spray format on demand) the Hawthorn effect and the participants’ desire/commitment to quit smoking may have contributed to the positive results obtained. Notwithstanding the above and although not statistically significant; positive trends within the data do suggest that the Tautopathic approach used in this study should be further investigated in future.

Introduction: Currently there are approximately 1.2 million people in the United States living with HIV and it is estimated that 25.6% of HIV-positive adults suffer from depression. The purpose of this study is to examine the contribution of depression on substance use and medication adherence specifically among HIV-positive adult Georgians receiving medical care for HIV. Methods: Secondary data with a probability sample of 608 HIV-positive adults who took part in the 2009-2012 Georgia Medical Monitoring Project (MMP) were analyzed. Descriptive analysis and multivariate logistic regression models were conducted to assess relationships between depression with current cigarette smoking, injection drug use, other non-injection drug use, and medication adherence, adjusting for sociodemographic covariates (age, gender, race, and education). All analyses accounted for non-response and complex sampling design and were performed using SAS 9.2 (Cary, NC). Results: Among HIV-positive adults in Georgia, approximately 9.2% met the criteria for major depression; 15.2% of women and 6.9% of men had major depression. Heterosexual adults also had a higher percentage of major depression (11.9%) compared to adults who identified as bisexual (8.3%) or homosexual (6.1%). Major depression was also highest among young adults (17.1%) and adults with high school diploma or GED (13.0%). Major depression was associated with a greater odds of current cigarette smoking (3.04; 95% CI: 1.48, 6.23); injection drug use (5.62; 95% CI: 0.96, 32.81), and other non-injection drug use (2.17; 95% CI: 1.10, 4.25), after adjusting for sociodemographic variables. Major depression was also associated with a greater odds of ART medication non-adherence, 2.52 (95% CI: 1.20, 5.28), after adjusting for gender. Conclusion: As previously found in the general population, we found significant associations between depression and smoking and other non-injection drug use among HIV-positive adults. Major depression was also associated with a greater odds of ART medication non-adherence, which is also consistent with the literature. Because HIV-positive adults have ongoing encounters with healthcare providers, screening and treatment for depression and other co-morbid substance use is needed to reduce an additional health burden in this population.

published_or_final_version / abstract / Nursing Studies / Master / Master of Philosophy

The incidence of smoking among mentally ill people is very high. Smokers have a 50%, rate of mental illness diagnosis compared with 23% rate for general population. To address this problem, the purpose of this project was to plan a smoking cessation program for patients in a mental health facility. The theoretical foundation for this project was based on the theory of planned behavior, which identifies the predictive nature of smoking and the benefits that can be derived from implementing a systematic approach for change. The project question examined the effectiveness of smoking cessation program using educational support, pharmacological strategies, and bi-weekly meetings to help patients in a mental health hospital to decrease smoking behavior. The project design was based on use of smoking questionnaires, the Hooked on Nicotine Checklist (HONC), effective pharmacological strategies, educational support, and counseling treatments to evaluate symptoms of dependency. The key results of this project included the creation of a plan that could foster reduction in illness, improved quality of life, and reduced costs related to the onset of major illness in this vulnerable population. This data collection process focused on a qualitative design in which selected professionals were asked to review the materials and answer questions. This project could increase awareness of the issue of smoking; in addition, this project could equip nurses with the tools to deliver evidence based interventions for tobacco dependence that may significantly reduce tobacco use. This project has the implications for positive social change through its potential to improve the health of people with mental illnesses. It also creates a safe and healthy environment in mental health facilities for patients who do not smoke.

published_or_final_version / Community Medicine / Master / Master of Public Health

Adolescence is a period of development when health-related behaviors can become rooted and subsequently contributes to leading causes of adult morbidity and mortality. The dissertation is based on three studies. The first is a cohort study (n=577) of sixth grade students followed for 2.5 years to assess changes in smoking susceptibility measured by intention to smoke. The second study applies a pre-post design to evaluate the outcomes of a 13-week after-school program and three-day, in-residence University camp on personal and familial factors among 37 sixth grade girls, most of whom were Mexican American. The third study is a cross-sectional study of depression among 80 sixth grade girls, the majority of whom were Mexican American. A survey measured depression severity and familial and individual factors that influence depression. Results showed smoking intention increased nearly six-fold from sixth grade to eighth grade (OR=5.8, 95% CI: 1.19, 3.05). The intervention study resulted in changes from pre to post test in familial and personal factors. The prevalence of depression was 50% among participants in the third study, 38% of girls reported moderate to severe levels. In sum, the greater prevalence of smoking intention over time suggests a norm of acceptance occurring as students' progress through middle school. Protective factors from such attitudes differ by gender and are influenced by the relationships surrounding the adolescent. Similarly, relationships were protective in the study of depression. The father's relationship with his daughter guards against depression as does positive peer relationships. These relationships can be strengthened through interventions as was suggested in the intervention study. Study findings emphasize the protective influence familial and peer relationships have on the developing adolescent.

Background: Tobacco use remains a major public health issue. Population-level efforts to curb tobacco use include media to promote smoking cessation. However, these campaigns (including tobacco package warning labels) commonly emphasize the addictiveness of nicotine and the difficulty of quitting with statements like ?nicotine is as addictive as heroin and cocaine?. Addiction oriented messages may have an iatrogenic effect on cessation by undermining behavioural precursors such as self-efficacy, cessation outcome expectations, behavioural control, and quit-aid efficacy. <br /><br /> Objectives: First, to determine the effects of addiction focused messages in comparison to efficacy enhanced messages and control messages on smokers? self-efficacy, cessation outcome expectations, behavioural control, and quit-aid efficacy. Second, to determine if the impact of addiction focused messages differ according to participant nicotine dependency level. <br /><br /> Methods: A sample of adult smokers (n>101) from Kitchener/Waterloo and Owen Sound were randomly assigned into one of three intervention conditions: addiction focused (M1), efficacy enhanced (M2), and control (M3). Outcome measures were collected at baseline, post intervention and 30-day follow-up and included: self-efficacy, outcome expectations, behavioural control, quit-aid efficacy, and outcome expectancies. The 30-day follow-up also included measures of smoking consumption, quit attempts and use of a quit-aid. <br /><br /> Results: Majority of the participants were males and between 18-25 years of age. Mean number of cigarettes smoked ranged from 12 to 15 across groups whereas the mean number of years smoked ranged from 12 to 17. General linear analyses revealed no significant effect of message type or nicotine dependence (as measured by the Fagerstrome Test for Nicotine Dependence) on the outcome variables of interest. However, when perceived addiction was substituted as the measure of nicotine dependence, the analysis revealed a main effect for nicotine dependence on self-efficacy post intervention and on cessation outcome expectations at follow-up. An interaction effect was found for outcome expectancy at post intervention. <br /><br /> Conclusion: The results of this study suggest that acute addiction oriented messages may not negatively impact smokers? self-efficacy, outcomes expectations, behavioural control, quit-aid efficacy, and outcome expectancies. However, this does mean that message orientation should be ignored when constructing smoking cessation messages. In fact, program designers are encouraged to employ messages that limit the use of addiction oriented statements such as ?nicotine is as addictive as heroin and cocaine?. Further research is required to examine the potential cumulative impact of addiction oriented messages on quitting behaviour and its precursors.

The issue of how to test and ultimately regulate tobacco products represents a critical challenge for the public health community. Although the current international testing regime for conventional cigarettes is widely acknowledged to be seriously flawed, there is a lack of data to guide potential alternatives, particularly in the area of human puffing behaviour. The current study sought to: 1) collect naturalistic measures of smoking behaviour, 2) examine the extent to which levels of tar, nicotine, and carbon monoxide from each of five testing protocols were associated with measures of nicotine uptake among smokers, and 3) examine the validity of self-report measures of smoking behaviour. These questions were examined through two different studies. First, a field study of smoking behaviour was conducted with 59 adult smokers, who used a portable device to measure smoking topography over the course of 3 one-week trials. Participants were asked to smoke their usual ?regular-yield? brand through the device for Trial 1 and again, 6 weeks later, at Trial 2. Half the subjects were then randomly assigned to smoke a ?low-yield? brand for Trial 3. The smoke intake and constituent yield of each brand was then tested under five testing protocols: ISO, Massachusetts, Canadian, a Compensatory protocol, and a Human Mimic regime. Participants also completed self-report measures of puffing behaviour at recruitment and immediately following each of the three one-week smoking trials. Several of these self-report measures were subsequently included in the Waves 2 and 3 of the International Tobacco Control Policy Evaluation (ITC) Survey?an international cohort survey of adult smokers from Canada, Australia, the US, and the UK. <br /><br /> The results of the field study indicate a high degree of stability in puffing behaviour within the same smoker over time, but considerable variability between smokers, including those smoking the same brand. Puffing behaviour was strongly associated with cotinine levels, particularly when included in an interaction term with cigarettes per day (<em>Part r</em> = . 50, <em>p</em><. 001). Smokers who were switched to a ?low-yield? cigarette increased their total smoke intake per cigarette by 40% (<em>p</em>=. 007), with no significant change in their in salivary cotinine levels. <br /><br /> The results indicate systematic differences between human puffing behaviour and the puffing regimes used by machine testing protocols. The puffing behaviour observed among participants during the one-week smoking trials was significantly more intense than the puffing parameters of the ISO and Compensatory testing regimes. When cigarette brands were machine tested using participants? actual puffing behaviour, the results suggest that participants ingested two to four times the level of tar, nicotine, and carbon monoxide indicated by the ISO regime, and twice the amounts generated by the Compensatory regime for ?regular-yield? brands. The Canadian and Massachusetts regimes produced yields much closer to the ?Human Mimic? yields, although nowhere near a maximum or intense standard, as they were designed to do. Only the nicotine yields from the Human Mimic regime were correlated with measures of nicotine uptake among smokers, and only moderately so (<em>Part r</em> = . 31, <em>p</em>=. 02). <br /><br /> Self-report measures of puffing behaviour collected during the field study were moderately correlated with physiological measures of puffing and exposure. Self-report measures of puff depth and puff number showed some promise as predictors of salivary cotinine, although the results are characterized by inconsistencies across models. The self-report measures included in the ITC survey were only weakly associated with age and cigarettes per day, with modest between-country differences. <br /><br /> Overall, this research highlights the importance of puffing behaviour as a determinant of smoke exposure, and provides strong evidence of compensatory smoking for ?low-yield? brands. The findings also highlight the variability in human smoking behaviour and the limitations associated with machine testing protocols. Perhaps most important, the findings underscore the immediate need to revise the ISO protocol, which systematically underestimates smoking behaviour among humans and exaggerates differences between cigarette brands.

The aim of this thesis is to explore methods to incorporate external effects on decision making of public health programmes in a UK setting, using smoking cessation as an example. The National Institute for Health and Clinical Excellence (NICE) methodological guidance for evaluating public health programmes is missing the incorporation of external effects. Therefore there is a need for considering their incorporation in such evaluations and to assess what are the appropiate methods to do so. Smoking cessation is an example where epidemiological evidence of external effects exists but has not generally been incorporated into economic evaluation. This thesis therefore focused in measuring the impact, in terms of costs and QALYs lost, of the incorporation of passive smoking, smoking during pregnancy and transmission of smoking behavior into economic evaluation of smoking cessation programmes previously developed to inform policy. A static Markov model is used to incorporate passive smoking and smoking during pregnancy, whereas transmisison of smoking behaviour is incorporated through a dynamic model. The findings show that some external effects can be incorporated without a system dynamic model, when this does occur, a static Markov model may be used to account for external effects in economic evaluation. Sometimes, to incorporate external effects, the model needs a change of population. Because smoking cessation interventions are generally highly cost-effective, the incorporation of external effects does not appear to change policy decisions, but there is a clear impact on the magnitude of the ICER. Passive smoking and smoking during pregnancy have higher impact in terms of costs and QALYs lost than transmission of smoking behaviour. Our discussion considers the validity of the methods used; how much the decision making process would be affected considering or not external effects on economic evaluation of smoking cessation interventions; and other valuation approaches for external effects, such as contingent valuation.