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No. of bitstreams: 1 schwarzmeier_la_me_sjc.pdf: 3091413 bytes, checksum: 654a7ae7d828dff5e2f782ebb4eb3c96 (MD5) Previous issue date: 2018-03-28 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / O objetivo desta pesquisa foi investigar a frequência de micronúcleos e anomalias metanucleares na mucosa bucal de vaporizadores de cigarro eletrônico e de fumantes de cigarro industrializado, e comparar com ex-fumantes e não fumantes para determinar se existe diferença no dano citogenético e citotóxico, bem como se o dano diminui após a cessação tabágica. Os pacientes foram divididos em 4 grupos: Controle; E-cig; Fumante e Ex-fumante. Os critérios de inclusão adotados foram: ausência de histórico de neoplasia maligna bucal e ausência de quaisquer sinais clínicos visíveis de alteração no local avaliado. Foi realizada avaliação quanto ao grau de dependência nicotínica, por meio do Teste de Fagerström para Dependênca à Cigarro e Escore de Consumo Situacional Issa, e quanto ao perfil tabágico dos pacientes. A mensuração de CO expirado foi utilizada como critério objetivo de avaliação de consumo de tabaco, bem como a concentração de cotinina no sangue capilar dos pacientes avaliados. As amostras foram coletadas por meio de citologia esfoliativa da região de bordo lateral de língua e soalho bucal. Os esfregaços obtidos foram fixados com spray alcoólico e as lâminas coradas pelo método de Feulgen. Posteriormente, foi realizada a investigação dos micronúcleos e das anomalias metanucleares. Para a comparação dos dados não paramétricos foram utilizados os testes Kruskal-Wallis e Mann-Whitney. Já para as correlações e associações entre os dados, foram utilizados o teste da correlação de Spearman e o Teste Exato de Fisher, respectivamente. Foi adotado um nível de significância de 5% para todos os testes. A partir dos resultados, observou-se diferença significante entre os grupos E-cig e Controle (p=0,0072), e também entre os grupos Fumante e Controle (p=0,0004), no total de MN. Em contrapartida os grupos E-cig e Ex-fumante foram semelhantes, enquanto que o grupo Fumante foi significativamente maior que o grupo Ex-fumante (p=0,0370) também no total de MN. Também foi possível observar diferença significante entre os grupos E-cig e Ex-fumante, bem como entre os grupos E-cig e Controle em todas as anomalias metanucleares, exceto cariorrexe. Os grupos Fumante e Ex-fumante foram diferentes em cariorrexe (p=0,0517), e nuclear bud (p=0,0470) apenas, e o grupo Fumante foi significativamente maior que o grupo Controle em todas as anomalias metanucleares. A comparação entre os grupos E-cig e Fumante não foi realizada, devido à ingestão de altas doses de bebidas alcoólicas no grupo E-cig. O tabagismo promove danos citotóxicos e citogenéticos e o uso de E-cig associado ao álcool parece causar genotoxicidade e citotoxicidade. A cessação tabágica promove reversibilidade dos danos causados anteriormente. / The objective of this research was to investigate the frequency of micronuclei and metanuclear anomalies in the oral mucosa of electronic cigarette vaporizers and smokers of industrialized cigarettes and to compare with former smokers and nonsmokers to determine if there is a difference in cytogenetic and cytotoxic damage, as well as if it decreases after smoking cessation. The patients were divided into 4 groups: Control; E-cig; Smoker; and Former smoker. The inclusion criteria adopted were: absence of a history of oral malignancy and absence of any visible clinical signs of alteration at the evaluated site. An assessment was made of the degree of nicotinic dependence, using the Fagerström Test for Cigarette Dependence and the Issa Situational Consumption Score, and of the smoking profile of the patients. Measurement of expired CO was used as the objective criterion for the evaluation of tobacco consumption as well as the concentration of cotinine in the capillary blood of the evaluated patients. The samples were collected from the tongue lateral region and floor of the mouth by means of exfoliative cytology. The smears obtained were fixed with alcoholic spray and the slides were stained by the Feulgen method. Subsequently, the investigation of the micronuclei (MN) and metanuclear anomalies was carried out. For the non-parametric data, the Kruskal-Wallis and Mann-Whitney tests were performed. For the correlations and associations between the data, the Spearman correlation test and the Fisher Exact Test were respectively used. A significance level of 5% was adopted for all tests. From the results, we observed a significant difference between groups E-cig and Control (p = 0.0072), and also between groups Smoker and Control (p = 0.0004), in the total of MN. In contrast, groups E-cig and Former smoker were similar, whereas the group of Smoker was significantly higher than Former smoker (p = 0.0370) also in the total of MN. It was also possible to observe a significant difference between E-cig and Former smoker, as well as between E-cig and Control in all metanuclear anomalies, except for karyorrhexis. Already Smoker and Former smoker, they were different in karyorrhexis (p = 0.0517), and nuclear bud (p = 0.0470) only, and Smoker was significantly higher than Control in all metanuclear abnormalities. The comparison between groups E-cig and Smoker could not be performed due to the ingestion of high doses of alcoholic beverages in E-cig group. Smoking promotes cytotoxic and cytogenetic damage and the use of alcohol-associated electronic cigarettes appears to cause genotoxicity and cytotoxicity. Smoking cessation promotes reversibility of previously caused harm.

Introdução: O tabagismo é um problema crônico e de enfrentamento complexo. A ampliação da legislação, a conscientização da sociedade e a menor aceitação social do tabagismo, aumentaram a procura por serviços de cessação do tabagismo. A avaliação de programas desse tipo é tarefa complexa, considerando os diferentes níveis de intervenção, a diversidade de cenários e atores envolvidos. A avaliação de programas de cessação do tabagismo necessita incorporar ferramentas participativas, capazes de apontar a eficiência do programa, além de fomentar ações de transformação das práticas. Esta pesquisa buscou configurar uma matriz avaliativa capaz de contribuir na organização e autoaprendizagem de serviços dirigidos aos sujeitos em suas tentativas de parar de fumar, captando os diferentes contextos presentes na intervenção, nos cenários e nos atores. As questões da pesquisa foram: Quais são os indicadores que podem apontar o quanto um serviço se aproxima ou se distancia das práticas baseadas em evidências e dos modelos e diretrizes da promoção da saúde? Quais são os elementos que indicam ou não a qualidade de um serviço de tratamento do tabagismo? Objetivos: Desenvolver a matriz de indicadores de um serviço de tratamento do tabagismo. Para tanto buscou-se a) Identificar a percepção de experts, usuários e profissionais sobre serviços de tratamento do tabagismo; b) Caracterizar as práticas e bases de um serviço de cessação do tabagismo; c) Construir o modelo lógico avaliativo desse serviço; c) Formular as bases teóricas e práticas para a construção de matriz avaliativa de indicadores para um serviço de tratamento do tabagismo. Método: Situado no desenho orientado por modelo teórico (theory-driven evaluation) na perspectiva da Promoção da Saúde preconizada por Hartz, o percurso metodológico foi apoiado nas abordagens qualitativas e participativas e na estratégia da pesquisa-ação. O cenário de estudo foi o serviço de cessação do tabagismo de um hospital universitário, no município de São Paulo. Foram sujeitos dessa pesquisa profissionais de referência para o PNCT (experts), profissionais que atuam diretamente no serviço (implicados) e usuários do serviço. A análise e discussão dos achados apoiaram-se na triangulação de dados, correlacionada com a literatura. Resultados: O desfecho desta pesquisa foi o desenvolvimento da matriz avaliativa. Utilizou-se as percepções dos experts, implicados e usuários sobre as dimensões de estrutura, processo e resultado. A legislação, o financiamento, extensão e cobertura, a acessibilidade, as instalações, os recursos humanos, os equipamentos e insumos foram apontados como categorias para estrutura. Na dimensão processo as categorias foram: divulgação e captação, acolhimento e busca ativa, o perfil sócio psicológico dos usuários, a rede de referência e contra referência, o diagnóstico, acompanhamento e as estratégias educativas com base no autocuidado e na redução de danos. No âmbito de resultados os sujeitos pontuaram: a taxa de sucesso na cessação do tabagismo, a regularidade do serviço, a adesão, o respeito à autonomia, a melhora na qualidade de vida e a satisfação do usuário. Conclusão: Conclui-se que a matriz avaliativa construída possui potencial para avaliar a qualidade do serviço e promover o aprendizado institucional e o desenvolvimento pessoal/profissional. Contribui para o movimento de reflexão-ação-reorientação das práticas de cuidado. Ao ampliar a análise para além dos importantes indicadores solicitados pelo Programa Nacional do Controle do Tabagismo, a matriz elaborada dirige-se ao fortalecimento (empowerment) dos envolvidos (profissionais e usuários). Ajuda a estabelecer papéis e responsabilidades na reorientação de aspectos que possam influenciar o desempenho no acesso, acolhida, diagnóstico, tratamento e acompanhamento dos que desejam parar de fumar. / Introduction: Tobacco smoking is a chronic problem and very difficult to face. The improvements in the legislation, the awakening of the society and the smaller social acceptance to tobacco smoking have increased the number of people looking for smoking cessation services. The evaluation of such programs is a complex task, considering the different levels of intervention and the diversity of sceneries and actors involved. The evaluation of smoking cessation programs needs to incorporate participatory tools in order to indicate the program efficiency, and foster transformation actions of the practices. This study sought to configure an evaluation framework capable of contributing to the organization and self-learning of the services addressed to individuals in their attempts to quit smoking by capturing the different contexts present in the intervention sceneries and actors. The research questions were: Which are the indicators that may point out how much a service comes close or is distant from evidence-based practices, guidelines and models of health promotion? Which are the elements that indicate or not the quality of a smoking cessation treatment service? Objective: Developing the indicators framework of a smoking cessation service. For this it was sought to a) identify the experts, users and professionals perceptions about smoking cessation services, b) Characterize the practices and basis for a smoking cessation service c) Build the evaluative logical model of such service c) Formulate the theoretical and practical basis for the construction of an evaluative framework of indicators for a smoking cessation service. Method: Situated in the theoretical model oriented design (theory-driven evaluation) from the perspective of health promotion proposed by Hartz, the methodological trajectory was based on the qualitative and participative approaches as well as in the strategy of the action research. The study setting was the smoking cessation service at a university hospital in São Paulo. The subjects of this study were reference for the NTCP professionals (experts), the professionals who work directly in the service (stakeholders) and service users. The analysis and discussion of the findings were based upon the triangulation of data, correlated with the literature. Results: The outcome of this research was the development of the evaluation framework. It was used the perceptions of experts, and users concerned about the dimensions of structure, process and outcome. The legislation, funding, the extension and coverage, accessibility, facilities, human resources, equipment and supplies were identified for \"structure\". In the dimension \"process\" the categories were: dissemination and uptake, host and active search, the social psychological profile of the users, the network of reference and cross reference, diagnosis, monitoring and educational strategies based on self-care and harm reduction. Within the scope of \"outcomes\" the subjects pointed: the success rate of stop smoking, the regularity of service, treatment adherence, the autonomy, the improvement in quality of life and user satisfaction. Conclusions: We conclude that the evaluative framework constructed has the potential for assessing the service quality and to promote institutional learning and personal / professional development. It contributes to the movement of the reflection-action-reorientation of care practices. By broadening the analysis beyond the important indicators requested by the National Tobacco Control Program, the elaborate framework is targeted to the empowerment of those involved (professionals and patients). It helps to set roles and responsibilities in reorienting the aspects that may influence the access, reception, diagnosis, treatment and monitoring performance of those who want to quit smoking.

Abstract Although smoking in adolescents and young adults has been declining in the 21st century in Finland, about 17% of 18-year-olds still smoke on a daily basis. Young adults are in fact one of the age groups that are most likely to smoke in several countries. Nevertheless, a large proportion of them are known to want to quit smoking. Relatively little is known about the smoking habits of young adults. There are no evidence-based guidelines for smoking cessation in this age group. In many cases, they have been included within studies of adolescents or older adults without any separate analysis. Consequently, smoking cessation interventions demonstrated to be effective in middle-aged smokers are often adapted for young adults even though their culture, somatic features and smoking habits in many ways are different from those of middle-aged people. This study focused on 18–26-year-olds in northern parts of Finland. Specific aims were 1) to describe their smoking habits, 2) to compare health and lifestyle in tobacco users and non-tobacco users, 3) to study their nicotine dependence and motivation to quit smoking, and 4) to examine the use and effectiveness of smoking cessation pharmacotherapy in this age group. A total of 1163 male military recruits from northern parts of Finland filled in the study questionnaire. The survey study revealed that young adult males in northern parts of the country used tobacco products relatively often. Their smoking was associated with lower education, higher body mass index, inactivity in sports and impaired physical fitness. In addition, a great part of young smokers displayed symptoms of chronic bronchitis. Although most daily smokers were clearly dependent on nicotine and had previously tried to quit smoking, only 47% of the quitters had utilized any pharmacological aids in their attempts. Snus use seemed to be related to more severe nicotine dependence in smokers. The prospective study consisted of 314 voluntary young adult daily smokers who were motivated to quit smoking. The study was a randomised, placebo-controlled clinical trial, and the results indicated that varenicline might be more effective than nicotine patches in smoking cessation of young adult heavy smokers, at least in short term. Abstinence rates during the follow-up were similar when the nicotine patch and placebo patch were compared in young adult light smokers. / Tiivistelmä Suomessa nuorten keskuudessa tupakointi on ollut 2000-luvun aikana laskusuuntainen. Kuitenkin arviolta n. 17 % 18-vuotiaista tupakoi edelleen päivittäin. Nuoret aikuiset ovatkin useissa maissa yksi eniten tupakoivia ikäryhmiä. Silti suuren osan tupakoivista nuorista aikuisista on todettu olevan halukkaita llopettamaan tupakoinnin. Nuorten aikuisten tupakointia on tutkittu verrattain vähän. Heille suunnattuja tieteelliseen näyttöön perustuvia hoitomuotoja tupakoinnin lopettamiseen ei ole. He ovat usein osana teini-ikäisten tai vaihtoehtoisesti vanhempien aikuisten ryhmää tupakointiin liittyvissä tutkimuksissa, eikä heitä yleensä ole analysoitu erikseen. Usein heitä hoidetaankin keski-ikäisiltä aikuisilta saadun tutkimusnäytön pohjalta. Kuitenkin nuorten kulttuuri, biologinen pohja ja tupakointitavat eroavat merkittävästi vanhemmista tupakoitsijoista. Tämä työ on keskittynyt tutkimaan 18–26-vuotiaita nuoria aikuisia Pohjois-Suomessa. Sen tavoitteina on ollut 1) kuvata heidän tupakointitottumuksiaan, 2) selvittää tupakoinnin yhteyttä terveyteen ja elämäntapaan, 3) tutkia heidän nikotiiniriippuvuuttaan sekä motivaatiota lopettaa tupakointi, sekä 4) selvittää tupakkavieroituslääkkeiden käyttöä ja niiden tehoa tässä ikäryhmässä. Terveystottumuskyselyymme vastasi 1163 Pohjois-Suomen varusmiestä. Selvisi, että varusmiehet käyttivät tupakkatuotteita Pohjois-Suomessa valtakunnallisia arvioita enemmän. Tupakoinnin todettiin liittyvän varusmiehillä alempaan koulutustasoon, suurentuneeseen painoindeksiin, vähäisempään fyysiseen aktiivisuuteen ja huonompaan aerobiseen suorituskykyyn. Lisäksi tupakoivilla varusmiehillä kroonisen bronkiitin oireet olivat yleisiä. Vaikka valtaosa heistä oli selvästi nikotiiniriippuvaisia ja oli yrittänyt lopettaa tupakointinsa, vain 47% lopetusta yrittäneistä oli kokeillut tupakkavieroituslääkettä. Nuuskan käyttö vaikutti liittyvän vahvempaan nikotiiniriippuvuuteen tupakoitsijoilla. Prospektiiviseen, satunnaistettuun ja lumekontrolloituun kliiniseen kokeeseen osallistui 314 vapaaehtoista päivittäin tupakoivaa nuorta aikuista, jotka olivat halukkaita tupakoinnin lopetukseen. Tulokset viittasivat siihen, että varenikliini saattaa olla nikotiinilaastaria tehokkaampi tupakoinnista vieroituksessa vahvasti nikotiiniriippuvaisilla nuorilla aikuisilla ainakin lyhyellä aikavälillä. Kevyemmin tupakasta riippuvaisilla nikotiinilaastari ei ollut lumelaastaria tehokkaampi.

Abstract The research focus for smoking and public health has typically been on serious smoking diseases such as cancer and coronary thrombosis, which typically require treatment in a hospital setting at an older age. In this thesis, primary health care utilisation and cardiovascular risk factors according to smoking status were studied in a younger cohort: at age 46 in the Northern Finland Birth Cohort of 1966. Primary health care costs of smokers vs. never-smokers were 28% higher for men and 21% higher for women. Signs of elevated risk of metabolic syndrome and cardiovascular disease were visible: smokers had 20% higher triglycerides, slightly larger waist-to-hip ratio, and type 2 diabetes prevalence was twice as high among smokers than never-smokers after adjustment for covariates. The calculated ten-year risk of a cardiovascular event was twice as high for smokers vs. either never-smokers, former smokers or recent quitters. These results should be seen as early warning signals in primary health care, and cost-effective actions should be taken to prevent later multimorbidity – smoking cessation aid by a physician is very cost effective. Only a minority of smokers receive cessation support from a physician, even though the majority of them wish to quit. In order to understand this discrepancy, a survey was conducted on physicians and smoking cessation. Physicians thought it was their responsibility to try to get the patient to quit, but practical measures to treat smoking dependence were rare. The most commonly reported restrictions for smoking cessation work – lack of time and functional treatment paths – could be addressed by administration and management. The attitudes and experiences of Finnish physicians were in line with the WHO recommendation to improve smoking cessation services and integrate them into health care: 80% were in favour of more resources being directed to smoking cessation services, and less than one third thought that smoking cessation was even somewhat well organised in the Finnish health care system. / Tiivistelmä Tupakoinnin terveys- ja talousvaikutusten tarkastelu keskittyy usein myöhemmällä iällä sairaalahoitoa vaativiin tupakkasairauksiin kuten syöpään ja sepelvaltimotautiin. Tässä väitöskirjassa tarkastellaan tupakoinnin ja perusterveydenhuollon käytön sekä sydän- ja verisuonitautien riskitekijöiden yhteyttä nuoremmassa otoksessa: 46 vuoden iässä Pohjois-Suomen vuoden 1966 syntymäkohortissa. Perusterveydenhuollon vuosittaiset kustannukset olivat tupakoivilla korkeammat kuin tupakoimattomilla: miehillä 28% ja naisilla 21%. Merkkejä kohonneesta metabolisen oireyhtymän ja sydän- ja verisuonitautien riskistä oli havaittavissa: tupakoivien triglyseridit olivat 20% korkeammat, heidän lantio-vyötärösuhteensa oli hieman suurempi kuin tupakoimattomilla, ja tyypin 2 diabetes oli heillä kaksi kertaa yleisempää taustamuuttujien vakioinnin jälkeen. Arvioitu riski saada vakava sydän- tai verisuonitapahtuma seuraavan kymmenen vuoden kuluessa oli tupakoivilla kaksi kertaa suurempi kuin heillä, jotka joko eivät olleet ikinä tupakoineet, olivat aiemmin tupakoineet, tai jotka olivat hiljattain lopettaneet. Perusterveydenhuollon tulisi nähdä nämä ilmiöt varhaisina varoitussignaaleina ja ryhtyä kustannusvaikuttaviin toimenpiteisiin myöhemmän multimorbiditeetin ehkäisemiseksi – lääkärin antama tuki tupakoinnin lopettamisessa on erittäin kustannusvaikuttavaa. Vaikka suurin osa tupakoitsijoista haluaa lopettaa, vain vähemmistö saa siihen tukea lääkäriltä. Tämän epäsuhdan ymmärtämiseksi tehtiin kyselytutkimus lääkäreille tupakastavieroituksesta. Lääkärit näkivät velvollisuudekseen yrittää saada tupakoiva potilas lopettamaan, mutta käytännön toimet tupakkariippuvuuden hoitamiseksi olivat harvinaisia. Yleisimmin raportoidut esteet vieroitustyölle – aikapula ja puutteelliset hoitopolut – olivat hallinnon ja johdon ratkaistavissa. WHO:n mukaan Suomella on parantamisen varaa lopettamisen tukipalveluissa ja tupakkariippuvuuden hoidon integroimisessa terveydenhuoltojärjestelmään. Tästä väitöskirjasta käy ilmi, että suomalaisten lääkäreiden asenteet ja kokemukset ovat linjassa WHO:n ohjeistuksen kanssa: 80% kannatti lisäresurssien ohjaamista lopettamispalveluihin ja alle kolmanneksen mielestä tupakastavieroitus toteutui edes jokseenkin hyvin suomalaisessa terveydenhuoltojärjestelmässä.

L’hypothèse traitée dans les travaux internationaux récents est celle d’un effet médiateur de la perspective temporelle entre insertions sociales et comportements de santé, en faisant ainsi un objet d’étude central dans l’analyse et la prévention des inégalités sociales de santé. L’arrêt du tabagisme, pris comme modèle d’addiction, constitue une situation exemplaire pour analyser les freins à la mise en œuvre de comportements de santé chez les publics en situation de précarité. Le sevrage, comme d’autres comportements de réduction et/ou d’arrêt de consommation de substances addictives ne peut s’opérer sans une gestion du temps et de la temporalité du sevrage, mais cette gestion est profondément impactée par la nature de la relation que l’individu entretient avec le temps. Ce croisement des temps est considéré dans cette recherche comme déterminant dans les possibilités d’édification et de maintien des changements cognitifs et comportementaux engagés par le sevrage. L’objectif de cette recherche est donc d’introduire les avancées récentes de la recherche en psychologie sociale sur le temps dans l’étude de la démarche de sevrage tabagique et plus particulièrement celle de publics en situation de précarité. Elle tente plus généralement de comprendre et de modéliser comment, et dans quelle mesure, la précarité et le rapport au temps peuvent influencer les résultats du sevrage tabagique. L’objectif final est de développer l’intégration des dimensions temporelles dans l’étude des mécanismes du sevrage tabagique, mais aussi plus largement d’accroître les connaissances des déterminants psychosociaux de la réussite du sevrage et ainsi d’optimiser la prise en charge des populations en situation de précarité. / Recent international works deal with the hypothesis of a mediation effect of time perspective in the link between social insertions and health behaviours, making it a key factor in the analysis and prevention of social inequalities in health.Smoking cessation, as a model of addiction, constitutes an exemplary situation to analyze the impediments in health behaviours implementation in socially deprived populations. Stopping tobacco, as well as other behaviours of reduction and/or cessation of addictive substances cannot operate without time management and the temporality of cessation, but this management is deeply impacted by one’s relationship with time. This crossing of times is considered in this research as a determinant in the possibilities to edify or maintain behavioural and cognitive changes needed by the cessation.The aim of this research is to introduce recent advances of time in social psychology in the field of smoking cessation and more precisely in socially deprived populations. It more generally attempts to understand and modelize how, and to what extent, precariousness and time perspective may influence the results of smoking cessation. The final goal is to develop the integration of temporal dimensions in the study of smoking cessation mechanisms, and to increase the knowledge about psychosocial determinants of success in order to optimize the care of socially deprived populations.

This study explored whether a relationship exists between smoking behaviors and racial discrimination induced anger among Black adolescents. Participants consisted of 134 Black adolescents from 14 to 18 years of age who frequently visited a recreation center in the Northeast. Forty-four participants were males and 90 were females. All participants were administered a modified version of the CAGE questionnaire, a background information questionnaire, and a measure designed to assess the extent to which they feel angry because they had been discriminated against. Only age was found to be predictive of scores on the CAGE. Only gender was found to be predictive of smoking frequency. The Black Anger Measure (BAM) was significantly correlated with smoking behaviors. Some implications for theory, research and practice are suggested.

Diploma thesis "Assesement of effects of antismoking policy focused on children and teenagers" deals with the problem of young smokers, whose numbers are not significantly decreasing in the Czech republic despite broad range of measures taken in recent years. Efficiency and funcionality of those measures leading to the protection of children and health promotion as well as the proposed solutions of battle against tobacco companies' marketing are evaluated. Czech republic legislation and its effects on children's cigarette consumption is therefor analyzed. Moreover, possible solutions in form of WHO's proposals are introduced.

Tabakkonsum bei Jugendlichen und erwachsenen Risikopopulationen. Einflussfaktoren und Ansätze zu Prävention und Intervention Die vorliegende Arbeit beschäftigt sich mit den Einflussfaktoren des Tabakkonsums bei verschiedenen Zielgruppen sowie möglichen Ansätzen zur nachhaltigen Beeinflussung des Rauchverhaltens. Die Arbeit besteht aus insgesamt sechs Manuskripten, die in nationalen und internationalen Fachzeitschriften publiziert oder zur Publikation angenommen sind. Diese sechs Beiträge lassen sich zwei Schwerpunkten zuordnen, die inhaltlich die zwei wichtigsten Möglichkeiten zur Reduktion des Tabakkonsums in der Bevölkerung widerspiegeln: die Verhinderung des Neueinstiegs in das Rauchen bei Kindern und Jugendlichen (Prävention) sowie die Förderung des Ausstiegs aus dem Rauchen (Intervention). Im ersten Teil wird im Rahmen eines Reviews sowie zweier Studien untersucht, ob sich verhältnispräventive Maßnahmen an Schulen auf das Rauchverhalten der Schüler auswirken. Im zweiten Teil untersuchen drei Studien die Motivation zur Verhaltensänderung, die Inanspruchnahme von Hilfsangeboten bzw. die Effektivität von Tabakentwöhnung bei Rauchern mit einer Alkoholabhängigkeit, Müttern in der Mutter-Kind-Rehabilitation sowie Patienten mit tabakassoziierten körperlichen Erkrankungen. / „Smoking in adolescents and adult risk populations. Factors of influence and approaches concerning prevention and intervention” This dissertation is concerned with factors influencing the smoking behaviour of different target groups and potential approaches for lasting changes of these behaviours. The dissertation consists of six manuscripts that are published or accepted for publication in national and international peer-reviewed journals. These six papers refer to two main emphases that reflect the two most important possibilities to reduce tobacco consumption in the population: Prevention of smoking initiation in children and adolescents (prevention), and support for smoking cessation (intervention). In the first part of the dissertation, a literature review and two empirical studies assess the influence of school tobacco policies on the smoking behaviour of students. In the second part, three empirical papers examine motivation to change, utilisation and effectiveness of smoking cessation in smokers with an alcohol dependence, mothers in mother-child rehabilitation and patients with smoking-related physical diseases.

In Deutschland fehlen bislang belastbare epidemiologische Daten über sowohl die Häufigkeit nikotinabhängiger Raucher im primärärztlichen Versorgungsbereich als auch das Ausmaß der von Hausärzten angebotenen Raucherentwöhnungsmaßnahmen. Die Ziele in der "Smoking and Nicotine Dependence Awareness and Screening (SNICAS)"-Studie waren/sind: (1) die Ermittlung repräsentativer Daten zur Prävalenz des Rauchens und der Nikotinabhängigkeit in Deutschland, (2) die Beschreibung des Rauchverhaltens und der Aufhörmotivation von Rauchern in der primärärztlichen Versorgung sowie (3) die Feststellung von Einstellungen, Fertigkeiten und Erfahrungen von Hausärzten im Zusammenhang mit der Raucherentwöhnung. SNICAS basierte auf einem zweistufigen epidemiologischen Studiendesign, woran sich eine derzeit noch laufende, klinische Interventionskomponente anschloss. In Stufe I (Vorstudien-Fragebogen) wurde eine repräsentative Auswahl von 889 Ärzten (Allgemeinärzte, praktische Ärzte, Internisten) hinsichtlich Erfahrungen und Einstellungen zu Raucherentwöhnungsmethoden charakterisiert. In Stufe II wurde an einem Stichtag (7. Mai 2002) in diesen Praxen n = 28 707 unausgelesene, konsekutive Patienten zunächst mittels eines Patientenfragebogens untersucht (konservative Ausschöpfungsrate: 52,8%). Daran schloss sich für jeden einzelnen Patienten eine unabhängige, standardisierte Arztbeurteilung (Erhebung des Rauchstatus, des Gesundheitszustands, vergangener und aktueller Interventionen u.ä.) an. Der Beitrag enthält eine Darstellung von Design und Methode der SNICAS-Studie und berichtet über die Gewinnung, Ausschöpfung und Repräsentativität der Arzt- und Patientenstichprobe. Auf der Grundlage ausgewählter Daten des Vorstudien- Fragebogens, aus denen eine geringe Anzahl (17,6%) an sich intensiv mit der Raucherentwöhnung befassenden Ärzten hervorgeht, werden ärztliche Interventionsstrategien, aber auch Einstellungs- und Strukturbarrieren vorgestellt. / Aims, Design and Methods of the "Smoking and Nicotine Dependence Awareness and Screening" (SNICAS) Study Germany lacks robust epidemiological data on the prevalence of smoking and nicotine dependence in primary care patients as it does on smoking cessation interventions provided by primary care physicians. Objectives of the "Smoking and Nicotine Dependence Awareness and Screening" (SNICAS) study are (1) to provide nationally representative data on the frequency of smoking and nicotine dependence among primary care patients in Germany, (2) to describe their smoking behaviour and motivation to quit as well as (3) attitudes, skills and experiences of physicians regarding smoking cessation. SNICAS is based on a 2-stage epidemiological design, supplemented by a subsequently conducted clinical intervention trial still ongoing. Stage I consists of a prestudy characterization of a nationwide sample of 889 primary care doctors (general practitioners, family doctors and internists with primary care functions). Stage II consists of a target day assessment (May 7th 2002) of n=28,707 unselected consecutive patients by means of a patient questionnaire (conservative response rate: 52.8%). For each patient a structured clinical appraisal form (screening of the patients' smoking status, physical and mental health, current and past interventions etc. ) was accomplished by the doctor. This article presents design and methods of the SNICAS study and describes its sampling strategy, its response rates and the representativity of primary care doctors and patients. By means of selected pre-study data, showing that only a small proportion of physician is extensively involved in smoking cessation (17.6%), intervention strategies of the doctors are presented as well as obstacles for smoking cessation (e.g. structures, attitudes).

Durch eine stärkere Einbeziehung deutscher Hausärzte in die Raucherentwöhnung soll die Versorgung von Rauchern flächendeckend verbessert werden. Inwiefern dieser Anspruch realisierbar ist, wird im Rahmen der "Smoking and Nicotine Dependent Awareness and Screening" (SNICAS) Studie überprüft. SNICAS ist eine zweistufige epidemiologische Punktprävalenzstudie [Stufe I (Vorstudie): Charakterisierung einer repräsentativen, bundesweiten Stichprobe von n = 889 Hausärzten; Stufe II: Stichtagserhebung an n = 28 707 unselektierten konsekutiven Patienten], an die sich eine regionale klinische Interventionskomponente anschließt. In diesem Beitrag werden Prävalenzraten des Rauchens, Aufhörmotivation und bisherige Aufhörversuche von Primärarztpatienten berichtet. Dargestellt werden Erkennens- und Interventionsraten von Rauchern durch Hausärzte, das ärztliche Interventionsverhalten sowie deren Einschätzung der Chancen und Barrieren von Raucherentwöhnung im Praxisalltag. Die Ergebnisse der Studie belegen ein großes Interesse der Hausärzte am Thema Raucherentwöhnung. Dennoch weisen niedrige hausärztliche Interventionsraten bei gleichzeitig hohen Prävalenzraten von Rauchen und Nikotinabhängigkeit auf ein beträchtliches Versorgungsdefizit. Als Ursachen hierfür werden neben ambivalenter Aufhörmotivation der Patienten strukturelle Barrieren diskutiert. Die Autoren fordern neue klinische Versorgungsmodelle, die ein abgestimmtes Zusammenspiel von Hausärzten mit anderen, auf Raucherentwöhnung spezialisierte Berufsgruppen fokussieren. / Through smoking cessation interventions, primary care physicians could play an important part in the treatment of smokers in Germany. In the "Smoking and Nicotine Dependent Awareness and Screening" (SNICAS) study, we examined whether this increased involvement of primary care physicians might be implemented. SNICAS is a two-stage epidemiological point prevalence study. In stage I (pre-study), a nationwide sample of 889 primary care doctors was characterized; in stage II, 28 707 unselected consecutive patients were assessed on the target day. The investigation was followed by regional clinical interventions. The present article contains our findings on the prevalence of smoking, the motivation to quit, and the history of quit attempts among primary care patients. Information will be provided on how frequently physicians recognize and treat smokers; what kind of interventions they offer; as well as how they judge the opportunities and obstacles for smoking cessation in routine care. Despite the high prevalence of smoking and nicotine dependence and the primary care doctors’ interest in treating smokers, insufficient interventions are provided. Reasons for this situation include, but are not limited to the patients’ ambivalent motivation to quit and structural barriers. Hence, new clinical models of health care with an improved cooperation between primary care physicians and other specialists in the field of smoking cessation seem necessary.