BackgroundIn rural America, cigarette smoking is prevalent and health care providers lack the time and resources to help smokers quit. Telephone quitlines are important avenues for cessation services in rural areas, but they are poorly integrated with local health care resources.ObjectiveThe intent of the study was to assess the comparative effectiveness and cost effectiveness of two models for delivering expert tobacco treatment at a distance: telemedicine counseling that was integrated into smokers’ primary care clinics (Integrated Telemedicine—ITM) versus telephone counseling, similar to telephone quitline counseling, delivered to smokers in their homes (Phone).MethodsSmokers (n=566) were recruited offline from 20 primary care and safety net clinics across Kansas. They were randomly assigned to receive 4 sessions of ITM or 4 sessions of Phone counseling. Patients in ITM received real-time video counseling, similar to Skype, delivered by computer/webcams in clinic exam rooms. Three full-time equivalent trained counselors delivered the counseling. The counseling duration and content was the same in both groups and was available in Spanish or English. Both groups also received identical materials and assistance in selecting and obtaining cessation medications. The primary outcome was verified 7-day point prevalence smoking abstinence at month 12, using an intent-to-treat analysis.ResultsThere were no significant baseline differences between groups, and the trial achieved 88% follow-up at 12 months. Verified abstinence at 12 months did not significantly differ between ITM or Phone (9.8%, 27/280 vs 12%, 34/286; P=.406). Phone participants completed somewhat more counseling sessions than ITM (mean 2.6, SD 1.5 vs mean 2.4, SD 1.5; P=.0837); however, participants in ITM were significantly more likely to use cessation medications than participants in Phone (55.9%, 128/280 vs 46.1%, 107/286; P=.03). Compared to Phone participants, ITM participants were significantly more likely to recommend the program to a family member or friend (P=.0075). From the combined provider plus participant (societal) perspective, Phone was significantly less costly than ITM. Participants in ITM had to incur time and mileage costs to travel to clinics for ITM sessions. From the provider perspective, counseling costs were similar between ITM (US $45.46, SD 31.50) and Phone (US $49.58, SD 33.35); however, total provider costs varied widely depending on how the clinic space for delivering ITM was valued.ConclusionsFindings did not support the superiority of ITM over telephone counseling for helping rural patients quit smoking. ITM increased utilization of cessation pharmacotherapy and produced higher participant satisfaction, but Phone counseling was significantly less expensive. Future interventions could combine elements of both approaches to optimize pharmacotherapy utilization, counseling adherence, and satisfaction. Such an approach could commence with a telemedicine-delivered clinic office visit for pharmacotherapy guidance, and continue w...

Background Cigarette smoking is a chronic, relapsing illness that is inadequately addressed in primary care practice. Objective To compare cessation rates among smokers receiving pharmacotherapy management alone or combined with either moderate- or high-intensity disease management that includes counseling and provider feedback. Design Randomized clinical trial from June 2004 to December 2007. Setting 50 rural primary care practices. Patients 750 patients smoking ≥ 10 cigarettes/day. Intervention Participants were randomized to one of three groups: pharmacotherapy management (n = 250); pharmacotherapy management supplemented with up to 2 counseling calls (moderate-intensity disease management (n = 249)); or pharmacotherapy management supplemented with up to 6 counseling calls (high-intensity disease management (n = 251)). Interventions were offered every six months for two years. All participants received offers of free pharmacotherapy; moderate-intensity and high-intensity disease management recipients had post-counseling progress reports faxed to their physicians. Participants and counselors were not blinded to treatment assignment. Measurements Self-reported point-prevalence smoking abstinence at 24 months (primary outcome) and overall (0 to 24 months) analyses of smoking abstinence, utilization of pharmacotherapy, and discussions about smoking with physicians (secondary outcomes). Research assistants, blinded to treatment assignment, conducted outcome assessments. Results Pharmacotherapy utilization was comparable across treatment groups, with 473 of 741 (63.8%), 302 of 739 (40.9%), 175 of 732 (23.9%), and 179 of 726 (24.7%) requesting pharmacotherapy during the 1st, 2nd, 3rd, and 4th 6-month cycles of treatment. Of participants that saw a physician during any given treatment cycle, 37.5 – 59.5% reported that they discussed smoking cessation with their physician, but this did not differ across the treatment groups. Abstinence rates increased throughout the 24-month study and overall (0 to 24 months) analyses demonstrated higher abstinence among recipients of high-intensity versus moderate-intensity disease management (OR, 1.43 [95% CI, 1.00 to 2.03]) and higher abstinence in the combined disease management groups compared to pharmacotherapy management alone (OR, 1.47 [95% CI, 1.08 to 2.00]). The primary outcome, self-reported abstinence at 24 months, was 68 of 244 (27.9%) and 56 of 238 (23.5%) in the high-intensity and moderate-intensity disease management groups, respectively (OR, 1.33 [95% CI, 0.88 to 2.02]) and 56 of 244 (23.0%) in the pharmacotherapy management group (OR, 1.12 [95% CI, 0.78 to 1.61] (combined disease management versus pharmacotherapy management alone)). Limitations The impact of pharmacotherapy management cannot be separated from the provision of free pharmacotherapy. Cessation was validated in only 58% of self-reported quitters. Conclusion Smokers are willing to make repeated pharmacotherapy-assisted quit attempts leading to progressively greater smoking abstinence. A...

The purpose of this study was to obtain descriptions of tobacco treatment services across different substance abuse treatment settings. We conducted mixed-method assessments in 8 facilities among 8 directors, 25 staff, 29 clients, and 82 client charts. Measures included systems assessment, chart reviews, and semi-structured interviews. Although many programs reported they offer key components of evidence-based treatment, few actually provided any treatment and none did so systematically. Many addressed tobacco as part of drug education or part of a health promotion session. Chart reviews suggested that provision of tobacco treatment is rare. By many reports, clients had to specifically request treatment and few staff reported encouraging unmotivated smokers to quit. Systems to facilitate consistent, evidence-based tobacco treatment and to implement quality improvement were nonexistent. The findings imply that drug treatment facilities may need to build capacity in several domains in order to deliver care that is consistent with national guidelines.

Background Most clients in drug treatment smoke cigarettes, but few facilities provide treatment for tobacco dependence. We identify subjective experiences and social processes that may influence facility adoption of tobacco treatment policies and practices. Methods Cross-sectional, semi-structured interviews were conducted with staff, directors and clients of 8 drug treatment facilities in the Midwestern U.S. We assembled a purposive sample stratified by ownership, methadone provision, and treatment service provision. We conducted in-person interviews with clinic directors and 54 staff and clients and employed a mixed-method analytic approach. Results Facility policies and philosophy related to tobacco differed from those regarding alcohol and other drugs. Participants suggested facilities may not treat tobacco dependence because it does not create legal and social problems that force clients into treatment. Tobacco dependence treatment falls outside of a core function of drug treatment, which is to help clients fix legal problems caused by their drug use. Moreover, proactively treating clients for tobacco dependence creates strong ambivalence among staff and directors. On the one hand, staff smoking would violate core principles of drug treatment (i.e., the importance of staff abstinence from drugs of abuse); on the other, staff who smoke feel their personal rights and jobs are threatened. This situation creates strong incentives for staff to resist adoption of tobacco dependence treatment. Unlike other studies, the fear of jeopardizing clients’ abstinence from other drugs did not emerge as a downside for treating tobacco dependence. Conclusions International and national trends will probably increase the pressure to treat tobacco dependence during drug treatment. However, the U.S. context of drug treatment, as a patchwork, under-funded industry with high employee turnover, may undermine true adoption. At present, many facility staff resolve their ambivalence by reporting they “offer” treatment, but actually providing none. To facilitate dissemination of service provision, it may be useful to identify incentives for U.S. facilities that are closely aligned with the criminal justice system, help facilities define policies and treatment roles for staff who smoke, and better define the role of facilities in preventing morbidity and mortality.

PURPOSE Cervical cancer screening is not well implemented in many low- and middle-income countries (LMICs). Mobile health (mHealth) refers to utilization of mobile technologies in health promotion and disease management. We aimed to qualitatively synthesize published articles reporting the impact of mHealth on cervical cancer screening–related health behaviors. METHODS Three reviewers independently reviewed articles with the following criteria: the exposure or intervention of interest was mHealth, including messages or educational information sent via mobile telephone or e-mail; the comparison was people not using mHealth technology to receive screening-related information, and studies comparing multiple different mHealth interventional strategies were also eligible; the primary outcome was cervical cancer screening uptake, and secondary outcomes included awareness, intention, and knowledge of screening; appropriate research designs included randomized controlled trials and quasi-experimental or observational research; and the study was conducted in an LMIC. RESULTS Of the 8 selected studies, 5 treated mobile telephone or message reminders as the exposure or intervention, and 3 compared the effects of different messages on screening uptake. The outcomes were diverse, including screening uptake (n = 4); health beliefs regarding the Papanicolaou (Pap) test (n = 1); knowledge of, attitude toward, and adherence to colpocytologic examination (n = 1); interest in receiving messages about Pap test results or appointment (n = 1); and return for Pap test reports (n = 1). CONCLUSION Overall, our systematic review suggests that mobile technologies, particularly telephone reminders or messages, lead to increased Pap test uptake; additional work is needed to unequivocally verify whether mhealth interventions can improve knowledge regarding cervical cancer. Our study will inform mHealth-based interventions for cervical cancer screening promotion in LMICs.