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The experience of becoming and having a sibling is a common situation for many preschool children. In order to clarify the implications of such an event for the older preschool child, the authors have surveyed the literature and interviewed a series of families where there was a second or third birth. This is a preliminary communication where a broad overview of the many variables involved is sought. Varied techniques for preparing the older preschool sibling were observed, as were varied coping mechanisms employed by the older child in adjusting to the change in his family status. Fourteen variables are discussed, and suggestions are made for further research. Everyday life is rich in surprise and novelty for the preschool child. He constantly encounters the previously unknown and is frequently coming upon new situations that push him to make new adaptations which usefully enlarge his repertoire of coping mechanisms. Some new experiences will delight him, while others puzzle, bewilder, confuse, or frighten him, thus putting him under stress. A common stressful situation in early childhood and one with lasting implications is the experience of becoming and having a sibling. For

This study determined whether higher dose nicotine patches are more efficacious than lower dose patches among heavy smokers. A randomized double-blind study compared 0, 21, 35, and 42 mg/day of a 24-h patch in 1039 smokers (> or = 30 cigarettes/day) at 12 clinical sites in the USA and one in Australia. Daily patches were used for 6 weeks followed by tapering over the next 10 weeks. Weekly group therapy occurred. Biochemically validated self-reported quit rates at 6, 12, 26, and 52 weeks post-cessation were measured. Quit rates were dose-related at all follow-ups (p < 0.01). Continuous, biochemically verified abstinence rates for the 0, 21, 35, and 42 mg doses at the end of treatment (12 weeks) were 16, 24, 30, and 39%. At 6 months, the rates were 13, 20, 20, and 26%. Among the 11 sites with 12 month follow-up (n = 879), the quit rates were 7, 13, 9, and 19%. In post-hoc tests, none of the active doses were significantly different from each other at any follow-up. The rates of dropouts due to adverse events for 0, 21, 35, and 42 mg were 3, 1, 3, and 6% (p = n.s.). Our results are similar to most prior smaller studies; i.e., in heavy smokers higher doses increase quit rates slightly. Longer durations of treatment may be necessary to show greater advantages from higher doses.

BackgroundReferral of patients to smoking cessation telephone counseling (i.e., quitline) is an underutilized resource by primary care physicians. Previously, we conducted a randomized trial to determine the effectiveness of benchmarked feedback on clinician referrals to a quitline. Subsequently, we sought to understand the successful practices used by the high-referring clinicians, and the perceptions of the barriers of referring patients to a quitline among both high and non-referring clinicians in the trial.MethodsWe conducted a qualitative sub-study with subjects from the randomized trial, comparing high- and non-referring clinicians. Structured interviews were conducted and two investigators employed a thematic analysis of the transcribed data. Themes and included categories were organized into a thematic framework to represent the main response sets.ResultsAs compared to non-referring clinicians, high-referring clinicians more often reported use of the quitline as a primary source of referral, an appreciation of the quitline as an additional resource, reduced barriers to use of the quitline referral process, and a greater personal motivation related to tobacco cessation. Time and competing demands were critical barriers to initiating smoking cessation treatment with patients for all clinicians. Clinicians reported that having one referral source, a referral coordinator, and reimbursement for tobacco counseling (as a billable code) would aid referral.ConclusionFurther research is needed to test the effectiveness of new approaches in improving the connection of patients with smoking cessation resources.Trial Registration NumberClinicaltrials.gov NCT00529256

PURPOSE We undertook a study to assess the impact of comparative feedback vs general reminders on practice-based referrals to a tobacco cessation quit line and estimated costs for projected quit responses. METHODSWe conducted a group-randomized clinical trial comparing the impact of 6 quarterly (18 months) feedback reports (intervention) with that of general reminders (control) on practice-based clinician referrals to a quit-line service. Feedback reports were based on an Achievable Benchmark of Care approach using baseline practice, clinician, and patient survey responses, and referrals per quarter. Comparable quit responses and costs were estimated.RESULTS Three hundred eight clinicians participated (171 family medicine, 88 internal medicine, 49 obstetrics-gynecology) from 87 primary care practices in Michigan. After 18 months, there were more referrals from the intervention than from the control practices (484 vs 220; P <.001). Practice facsimile (fax) referrals (84%, n = 595) exceeded telephone referrals (16%, n = 109), but telephone referrals resulted in greater likelihood of enrollment (77% telephone vs 44% fax, P <.001). The estimated number of smokers who quit based on the level of services utilized by referred smokers was 66 in the feedback and 36 in the gentle reminder practices.CONCLUSION Providing comparative feedback on clinician referrals to a quit-line service had a modest impact with limited increased costs. INTRODUCTIONS moking cessation interventions have proved to be effective in primary care settings according to the systematic reviews of controlled clinical trials that resulted in Clinical Practice Guidelines on Smoking Cessation by the Public Health Service.1,2 Clinicians report various reasons for not following the guidelines, such as focusing on acute or chronic care rather than preventive care, having little training in giving brief advice to quit smoking, and not being subject to accountability or feedback. 3,4 Survey fi ndings show that physicians understand the importance of smoking cessation and espouse its value, but they often do not implement the key elements of offi ce-based methods. 3,4 Physicians rarely schedule smokers for follow-up visits or arrange referrals for support services.1,3-5 Several community-based and health-system-based studies have shown fairly high rates of long-term smoking cessation (20% to 36%) by combining physician identifi cation, advice, and referral for follow-up care with telephone support counseling. [6][7][8][9][10][11] Telephone counseling services for smoking cessation (quit lines) have become widely available through health plans and state or national services, 12 but they are often underutilized. Methods to enhance clinician referrals to quit-line services are needed. 136 TOBACCO C ES S AT ION QUI T L INEFeedback on clinical performance has been studied in numerous randomized clinical trials and reported in systematic reviews to have modest effects.13 Comparing personal performance with peer performance should be a powerful motivator ...