The Southern African Journal of Epidemiology and Infection 2006; 21 (4):152-160 Guideline for the management of nosocomial infections in South Africa* A Brink, C Feldman, A Duse, D Gopalan, D Grolman, M Mer, S Naicker, G Paget, O Perovic, G Richards Objective: To write a guideline for the management and prevention of nosocomial infections in South Africa in view of the following: i) nosocomial infections are a common and increasing problem globally, including South Africa; ii) widely varying standards of prevention and management of these important infections; iii) increasing and emerging antimicrobial resistance among commonly isolated pathogens, and iv) the significant economic burden of these infections on the healthcare system as well as their impact on patient morbidity and mortality. The main aims of the guideline are to provide recommendations for the initial choice of antimicrobial agents and the appropriate management of these infections encompassing the following conditions: i) nosocomial pneumonia, healthcare-associated pneumonia and ventilator-associated pneumonia; (ii) nosocomial bloodstream infections; (iii) nosocomial intravascular infections; (iv) nosocomial urinary tract infections; (v) nosocomial intra-abdominal infections; and (vi) nosocomial surgical skin and soft-tissue infections. Evidence: Working group of clinicians from relevant disciplines, following detailed literature review. Recommendations: These include details of the likely pathogens, an appropriate diagnostic approach, antibiotic treatment options and appropriate preventive strategies. Endorsement: The guideline document was endorsed by the South African Thoracic Society, the Critical Care Society of Southern Africa and the Federation of Infectious Diseases Societies of Southern Africa. Guideline sponsor: The meeting of the Working Group and the guideline publication were sponsored by an unrestricted educational grant from Sanofi Aventis South Africa.
Quintessenz journalsAlle R Copyright
Evaluation of Tobacco Use Cessation (TUC) Counselling in the Dental Office Ian Needlemana/Saman Warnakulasuriyab/Gay Sutherlandc/ Michael M. Bornsteind/Elias Casalse/Thomas Dietrichf/Jean Suvana Abstract: Tobacco use cessation (TUC) in dentistry is critical to reducing the effect of a major risk factor for both oral andsystematic diseases. The effect of TUC interventions has been widely reported. The data show that the success of TUC with-out professional support is negligible but that behavioural and pharmacological interventions are effective. Furthermore,the greater the intensity of support, the greater the quit rate and success rates are similar comparing different health careprofessionals including dental professionals. Although few studies have been performed in dental practice, it is clear thatTUC should be embedded in routine oral health care. In addition to evaluating the effect of TUC, several studies have inves-tigated barriers to implementing TUC in dental settings. A large number of barriers have been reported. These studies high-light the importance of further training for dental professionals but also identify the need for major cultural and policychanges to facilitate the provision of TUC. Research on barriers to TUC in dental care could be facilitated by employing quali-tative or mixed methods designs and studies that evaluate the impact of changing such barriers on TUC provision. Such anapproach will help to close the gap between research findings and implementation. Regarding the measurement of out-comes from TUC, no gold standards exist currently. Therefore both self-reported and biochemical measures of tobacco useshould be reported in evaluation studies. It is also clear that feedback from biochemical testing of tobacco use can increasesuccess rates in tobacco use cessation.
Key words: tobacco use cessation, smoking cessation, smoking, risk factors, oral health, barriers, primary prevention Oral Health Prev Dent 2006; 4: 27-47. Submitted for publication: 01.12.05; accepted for publication: 09.01.06. Tobacco use cessation (TUC) in dentistry is critical gienists but also including other dental care profes- to reducing the effect of a major risk factor for sionals) may see their patients on a frequent and re- both oral and systematic diseases. Dental health curring basis. As a result, it has been suggested that care providers (particularly dentists and dental hy- dental personnel have unparalleled opportunities toeducate and help those who use tobacco to quit(Christen et al, 1990).
In order to make recommendations for tobacco a International Centre for Evidence-Based Oral Health, Unit of Peri- odontology, UCL Eastman Dental Institute, UCL, London, UK. use cessation in dental practice, this paper will re- view interventions for which evidence of efficacy ex- Dept of Oral Medicine, WHO Collaborating Centre for Oral Cancer &Precancer, King's College London Dental Institute at Guy's, King's & ists. Sources of evidence consulted include guidelines St Thomas' Hospitals, London, UK. and systematic reviews (including Fiore et al, 2000; c Tobacco Research Unit, Institute of Psychiatry, King's College Lon- Stead and Lancaster, 2005; Marlow et al, 2003).
Less-studied interventions like hypnosis, acupunc- d Department of Oral Surgery and Stomatology, School of Dental ture, exercise, anxiolytics or opioid agonists require Medicine, University of Berne, Switzerland. further clinical evidence before recommendations e Department of Community and Preventive Dentistry, University of Barcelona, Spain. can be made.
f Dept of Health Policy and Health Services Research, Dept of Peri- An ideal tobacco use cessation programme must odontology and Oral Biology, Boston University Goldman School of be individualised, accounting for the reasons the Dental Medicine, Boston, USA. person uses tobacco, the environment in which the Reprint requests: Dr Ian Needleman, International Centre for Evi- use occurs, available resources to quit and individual dence-Based Oral Health (ICEBOH), Unit of Periodontology, UCL East-man Dental Institute, 256 Gray's Inn, Road, London WC1X 8LD, UK. preferences about how to quit. The clinician should always bear in mind that cessation can be very diffi- Vol 4, No 1, 2006 Alle R Copyright
longer. They showed that very br cult to achieve, and it is important to be patient and ief oppor etunistic ad-
persistent in developing, implementing and providing vice from a physician to st op smoking (lasting not each patient with an individual cessation-programme.
more than three minutes) will help an additional 2% There is increasing evidence that the success of any of smokers to quit their habit.
tobacco use cessation strategy or effort cannot be Motivational interviewing (MI) is a style of behaviour divorced from the health care system in which it is change counselling (motivational enhancement ther- embedded. Data indicate that cessation requires co- apy) developed originally to prepare people to change ordinated interventions between different institu- substance abuse behaviours. MI is a patient-centred tions and professionals. approach that begins with the patient's goals and en- Several behavioural and pharmacologic interven- courages them to reach those goals. It was applied for tions are recognised as having high levels of support- the first time to tobacco cessation practices in 1998, ing evidence of effect (Fiore et al, 2000, Silagy et al in a hospital emergency room with adolescents (Colby 2002, Marlow et al, 2003). These include counselling et al, 1998) but results did not show a significant ef- by various health care providers, nicotine replace- fect, although the sample size was small (n=40). Mo- ment and bupropion therapies. High levels of evidence tivational interviewing was also applied in the UK to a means that there are 'multiple well-designed ran- group of adults using a 10-minute intervention deliv- domised clinical trials, directly relevant to the recom- ered by general practice registrars trained only for a pe- mendation, that yield a consistent pattern of findings' riod of two hours (Butler et al, 1999). The effect of MI (Fiore et al, 2000). Indeed, the data are compelling was low (3% success rate for MI compared to 1.5 for that pharmacological and counselling treatment each brief advice at six month's follow-up for self-reported independently boost cessation success. These data last month's abstinence), although it achieved statis- suggest that optimal cessation outcomes may require tical significance compared to brief advice. This size of the combined use of both counselling and pharma- effect might be related to the short time spent on train- ing (two hours). More studies in different clinical set-tings and populations are needed before MI could bedisseminated as a behavioural smoking cessation method (Dunn et al, 2001).
The intensity of the intervention has an impact on Behavioural counselling interventions in clinical set- its success. Minimal intervention (<3 min) had an es- tings are an important means of addressing prevalent timated cessation rate of 13.4% (95% CI: 10.9, 16.1) health-related behaviours, such as lack of physical ac- while the success rate grew to 16% (95% CI: 12.8, tivity, poor diet, substance (tobacco, alcohol, and illic- 19.2) with a longer intervention (3-10 min) and up to it drug) use and dependence, and risky sexual behav- 22.1% (95% CI: 19.4, 24.7) with activities above this iour (Butler et al, 1999). In the dental setting, oral hy- time (Fiore et al, 2000). Moreover, the number of ses- giene may be viewed in a similar context. The 5As mod- sions has also an impact on the rate of success, rising el, as defined by the US 2000 Public Health Services from a rate of 12.4% for one session to 24.7% for a pro- Clinical Practice Guidelines, is a user-friendly method gramme of at least eight sessions (Fiore et al, 2000).
that starts by asking the patient about his or her to- Meta-analyses from two systematic reviews have bacco use, advising all tobacco users to quit (high- shown similar findings. A Cochrane review of group lighting oral health effects of tobacco), assessing, as- counselling in various formats showed higher success sisting and arranging follow-up. The 5As have been for quitting with group counselling compared to no in- proposed as a user-friendly, brief intervention ap- tervention (OR=2.17 95% CI: 1.37, 3.45) (Stead and proach, adaptable to an in-office tobacco cessation Lancaster, 2005) while the USDHHS review (Fiore et program (Christen, 2001).
al, 2000) showed an estimated abstinence rate of Individual brief counselling (two to five minutes 13.9% (95% CI: 11.6, 16.1) compared to no interven- advice) has been found to increase the absolute rate tion (OR=1.3, 95% CI: 1.1, 1.6). Fiore et al (2000) of abstinence by 2.5% over usual care (OR 1.69).
found telephone counselling to have some effect on The abstinence rate will increase if follow-up visits tobacco use cessation counselling (OR=1.2 95% CI: are included and results are not dependent on the type of health-care worker involved (Marlow et al, The evidence regarding self-help materials is 2003). West and co-workers (West et al, 2000) de- rather sparse, and the large variety of different prod- scribed the incremental effects of smoking cessation ucts included in this intervention (booklets, leaflets, interventions on abstinence for six months and brochures, videos, CDs, helpline and computer or in- Oral Health & Preventive Dentistry Alle R Copyright
ternet resources) makes it difficult to apply a general bo 15.6% (Jorenby et al, 1 999). Minimal side-effects conclusion. The review of 12 studies by Marlow were reported in both studies, with t he most commonz
(2003) showed an OR=1.24 compared to no inter- adverse events being insomnia, headache and dry vention. Fiore et al (2000) concluded that some evi- mouth. On the positive side the use of bupropion dence supported the use of these materials (OR=1.2), seemed to avoid gaining as much weight as for place- and it was also identified as having the highest bo (1.5 vs. 2.9 kg) after quitting tobacco (Hurt et al, strength of evidence (Fiore et al, 2000).
1997; Hughes, 2003b). One of these studies looked ata combination therapy using both bupropion and trans-dermal nicotine (patch). While higher abstinence rates were reported with combination therapy than withbupropion alone, the difference was not statistically sig- The adjunctive use of nicotine replacements has nificant (Hurt et al, 1997). A Cochrane review of seven been extensively studied in numerous randomised trials found an average 10% better cessation rate with controlled trials and subsequent meta-analyses. Nico- bupropion compared to placebo (OR=2.1) (Hughes et al, tine replacement therapy (NRT) is available in differ- 2003b). Adverse effects include seizures with a rate of ent forms: patch, gum, lozenges, nasal spray and 1/1000 (similar to any antidepressant) and risk of dry inhaler. Five published meta-analyses consistently re- mouth in 10% of individuals. These studies provide port that the use of transdermal nicotine patches, as good evidence to recommend the use of bupropion as an adjunct to counselling, is significantly more effec- an adjunct to tobacco use cessation (highest strength tive than the use of a placebo (Li Wan Po, 1993; Tang of evidence).
et al, 1994; Fiore et al, 2000; Gourlay, 1994; Silagyet al, 1994). Transdermal nicotine more than doubledthe one-year quit rates obtained in control groups Implications for clinical practice/health care with combined ORs of different meta-analyses rang-ing from 2.07 to 2.6. Nicotine patches increase the • The success of tobacco use cessation without pro- success rate by 7.0-7.7% (Silagy et al 1994, Fiore et fessional support is negligible.
al, 2000). Meta-analyses give good evidence to rec- • Tobacco use cessation activities (both behavioural ommend the use of the transdermal nicotine patch and pharmacological) have been proven effective. as an adjunct to smoking cessation services with a Behavioural support approximately doubles quit rating of highest strength of evidence.
rates. The greater the intensity of support, the Three meta-analyses assessing the adjunctive use greater the quit rate. NRT and buproprion approxi- of nicotine chewing gum reported significantly in- mately double quit rates compared with placebo.
creased cessation rates to control interventions • Combinations of behavioural support and pharma- (Tang et al, 1994; Silagy et al, 1994; Cepeda-Benito, cotherapy boost quit rates further.
1993). These meta-analyses report that the use of • With training, a wide range of health professionals nicotine gum increases one-year cessation success can achieve similar success rates.
by approximately 50%, with combined ORs of differ- • Most of the interventions described have the po- ent meta-analyses ranging from 1.4 to 1.6.
tential to be carried out in a dental setting.
Bupropion (BUP) is an antidepressant also used as a new anti-smoking product for its properties. If fact, ini-tial interest in the use of bupropion for smoking cessa- Implications for research tion arose from anecdotal reports of successful quit at-tempts by smokers taking the drug as an antidepres- • More evidence is required on cessation activities sant (Brothwell, 2001). Bupropion is not indicated in pa- in relation to smokeless tobacco (ST) users.
tients with epilepsy or in individuals at risk of seizures.
Two randomised controlled trials on the adjunctive useof bupropion for tobacco use cessation reported that WHAT IS THE EFFECT OF TOBACCO-USE CESSA- bupropion significantly increases the proportion of peo- TION COUNSELLING IN THE DENTAL OFFICE? ple who successfully quit smoking (Hurt et al, 1997;Jorenby et al, 1999). The adjunctive use of bupropion It has been stated that ‘no dentists practising in the approximately doubled the quit rate obtained with 21st century can ignore tobacco use of their pa- placebo at 12 months (BUP 300 mg 23.1% vs. place- tients' (Jones, 2000). Dental health care providers bo 12.4% (Hurt et al. 1997), and BUP 30.3% vs. place- generally see their patients on a frequent and recur- Vol 4, No 1, 2006 Alle R Copyright
these data, only 18% of dental of ring basis, therefore these treatment providers have fices provided fol- unparalleled opportunities to educate and help those low up for interested patients.
who smoke to quit smoking (Christen et al, 1990).
Warnakulasuriya (2002) reviewed data from differ- However, the provision of advice is lower among den- ent studies about dental professionals' attitudes and tists than physicians (Tomar et al, 1996; Warnakula- practices towards smoking cessation and noted an suriya, 2002). In the COMMIT study run in the USA in upward trend in the use of nicotine replacement 1989, 48% of dentists reported counselling versus therapy prescriptions among dentists.
94% of physicians (Jones et al, 2000). The proportionof dentists offering smokeless tobacco cessation ad-vice is also low (Severson et al, 1998).
Tobacco cessation in dentistry Severson and co-workers (1990) found that al- though 65% of dentists advised their patients to quit The trials reporting on tobacco cessation programmes tobacco but only a few recorded these data, and few and protocols discussed in the following section are patients were provided with self-help materials by listed in Table 1.
their dental team (from 11-27%). A comprehensive A pioneering study about the effectiveness of in- study from Minnesota (USA) found that while 46% of terventions for tobacco cessation in the dental office dentists asked their patients about tobacco use, only by Christen and co-workers (Christen et al, 1984) in- 19% discussed cessation strategies or techniques, troduced the use of a nicotine gum for assisting and only 2% offered their patients any kind of follow- smoking cessation by dentists. After 15 weeks, they up intervention (Hastreiter et al, 1994).
reported significant differences in quit rates between In the UK, only about 50% of dentists asked their pa- patients provided with the experimental nicotine-con- tients about tobacco use, and approximately 30% pro- taining gum (12.4%) and the placebo gum (4.8%).
vided brief advice to quit tobacco (Warnakulasuriya et Another early trial with 44 dentists from private al.1999). Other UK studies among general dental dental offices, receiving a one-hour lecture training, practitioners showed even lower figures. A study in reported test group quit rates of 16.9% compared to 1996 showed that only 37% of dentists believed that 7.7% for the control group at twelve months (Cohen they were effective in smoking cessation and only 18% et al, 1989a). In this case, the use of a brief advice of dentists actually recorded the smoking status of (consisting of assessment, advice, setting a quit date their patients (John et al, 1997). There is new evidence and checking patients' progress) with regular re- to suggest that this situation is improving and that minders plus the use of nicotine gum showed the more dentists are now keen to participate in tobacco highest success rate (16.9%) after a year, while brief use cessation programmes (Johnson et al, 2005), at advice plus regular reminders achieved a 8.6% rate least in the UK. Data from private practitioners in the success and an only advice group achieved a 7.7% USA showed that they were more active regarding to- success rate, showing that private practice practi- bacco use than their colleagues in the NHS (Tomar et tioners could be very effective regarding tobacco al, 1996). Still, more than 40% of dentists do not rou- cessation. There was biochemical validation of to- tinely ask their patients about their tobacco use, and bacco use status with carbon monoxide determina- 60% do not routinely advise tobacco users to quit tion. These initial studies showed the positive effect (Tomar, 2001). Additionally, less than one-half of the of programmes that included NRT, in particular with dental schools and dental hygiene programmes in the the use of chewing gums. These outcomes are very US provide clinical tobacco intervention services. More similar to studies performed in medical practice, as data from 1746 individuals in a US national survey re- discussed earlier.
ported that 33% of dentists asked all or nearly all their A further study reported on 118 volunteers in a hos- patients about tobacco use, 66% advised smoking pa- pital-based smoking cessation programme in which tients to quit, and 29% provided some kind of tobacco nicotine gum (2mg) was used as an adjunct to behav- use service (Dolan et al, 1997). Researchers attribute ioural modification (Cooper and Clayton, 1989). The some of the observed discrepancies to over-reporting authors report quit rates after a one-year period of 40- by health care providers.
Canadian data from rural dental professionals A UK study assessed the feasibility of using pri- showed that 22% of dentists and 16% of hygienists mary care dentists and the dental team to provide routinely ask their patients about tobacco use, but smoking cessation advice in practice (Smith et al, only 19% of dentists and 13% of hygienists advise 1998). In addition to dentist's counselling, nicotine smokers to quit (Brothwell et al, 2004). According to patches were made available on request. Salivary co- Oral Health & Preventive Dentistry Alle R Copyright
tine gum (BA&Q), oup consisting of tape, a self-help oups: dentists pr he study and randoml ief advice/counselling and raining and educational mat ts (BA&R), BA and nico tine gum (2 mg) as an adjunct t vioural modification (gr ief advice in smoking cessation (BA), assigned a usual car Dental practices in a 75 dental practices and dentists as t eless tobacco cessation tr andomised, double blind, andomised clinical tr parallel, placebo-contr longitudinal study Table 1 Smoking and smok Vol 4, No 1, 2006 Alle R Copyright
A new Cochrane systematic revie tinine assay was used for validation of smoking levels at the initial visit and at nine months after eness of randomised/pseudo-randomised treatment initiation. Of 54 enrolled dental practices clinical studies for tobacco cessation offered to only 22 recruited patients. One hundred and fifty- smokers and smokeless tobacco users in the dental four patients were evaluated, but only 74 reported at office or in a community setting with at least six nine months. Of the total cohort, 17 (11%) were suc- months of follow-up (Ebbert et al, 2006). Six trials cessful in their smoking cessation effort. Although met the inclusion criteria; all of these studies as- the performance of the participating practices was sessed the efficacy of interventions for smokeless to- uneven, the authors conclude that the success of bacco users, only one included cigarette smokers.
this cessation programme closely parallels those re- Three studies were conducted in a dental practice ported in general medicine practice settings. The au- setting, and three involved oral health care profes- thors commented that practices utilising a ‘team sionals (dentists and/or hygienists) providing inter- approach' had higher success rates.
ventions to athletes within high school or college To examine the effectiveness of advising patients community settings. All studies employed behavioural who use tobacco to quit Severson conducted a ran- interventions and only one offered pharmacotherapy.
domised clinical trial (the only RCT located investigat- When the six trials were pooled, a statistically signifi- ing cessation in smokers in a dental setting) to test a cant increase in the odds of tobacco abstinence at brief office-based intervention with all tobacco users 12 months or more was observed, compared to usual in 75 fee-for-service dental practices in Oregon (Sev- care or no contact controls (OR 1.48; 95% CI: 1.21- erson et al, 1998). Dentists and dental hygienists 1.80). Based on these data, the authors calculated a trained with a three-hour workshop, used a basic in- number needed to treat (NNT) of 33, i.e. for every 33 tervention protocol for smokers including determin- people given TUC in a dental setting, one additional ing tobacco use status, identifying and recording person will cease tobacco use. However, the authors findings related to tobacco use, giving direct advice report statistically significant heterogeneity between to quit (with special information of the effects of to- the studies that could not be explained through sub- bacco on oral health) and giving some informative group or sensitivity analysis.
leaflets plus sugarless sweets and other items to An interesting different approach to the tobacco help the patient in the cessation programme. issue was a study from San Diego, USA, which tested The basic intervention was enforced providing an whether orthodontists can prevent preteens/adoles- intensive quitting programme, including setting a cents from initiating smoking (Hovell et al, 2001).
quit date, giving the patient a video tape (for home This multi-site trial with 154 participating orthodontic viewing) and carrying out a follow-up phone call two private practices found that orthodontists do not au- weeks after the quit date. The whole package of tomatically provide anti-tobacco prevention services.
measures achieved a quit rate at 12 months for The authors further observed that orthodontists smokeless tobacco users of 10.2% versus a 3.3% for were uncomfortable talking to youths for whom there dental offices not providing any support. Quitting to- was no evidence of a so-called 'misbehaviour'. This bacco meant a whole week of sustained abstinence suggests that orthodontists need more training to just before the date in which patients where asked become comfortable with counselling young individu- about their tobacco use. Surprisingly, there was no als not to start smoking. The authors conclude that difference in quit rates for smokers at 12 months preventing tobacco use in adolescence may halt ad- (test groups 2.5% and 2.6%, control group 2.4%).
ditional risk behaviours and thereby reduce morbid- There was no biochemical verification of the pa- ity/mortality even more than expected from tobacco tient's self-reported tobacco use.
Another study examined the effectiveness of a sin- gle cessation intervention for smokeless tobaccousers delivered by dentists and dental hygienists in Implications for clinical practice/health care the course of routine dental hygiene care to 518 sub-jects (Stevens et al, 1995). Success was defined as • Oral health care professionals could play an im- no smokeless tobacco use at both three- and 12- portant role in promoting tobacco cessation for month follow-up as reported by subjects via interview smokers in dental settings, but the magnitude of or mailed questionnaire. Results indicated no smoke- effect is still unclear less tobacco use by 18.4% in the intervention group • Oral health care professionals can play a significant and 12.5% in the control group.
role in promoting tobacco cessation for smokeless Oral Health & Preventive Dentistry Alle R Copyright
(Scott et al., 2001). The most frequentl nt
tobacco users in dental settings, based on the lim- ited studies available in the literature biochemical measures to "validate" t are cotinine (measured in blood, saliva or urine),thiocyanate (measured in blood, saliva or urine) or Implications for further research carbon monoxide (measured in blood [CoHb] or in ex-haled air, not suitable for smokeless tobacco).
• Research is urgently needed addressing the im- However, biochemical measures do not provide a pact of the following factors on the efficacy and ef- gold-standard, and are less than perfect. It is illustra- fectiveness of TUC: types of dental personnel, tive of this problem that biochemical measures are types of interventions (feasible in dental settings considered the gold-standard in studies that evalu- including brief opportunistic advice and support, ate the accuracy of self-report (Patrick et al., 1994), including combinations of pharmacological and while self-report is considered the gold-standard in behavioural interventions), identification of opti- studies that evaluate biochemical measures (Jarvis mal TUC strategies with different patient profiles et al., 1987).
• These issues should be addressed with appropri- Cotinine, a metabolite of nicotine, has a half-life of ate definitive research designs, including RCTs 15-20h and is considered the most accurate bio- with adequate follow-up (at least six months) and chemical measure of tobacco status (Jarvis et al., conducted in different settings (practice, hospital, 1987; Scott et al., 2001; Velicer et al., 1992). How- ever, since nicotine replacement will likely be usedby some individuals in a cessation trial, even if it isnot part of the primary intervention, cotinine may not WHAT ARE THE APPROPRIATE OUTCOME be an appropriate measure in a cessation study, at MEASURES IN TOBACCO-USE CESSATION least in the short-term (Scott et al., 2001). Thio- cyanate has poor sensitivity and specificity and ishence not a useful outcome in smoking cessation For the purpose of this review, we will consider to- studies (Jarvis et al., 1987). Exhaled carbon monox- bacco cessation to be the endpoint of interest in ide (CO) measurement is currently the best studied tobacco cessation studies in dental practice. Specifi- biochemical measure that is considered appropriate cally, we will not consider the question whether or and has been used for cessation studies in dental not oral health benefits (e.g., differences in periodon- settings (Preshaw et al., 2005; Scott et al., 2001).
tal treatment outcome) of a tobacco cessation inter- CO is absorbed rapidly into the bloodstream and has vention should be measured. Longitudinal studies a relatively short half-life of 3-5 hours in sedentary evaluating the effect of tobacco cessation interven- adults. The half-life is dependent on the respiratory tions on oral health outcomes are scarce (e.g. out- rate and may be less than 1 hour during exercise.
come of periodontal therapy (Preshaw et al., 2005) Hence, CO levels are influenced by time of day and and tobacco cessation per se may be considered a time elapsed since last cigarette. Assessments late surrogate endpoint (Hujoel, 2004). However, tobacco in the day may be considered more valid (Benowitz, cessation is clearly the immediate goal of a tobacco 1983), and self-report of frequency of tobacco use cessation intervention, and the documented benefits can improve accuracy (Bauman et al., 1982). Speci- of tobacco cessation for various medical diseases ficity can be affected by other environmental sources and conditions clearly justify cessation itself as an of CO, including for example air pollution or exposure to environmental tobacco smoke. Reported sensitivi-ties and specificities of exhaled CO for classifying ac-tive are typically in the range of 80-90% (Benowitz, Self-report or biochemical measures? 1983; Jarvis et al., 1987), which imply considerablemisclassification rates. Hence, when compared to The central question when considering how to as- cotinine, CO measurements overestimate false nega- sess tobacco cessation is whether to rely on sub- tive rates when utilized to verify self-reported absti- jects' self-reports of abstinence/continued tobacco nence (Velicer et al., 1992).
use or whether biochemical "validation" is necessary.
Measurement of exhaled CO is relatively inexpen- Because biochemical measures are believed to be sive, easy and has the additional advantage of not re- more objective and less susceptible to bias, they quiring resources to obtain and store samples. Fur- have been considered mandatory in cessation trials thermore, it provides immediate feedback, a charac- Vol 4, No 1, 2006 Alle R Copyright
counsellors, who also assess t teristic that may serve as a motivational tool and im- obacco status. Under prove cessation rates (Barnfather et al., 2005; Jam- such higher demand conditions, bioc hemical v nz
rozik et al., 1984). However, the fact that measure- tion of self-report may be necessary to improve accu- ment of exhaled CO requires direct contact with study racy. For example, special intervention subjects in the subjects can be an immediate problem in clinical re- Multiple Risk Factor Intervention Trial (MRFIT) who re- search. Ascertainment of CO levels from a large pro- ported to be quitters had biomarker levels between portion of study subjects may not be feasible in large- those of never and continuing smokers (Ockene et al., scale dental office based intervention studies. Even in smaller scale clinical intervention studies, drop-out The type of population under study may be even rates may be high. In a recent clinical study on the ef- more important than the type of study. For example, fect of quitting smoking on periodontal treatment out- adolescent or student populations and high risk/ comes, 23 out of 49 patients (47%) were not available medical patients may exhibit considerably higher for follow-up (Preshaw et al., 2005). Similarly, in a rates of false negatives (Pechacek et al., 1984) study of a smoking cessation program conducted in (Patrick et al., 1994). Demand characteristics have UK dental practices, 80 out of 154 subjects (52%) did been extensively studied in the context of the "bogus not provide saliva samples for cotinine assays at fol- pipeline", where biological samples are collected (but low-up (Smith et al., 1998). Such drop-out rates pose not analyzed) with an assertion to study subjects an immediate threat to validity of any study, making that biochemical validation will be performed (Mur- the use of biochemical measures less appealing, while ray et al., 1987). However, it has been suggested self-reported measures of smoking cessation are that an effective procedure to ensure anonymity can much easier to obtain by mail or telephone interview.
reduce the need for the bogus pipeline (Murray and Furthermore, biochemical measures can only deter- Perry, 1987). A review of study characteristics and mine the point prevalence of abstinence and their val- the rates of false negative reports found that false ue is limited when measuring continuous abstinence negative rates are similarly low for untreated volun- in long-term studies (see below).
teer samples and intervention studies. However, The rationale to use biochemical validation of ab- false negative rates were >10% for special popu- stinence is the assumption that unsuccessful quit- lations (high risk/medical patients) (Velicer et al., ters will tend to underreport tobacco use. Self-report of current tobacco use among recent abstainers (i.e.
Several excellent discussions of self-report mea- cessation trial setting) is often considered particu- sures in the context of tobacco cessation have been larly unreliable (Scott et al., 2001). It is common published (Hughes et al., 2003a; Velicer et al., 1992).
practice in research on smoking cessation that sub- Several distinct self-report measures of tobacco ces- jects who are lost to follow-up are considered smok- sation are typically assessed: point prevalence absti- ers or relapsers, and this generally seems to be a nence (the proportion of subjects not using tobacco at reasonable assumption (Foulds et al., 1993). How- a specific point in time), continuous abstinence (the ever, the possibility exists that differences between proportion of subjects abstaining since the interven- self-report and biochemically validated cessation tion), and prolonged abstinence (proportion of sub- rates may be overestimated because subjects who jects not using tobacco for a specified time interval).
have missing values for the biochemical validation Each of these measures provides complementary in- are considered smokers (Hays et al., 1999; Rigotti et formation on the outcome of a tobacco cessation in- The validity of self-report is dependent on several Point prevalence abstinence is frequently used and factors (Velicer et al., 1992): (i) the type of study, (ii) is the only self-report measure that can be validated by the nature of the target population, and (iii) the pres- use of biochemical measures. However, particularly in ence of demand characteristics.
the context of a cessation study, it is important to spec- Tobacco cessation studies can be broadly catego- ify a minimum period of abstinence for classification, rized based on the intensity of the intervention into: e.g. 24 hours, 7 days or 30 days, a choice that affects self-change studies, minimal intervention studies, min- the potential for biochemical verification. Another ad- imal interaction studies, clinic studies and intensive in- vantage is that the measure allows lapses or relapses tervention studies and the likelihood of false-reporting to occur following treatment without making it neces- increases with increasing intensity of the intervention sary to classify a subject as a permanent failure. How- (Velicer et al., 1992). In clinic or intensive intervention ever, this may also be viewed as a disadvantage as a studies, close relationships are developed with the former smoker at one point in time may be a current Oral Health & Preventive Dentistry Alle R Copyright
The specifics of each of these self-r nt
smoker at a later point in time. This also means that point prevalence measures are less stable than con- sures make them suitable for different pur ssen
tinuous abstinence measures as they depend on the different times during the course of a tobacco cessa- minimum duration of abstinence used to define quit- tion study (Velicer et al., 1992). Point prevalence will ters as well as the point in time at which the assess- be an appropriate measure earlier in a study, as the ment is made. The use of point prevalence generally immediate goal of practically any intervention is to includes as former smokers individuals with varying stimulate action. A tobacco intervention that fails to quit times. Therefore, point prevalence measures may stimulate action early on, will also fail in the long- be difficult to interpret in relation to the health effects term. Hence, a dynamic, sensitive short-term point of tobacco cessation, because of the heterogeneity of prevalence will be the adequate measure at an early former smokers with respect to quit time. However, the stage of the intervention (e.g. at 3 months post-inter- importance of this limitation in the context of cessation vention). In contrast, at 2 years post-intervention, a interventions depends on the health outcome consid- measure assessing successful maintenance of quit ered, specifically the time it takes for tobacco cessation status, like a one-year prolonged abstinence propor- to have a measurable effect. For example, it will be tion, may be a more appropriate outcome measure.
much more important for health outcomes which im- To summarise, biochemical measures do not pro- prove rapidly after tobacco cessation (e.g., respiratory vide a gold-standard and are not without problems, function (Bosse et al., 1981; Scanlon et al., 2000)). In despite their believed objectivity. Hence, studies that such cases, novel approaches that capture exposure do not include biochemical verification of self-report to tobacco over time may be helpful if the study results should not be lightly disregarded as invalid. Interest- are to be interpreted in relation to health outcomes ingly, of the 6 studies included in a recent systematic (Dietrich and Hoffmann, 2004).
review of tobacco-use cessation interventions in the Continuous abstinence reflects the proportion of dental setting, no biochemical confirmation was used smokers who have abstained continuously since the to validate self-report in 3 studies. In the remaining 3 intervention. It is more stable over time and across studies, biochemical confirmation was initially utilized studies. However, an obvious problem with the mea- and abandoned, or used to enhance self-report (i.e., sure is the fact that tobacco cessation may not follow "bogus pipeline") (Ebbert et al. 2006).
such a clear pattern in many individuals. Typically, It is also evident from the above that self-report many subjects experience lapses or relapses (Cohen measures of abstinence remain the primary out- et al., 1989b). Continuous abstinence can only de- come measure in cessation studies, whether or not cline over time, as more quitters lapse or relapse, augmented with biochemical measures. The use of a and the measure is insensitive to delayed quits.
combination of different self-report measures is Prolonged abstinence can be viewed as a combina- likely the most appropriate approach.
tion of continuous and point prevalence abstinencemeasures. Subjects are counted as quitters if theyhave been continuously abstinent for a defined time Implications for clinical practice/health care period (e.g. 1 year); however, this time period does notnecessarily include the intervention. It can as such be • Feedback from biochemical testing of tobacco use viewed as a prolonged point prevalence. The major ad- has a motivational effect on tobacco users to at- vantage of prolonged abstinence vs. continuous ab- tempt quitting.
stinence is that it allows for a grace period after the set • Feedback from biochemical testing of tobacco use quit date and such allows for long-term abstainers that can increase the success rate in tobacco cessation.
initially slip. A 2-week grace period has been recom-mended for most cessation intervention trials; howev-er, the length of the grace period may need to vary de- Implications in/for further research pending on the specifics of the intervention understudy (Hughes et al., 2003a).
• Self-report supported by biochemical abstinence Since relapse is inversely related to time since measurements should be employed.
cessation (Hunt et al., 1971) one-year abstinence • New biomarkers are needed (with ideal properties rate would be more stable than a short period point including inexpensive, valid, user friendly, etc).
prevalence. However, only after 5 years or more of • Biochemical validation and follow-up for a mini- prolonged abstinence are the risks of relapse consid- mum of six months to assess outcomes are highly ered negligible (DHHS, 1989; Krall et al., 2002).
desirable in TUC activities.
Vol 4, No 1, 2006 Alle R Copyright
light many possible barriers to the req n
• The feasibility and effect of employing different outcome measures in research and clinical prac- A brief overview of the findings present ed in T enz
establishes the context of potential barriers to to-bacco cessation counselling in the dental office, withthe following three categories emerging as primary WHAT ARE THE BARRIERS TO TOBACCO-USE CESSATION COUNSELLING IN THE DENTALPRACTICE? • Barriers to implementing tobacco use cessation Traditionally, smoking cessation counselling has not • Barriers to participation in tobacco use cessation been a part of the dental professional's role as a (by clinicians or patients) care provider. However, a growing number of dental • Barriers to effectiveness of tobacco use cessation practices have successfully overcome a number of barriers and made this change (Warnakulasuriya,2002). Change management theory suggests that The barriers from Table 2 are presented below in the successful change is a result of the interaction be- context they were studied with some transcending all tween the content of change (objectives), the context three categories.
of change (environment) and the process of change(implementation plan) and incorporates identifica- Barriers to implementation of tobacco use tion of barriers as a key element contributing to suc- cessation counselling cessful change (Pettigrew et al, 1989; Dawes, 1999).
Therefore, whether implementing tobacco cessation • Tobacco use by clinician (less likely to discuss or counselling in a dental practice or increasing partici- feel they can influence) pation by team members and patients, or increasing • Lack of feeling that is part of their responsibility or the effectiveness of an existing programme, consid- feeling that it is appropriate role eration of the barriers is a key factor.
• Discomfort with discussing tobacco use In order to address the question 'what are the bar- • Doubts by clinician of the value or legitimacy of riers to tobacco use cessation counselling in the dental practice?' an electronic literature search was • Lack of financial incentives carried out as outlined previously. Additional elec- tronic searching and checking of bibliographic refer- • Lack of knowledge and/or skills (confidence) ences focusing on barriers in the dental practice was • Lack of resources performed to supplement the initial search. Screen- • Lack of team approach and communication ing of 144 titles and abstracts resulted in 95 publi- • Lack of early education cations appearing to be highly relevant. Sixty-two full • Resistance or scepticism of administrative or aux- text articles comprised of single studies and narra- iliary team members tive reviews were obtained and reviewed for rele- • Belief that patients would not cooperate vance. No systematic reviews addressing barriers • Fear of damaging dentist-patient rapport were located. Due to the large body of literature in • Unwillingness to increase workload this area and the progress in the field over recent • Lack of staff loyalty years, the decision was made to focus on recent • Lack of peer support publications (1998-2005). The evidence deemed • Lack of organisation or plan most relevant is summarised in Table 2 in descend- • Fatalistic attitude toward prevention ing chronological order.
• View of tobacco cessation in prescriptive manner • Lack of private space in practice to discuss issues such as tobacco cessation.
Barriers to participation in tobacco use cessation Evidence reviewed confirmed that the integration counselling (by clinician) and success of tobacco cessation counselling in adental practice setting involves change in knowl- • Lack of early education edge, attitudes and behaviour of both dental team • Tobacco use by clinician (less likely to discuss or members and their patients. Research findings high- feel they can influence) Oral Health & Preventive Dentistry Alle R Copyright
spend counselling/ om a dental healt o discuss smoking habits), e if no added cost h, communication wit client/ patient r onment, financial incentiv h additional paper hool about cessation mor hat counselling fr eness of counselling about possible bar es, legal limitations ecalled counselling fr eelings diminished o thod of smoking cessation verall oral healt xpectation or open attitude of patient esistance and scep lack of training and skills, - clinicians educat plementation, par plementation of t plementation, par (clinician and patient), vention (academic e smoking cessation int dental practice en training, and financial incentiv tobacco cessation assistance Vol 4, No 1, 2006 Alle R Copyright
k of a place in dental practice egular communication mee ved dentists should be non-smoking r uitting and 70% r s included high staf e included financial f s included patient f hought dentists should par or identified as most im obacco cessation in light of a pr ry out a confidential or per estyle, especiall tobacco cessation tobacco cessation cessation counselling dentist attitudes (if negativ - 90% dentists advise q plementing in practice plementing in practice plementation and tionist, practice vidence (continuation) t 2 of study included discussions general dentists t including dentists, dental h dentists (72.2% r Oral Health & Preventive Dentistry Alle R Copyright
obacco cessation as a in smoking cessation obacco cessation k of possible cessation specialists ms of number of patients and time spent in obacco cessation. These w ded smoking status (incr oo time consuming and no or dental practice must pr ed about smoking status r t of handing out pam ys discussed habit wit ther training in t hought dentists ef k of confidence in dentists least amount of w tobacco cessation counselling those who had att 88.6% of dentists t status and discussing smoking (48% vs. 66%) 25% of dentists t smoking or assist in t dental practitioner cessation activities 60 patients (26% smok ustralian dental practices vidence (continuation) e and post consultation e and post consultation ustralian dentists 528 dentists and 353 dental h cessation counselling and bar Question and discussion amongst Vol 4, No 1, 2006 Alle R Copyright
e training, 12.5% f uit use of specific egies of cessation, time spent on uency of giving advice, ho fects of smoking but inadeq fices, 9.4 % had r ver dentist-patient r obacco cessation discussions wit een confidence about smoking cessation o assist patients in t o include cost, lac or smoking cessation advice in 96% of of o counsel on beha tion of visits), discussions of smoking and g ygienist in 3% of of ems" in place in practices h, discussions of specific strat k of time in a busy sc and confidence, concer 95% of clinicians w counselling (highest cor training in smoking cessation t clinician confidence associat fear of alienating patients plementation, par plementation, par e, attitudes and obacco cessation w of smoking cessation y (29 close ended q vidence (continuation) cessation counselling (4As) counselling in of Oral Health & Preventive Dentistry Alle R Copyright
ple of insurance vices and/or training, e, if dentist does no h an individual f h patient and practitioner pliance of clinicians in t ygienists and dentists obacco cessation ser riance amongst patient insurance plan co ound in incidence of t ied but had a bad e ed cessation activities t table discussing smoking wit o discuss if visible ef vement in cessation activities essionals who att k of confidence amongst bo as no indication of "misbeha ficulty in maintaining pr oup – doubts and discomf of smoking cessation wit if patient must pa fear of alienating patients seen as bar ticipation (clinician and ticipation of dental t vention counselling t vidence (continuation) practices randomised t teens or no counselling Vol 4, No 1, 2006 Alle R Copyright
• Discomfort with discussing tobacco usee
• Lack of knowledge and/or skills (confidence) – those who have taken a course more likely to par- • Lack of resources • Lack of patient perceived benefit of counselling by health professional (positive feedback) • Lack of financial incentives for dental profession- • Lack of visible effects of tobacco use in oral cavity t discussing issues and r • Lack of team approach and communication • Frustration over success rates • Failures in previous attempts • Legal limitations on prescribing NRTs.
hat patients do no • Lack of openness or expectation of dental person- • Lack of feeling that their dentist is interested (smok- ers tend to be less positive than non-smokers abouttheir perception of dentist interest in their habit) • Costs to patient (if fee charged) • Lack of confidence that a dental health profession- al could influence tobacco use • Lack of patient awareness of availability • Discomfort discussing tobacco use.
Barriers to effectiveness of tobacco use cessation • Time spent in counselling • Lack of resources and sources for referral y of 2000 dentists • Lack of regular patient attendances • Discomfort discussing tobacco use • Non-existence of smoke-free practice vidence (continuation) • Lack of time (based on perception that success is based on time spent) • Lack of knowledge and/or skills (confidence) dentists about cur • Approach to tobacco cessation in prescriptive With the focus on addressing the question 'what are the barriers to tobacco cessation in the dental prac- tice', this section has highlighted some of the pub- lished evidence relevant to this issue. Studies varied Oral Health & Preventive Dentistry Alle R Copyright
themselves? Are all dental prof essionals r t
in context and design, resulting in differing risks for potential bias in study results. These details have not ceive intervention at the 'assisting' and 'ar ssen
been addressed in the context of this summary.
level? That is, are they ready to participate in educa- Many barriers were common across various stud- tional courses addressing the 'how'? Maybe the need ies, with review articles highlighting similar points. It still exists to emphasise the 'why'. Is communication is clear that barriers may be related to dental profes- at the ask, advise and assess level a possible key to sional factors, practice factors or patient factors.
increase commitment of the dental team to tobacco Variability in potential barriers may be present and cessation activities? Information may need to be de- dependent on the various external and internal fac- signed to target all the 5As among dental profession- tors, such as population level, cultural factors or den- als first. A continuing education course designed to tal practice organisational factors. The importance of increase knowledge of strategies in smoking cessa- well-designed 'systems' and communication within tion may not be effective at initiating or reinforcing the team has been highlighted in studies from the change. This could be attributed to an underlying neg- medical community (Braun et al, 2004). Although, ative attitude of the dental professional toward the the barriers identified may be similar, the magnitude changes necessary to increase involvement in to- of each in a given setting at a set point in time may bacco cessation at any level. The challenge may still vary. Surveys of dental professionals' attitudes to- be motivating some clinicians to participate in a ward and involvement in tobacco cessation activities course. Hovell et al (2001) wrote that even in a to- have been conducted throughout the world with vari- bacco cessation research study setting (programme able results (Johnson, 2004). In fact, such results fully provided), clinicians have been reported to be may differ not only by country and region, but even non-compliant with implementing the study protocol within patient populations or practice settings. This as provided. Therefore, is it valid to lecture to dental infers that each individual and practice must take professionals to initiate behaviour change or is a dif- the time to analyse the barriers relevant to their spe- ferent approach needed to help overcome barriers? cific situation and appropriately set a well-designed, A correlation between health professionals' smok- step-by-step plan.
ing habits and their involvement in tobacco cessation The 5As, ask, advise, assess, assist, and arrange counselling was suggested by Hall et al (2005) who (as defined by the US 2000 Public Health Services described a sample of 152 UK nurses. Those who Clinical Practice Guidelines) have been proposed as were smokers had a less positive attitude about par- a user-friendly, brief intervention approach to an in ticipation in tobacco cessation counselling and per- office tobacco cessation programme (Christen, 2001).
ceived it to be less effective than those who are This approach has been discussed in numerous arti- non-smokers. Burgan et al (2003) reported similar cles and guidelines, However, is it being used? Evi- correlation in a survey of Jordanian dentists. A man- dence suggests that although many dental professio- date has been proposed to specifically promote nals discuss smoking as an issue related to oral and smoking cessation amongst health professionals be- overall health with their patients, a gap still exists be- cause smoking by health professionals has been tween this and the suggestion of strategies toward identified as a barrier to their participation in tobacco cessation (Albert et al, 2002; 2005; Severson et al, cessation counselling (Hall, 2005). This may be par- 1998; Tomar, 2001). Few practices seem to have 'sys- ticularly relevant to populations such as Poland, tems' in place for facilitating cessation or referral to where it was recently reported that 23% of dental fac- cessation specialists, if necessary (Albert et al, 2002).
ulty, 37.5 % of dental hygienists and assistants, and Lack of knowledge and confidence emerged from 58.3% of dental administrative staff smoke (Bal- almost each article as a barrier. It has been suggested czewska, 2004).
that a primary barrier is lack of education on cessa- In The Bulletin of the WHO, Reibel (2005) com- tion techniques during educational programmes of mented that 'given the evidence, tobacco cessation dentists and hygienists. In addition, continuing educa- activities should be as natural as oral hygiene mea- tion modules need to be more readily available (War- sures in dental offices'. The message is that it needs nakulasuriya, 2002), and there is a need to establish to be an integral part of therapy. However, the attitude legitimacy of tobacco cessation in the dental teams' toward preventive measures in general needs to be attitudes (Trotter and Worcester, 2003). Considering amended to incorporate current knowledge of facilitat- the dental team in the context of behaviour change ing behaviour change (Watt et al, 2004b). In some models, could it be argued that the 5As might also practices, tobacco cessation is approached in a simi- apply to changing the behaviour of dental personnel lar context as oral hygiene has traditionally been ad- Vol 4, No 1, 2006 Alle R Copyright
dressed - in a paternalistic, lecturing, prescriptive ap- proach. Training of dental professionals has tradition- ally been focused on clinician-rendered treatment for Numerous barriers may influence implementation of, disease rather than on assisting people to change participation in, and effectiveness of tobacco cessa- their behaviour (Monaghan, 2002). Scientific ad- tion counselling in the dental office, with no one fac- vances that have altered our understanding of health tor being identified as the most influential. and oral health have elucidated the importance oflifestyle factors to health. As the approach to oralhealth promotion measures is viewed from a behav- Implications for clinical practice/health care ioural viewpoint, this may facilitate the effectivenessof dental professionals in both tobacco cessation and • Characteristics of each dental practice defines the other preventive measures, such as oral hygiene.
barriers to be found To facilitate required changes, the dental team • Barriers should be anticipated and discussed members may need to expand not only their knowl- among the dental team as part of the strategic plan- edge and skills, but also their perception of roles ning of in-office tobacco use cessation programmes (Mecklenburg, 2001). The dental practice needs to in- • Different barriers may emerge through time, so reg- clude the involvement of dental auxiliaries in tobacco ular review of barriers to TUC is needed. cessation programmes (Monaghan, 2002; Watt et al,2004b). Much of the published surveys and data lo-cated on this topic investigated dentists only. In the Implications in/for further research studies where dentists and hygienists were surveyed,differences between the two groups became appar- • Questionnaire studies may have little influence on ent particularly in terms of attitudes and perceptions future knowledge. Future studies should investi- of barriers (Albert et al, 2002; Lund, 2000; Watt et al, gate alternative designs, such as qualitative as 2004b). In a survey conducted by Albert et al (2004) well as mixed methods. These designs would pos- it was reported that the dentist was responsible for sibly give further opportunities to discover factors tobacco use cessation advice in 96% of offices and influencing barriers not listed in existing surveys the dental hygienist in only 3% of offices. and assist in closing the gap between research A team approach has been proposed as vital to findings and implementation.
overcoming barriers (Smith et al, 1998). The team ap- • Research questions that should be investigated in- proach should take into consideration differences in clude the validity and impact of reported barriers team members' roles within the practice with the in- and the effect of removing barriers. These barriers tent to maximise the efficiency of each member in the will range from governmental policy and priorities overall objective to influence tobacco use. A strategic issues to personal and practice-related barriers.
plan is recommended for implementation of a pro-gramme into a practice. The team approach would in-clude team members in the formulation of the plan, Implications for education therefore avoiding implementation that is haphazardor individual (Christen, 2001). Formulation of a plan or • Discussion of potential barriers should be incorpo- ongoing communication once a plan has been imple- rated into tobacco use cessation training pro- mented also serves to confirm or alleviate perceptions grammes in undergraduate, graduate and con- tinu- of barriers. For example, lack of time has been cited ing education programmes. Emphasis should be as a barrier to tobacco cessation counselling. How- placed on identification of barriers in a specific situ- ever, many approaches based on brief intervention ation or practice.
have been proposed suggesting that impact on sched-ule is minimal. Each team should assess this issue oftime in the context of their setting.
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Vol 4, No 1, 2006
European Journal of Economic and Social Systems 14 N° 3 (2000) 229-270 Innovation networks and competitive coalitions in the pharmaceutical industry: The emergence and structures of a new industrial organization MARC-HUBERT DEPRET* AND ABDELILLAH HAMDOUCH** Abstract. – Today, the pharmaceutical industry is subjected to wide-scale