Sociaaleconomische verschillen in roken in Nederland: 1988-2011

Achtergrond
Laagopgeleiden zijn gemiddeld ongezonder dan hoogopgeleiden. Dit komt onder meer doordat roken en zwaar alcoholgebruik meer voorkomen onder laagopgeleiden dan hoogopgeleiden. Er zijn aanwijzingen dat sociaaleconomische verschillen in roken toenemen door de tijd heen. In deze studie kijken we naar trends in sociaaleconomische verschillen in roken in Nederland tussen 1988 en 2011.

Methode
Voor dit onderzoek zijn gegevens uit het Continu Onderzoek Rookgewoonten (COR) gebruikt. Per week vullen ongeveer 350 Nederlanders van 15 jaar en ouder de COR-vragenlijst in. Van 1988 tot en met 2000 werd de vragenlijst door middel van persoonlijke interviews afgenomen en vanaf 2001 via internet. Voor deze studie is gekeken naar trends in rokersprevalentie, stoppogingen, stopsucces, aantal sigaretten/shagjes per dag, shagroken, eigen effectiviteit en stopintentie en of en hoe deze trends verschillen tussen opleidingsniveaus.

Resultaten
Laagopgeleiden waren in 2010 vaker roker, rookten meer sigaretten/shagjes per dag, rookten vaker shag in plaats van sigaretten en hadden een lagere eigen effectiviteit dan hoogopgeleiden. Deze verschillen zijn bovendien in de jaren tot en met 2010 toegenomen. Verschillen in stoppogingen tussen opleidingsniveaus waren niet significant in 2010. Verschillen in stopsucces en stopintentie waren alleen significant tussen middelbaar en hoogopgeleiden. De data van 2011 wordt momenteel nog geanalyseerd en zal tijdens het congres voor het eerst worden gepresenteerd.

Conclusie
Wanneer de huidige trend doorzet, zullen de sociaaleconomische verschillen in roken in Nederland in de toekomst verder toenemen. Implicaties van de bevindingen voor tabaksbeleid zullen worden besproken.

Are there unintended consequences of smoke-free legislation on stigmatization, and does stigma affect smoking cessation? Findings from ITC Netherlands

Smoke-free legislation reduces exposure to second-hand smoke and may encourage smokers to quit smoking. However, smoke-free legislation may also increase feelings of stigmatization of smokers as an unintended consequence, by forcing smokers to smoke outside. It is still unclear whether smoke-free legislation indeed leads to stigmatization and if so, whether stigmatization leads to smoking cessation. Our study aims to examine (1) the effects of smoke-free legislation and smoking outside on experienced stigmatization of smokers, (2) the effects of experienced stigmatization on smoking cessation, and (3) the possible moderating effects of gender and educational level on these relationships. Longitudinal data from the International Tobacco Control (ITC) Netherlands Survey was used, involving a nationally representative sample of 1,176 smokers aged 15 years and older who participated in a survey before and after the implementation of national smoke-free legislation. The Netherlands already had smoke-free workplace legislation in place from January 2004 and implemented smoke-free hospitality industry legislation in July 2008. The baseline ITC Netherlands Survey was conducted in 2008 before the implementation of the legislation. Two follow-up surveys were conducted in 2009 and 2010 after the implementation of the legislation. Findings suggest that experienced stigmatization of smokers did not change after the implementation of the smoke-free legislation. Smoking outside has also not increased feelings of stigmatization. Furthermore, stigmatization had a positive effect on smoking cessation. The results indicate that smoke-free legislation does not increase stigmatization among smokers. Therefore, it appears unwarranted for policy makers to fear an increase in stigmatization as an unintended consequence of smoke-free legislation. This study raises ethical issues about whether tobacco control advocates should aim for increasing smoking cessation by increasing feelings of stigmatization.

Smoking cessation and depression

Introduction
Smokers with past major depression (MDD) who attempt to quit smoking have a higher risk of relapsing than smokers without past MDD. This may be attributable to elevations in negative mood and depressive symptoms. These smokers may be able to quit more easily if they can better manage mood swings. Therefore a new intervention was developed. The aim of the study was to assess whether the addition of a mood management component to TC produces higher abstinence rates in smokers with past MDD and helps to prevent recurrence of depressive symptoms

Method
Pragmatic randomized controlled trial with two conditions, including 485 daily smokers with past MDD

Results
The mood management intervention resulted in significantly higher prolonged rates at 6- and 12-month follow up (30.5% and 23.9% in experimental condition, 22.3% and 14.0% in control condition). The ORs were 1.6 (95%CI 1.06-2.42) and 1.96 (95%CI 1.22-3.14)

Conclusion
Adding a mood management component to TC for smoking cessation in smokers with past MDD increases cessation rates without necessarily reducing depressive symptoms.

Furthermore, I like to discuss an article we are currently working on: 1. What are characteristics of smokers with current, past and no lifetime depressive symptoms? Do quit rates differ between these smokers?

The Strategic Role of Tobacco Industry Research to "Resolve the Social Acceptability Issue”

Objective
Already in 1979, tobacco industry analysts identified “the social acceptability issue” as “the central battleground on which our case in the long run will be lost or won”. This battle has raged relentlessly since then. Little is known about the type of research that the tobacco industry undertakes to make strategic choices about where to direct their lobbying efforts to prevent and undermine smoking bans.

Methods
Search of documents from the Legacy Tobacco Documents Library.

Results
Newly disclosed tobacco industry documents reveal the type of research that the industry relies on. This turns out to be highly sophisticated and expensive multi-country studies showing their interested in whole populations, not individuals.
These documents confirm that the industry assigns highest priority to influencing social acceptance of smoking worldwide. They are able to identify countries in which the public opinion is relatively open to governmental regulations and smoking bans, thus needing intensified and targeted action. Because of the large number of countries that were included in some of the industry paid studies, the industry was able to conduct cross-country analyses using country as the unit of analyses. This revealed strong associations between support for government actions on the one hand and annoyance from ETS and concern about health risks on the other.
Tobacco industry was interested in factors operating on a population level, ultimately determining reduction of tobacco consumption levels. Factors include level of awareness of health risk, level of societal acceptance of smoking, and level of support for governmental regulations.

Conclusions
Industry documents suggest that the tobacco industry has put in place a well defined monitoring system specifically looking at important population level factors, and already did this long ago. The Industry seems more advanced than the EU and the WHO when it comes to collecting the right population data. Important population factors are not yet being monitored in a systematic and comprehensive (covering large numbers of countries) enough manner.

As shown by several recent reviews, web-assisted tobacco interventions (WATI) have great promise for helping smokers wishing to stop. Due to their interactive nature, easy access and world-wide availability, WATI have the potential to revolutionise current treatment for smokers, being able to combine the best of both worlds - the wide reach of minimal, low-efficacy interventions and the efficacy of intensive behavioural, low-reach interventions. However, much remains to be explored in this relatively new field of research concerning the development, implementation and evaluation of WATI to optimise their impact. This symposium draws together several strands of ongoing research into state-of-the-art WATI and aims to present optimal ways for designing evidence-based internet interventions for smoking cessation, targeting potential users and delivering as well as assessing their efficacy.

Chair:
Andrée J. van Emst

Presenters:
Shahab, L.
Smit, E.S.
Elffedali, I
Selby, P
Van Emst, A.J

Tobacco Industry’s efforts to prevent smoke-free legislation in the Netherlands for over a decade

Objectives
In 1990 a Dutch Tobacco Law was implemented, which included a partial smoking ban in Dutch governmental buildings. The law allowed for many exceptions. Smoking in non-governmental worksites was not prohibited by law. Instead, the decision to implement smoke-free policy was left to employers. Eventually, a workplace smoke ban was implemented in 2004 although the hospitality industry was exempted from it. In 2008 this exemption was abolished. The objective of this study is to determine how the tobacco industry tried to delay or prevent Dutch smoking restrictions in the 90’s.

Methods
Tobacco industry documents, released to the public through US litigation, were used as a primary data source, triangulated with secondary data sources such as peer-reviewed academic articles, policy reports and newspaper articles. Documents were retrieved between February and June 2010 from the University of California San Francisco Legacy Tobacco Documents Library (www.legacy.library.ucsf.edu).

Results
Tobacco documents show that the industry was already trying to prevent workplace smoking bans before the topic was even fully on the political agenda. Their focus was mainly on influencing the public opinion and social acceptability through highly successful tolerance campaigns, using the Dutch Smoker’s Rights Group successfully to prevent smoking bans and taking an interest to the mentality of the Dutch people, in order to ultimately influence government decisions. The main message of the industry was that smoking at the workplace should be left to tolerance between individuals and agreement between employers and employees. To prevent smoking in bars and restaurants, the industry maintained a successful partnership with the Royal Horeca Netherlands. Accommodation programs were used to maintain self-regulation. They even implemented the program in the Parliament restaurant in the Hague and were therefore directly able to show the government why accommodation should be preferred over legislation.

Conclusions
The industry tried to influence the government directly and indirectly and booked several successes but ultimately smoking at the workplace and in the hospitality industry were prohibited by law. Their accomplishments can be attributed mostly to the Dutch Smoker’s Rights Group, the Dutch National Manufacturers Association, and the Dutch Tobacco Information Bureau which was responsible for the tolerance campaigns as well as successful partnerships with allies such as horeca associations and employers organisations. These organisations targeted the public, the workplace and the government with a clear message of tolerance. The tolerance campaign ‘Together we will solve it’ ran for many years and was described by the industry as very successful. This contributed to the public’s opinion regarding smoking in the 90’s and maintained the social acceptability of smoking. Even though smoke-free laws passed in 2004 and 2008, the ban in the hospitality industry is still struggling for acceptance.

Minimising Exposure to Second-hand Smoke. Findings from the International Tobacco Control Policy Evaluation (ITC) Project

Smoke-free laws are crucial to protect non-smokers from exposure to second-hand smoke and to de-normalize smoking. Smoke-free environments can be achieved across a broad range of venues, including workplaces, public venues including bars and restaurants, cars, private homes, and outdoor environments. This symposium explores progress with several smoke-free laws in Europe, will compare this to results from countries outside Europe, and will discuss new frontiers in smoke-free environments. Data are from the International Control Policy Evaluation (ITC) Project.
 
Gera Nagelhout presents data from Ireland, France, Germany and The Netherlands on the effectiveness of smoke free policies in bars, showing that partial smoke-free legislation (Netherlands, Germany) is insufficient to prevent continued smoking in bars. Comprehensive bans (Ireland, France) are needed. Furthermore, Gera will present the results of analyses examining individual smoker characteristics that are predictive of continued smoking in bars.
 
Ute Mons examines factors associated with the adoption of home smoking restrictions.  She compares data on smokers from four countries (Ireland, France, Germany, The Netherlands), collected before and after the implementation of national smoke-free policies. The proportion of smokers having smoking restrictions varied between countries, but increased significantly in all four countries after the introduction of a national smoking ban. Smoke-free policies in public venues thus might stimulate smokers to establish smoking bans in their homes as well.

Sara Hitchman presents data on prevalence of smokers smoking in cars in the presence of non-smokers across 7 countries. Data from four ITC Europe countries (Germany, France, the Netherlands, and the UK) will be contrasted to data from Australia, the UK, Canada and the US. In addition, potentially modifiable characteristics of smoking in cars will be examined.

Geoffrey Fong will discuss these presentations on smoke-free laws in the light of ITC findings from outside Europe and will discuss new frontiers in smoke-free initiatives.

Chair:
Ann McNeill, University of Nottingham, United Kingdom

Co-chair:
Marc Willemsen, CAPHRI, Maastricht University, the Netherlands

Presenters:
Gera Nagelhout, CAPHRI, Maastricht University, the Netherlands
Ute Mons, Unit Cancer Prevention and WHO collaborating Centre for Tobacco Control, Germany
Sara Hitchman, Department of Psychology, University of Waterloo, Ontario, Canada
Geoffrey Fong, Department of Psychology, University of Waterloo, Ontario, Canada

Differential impacts of tobacco control policies in Europe: Findings from the ITC Project

To date, few studies have examined the effectiveness of tobacco control policies across different European countries, research complicated by different languages used and distinct cultural contexts. The ITC Project is a long established study using very similar questionnaires and methodology, involving longitudinal cohort of smokers across over 70% of the world’s tobacco users. Since 2002, seven survey waves in the UK, two in France, two in Germany, and three in the Netherlands have been conducted, thus providing a unique dataset enabling comparisons of the impact of tobacco control policies across these European countries, the focus of this symposium.

Guignard will compare data on the impact of smoke-free legislation. Remarkable declines in smoking in public places and increases in support across the countries were observed eg French smokers’ support for the ban in bars increased from 28% pre- to 60% post-ban. However, the data indicate that smoke-free laws introduced in Germany and the Netherlands are less effective than those in France and UK. Nagelhout will present data comparing changes in quitting behaviour before and after smoke-free legislation. Mons will present results of smokers’ reactions to the same EU-text-only warning labels (apart from the language) and investigate the inter-country variability: French and British smokers notice and read the warning labels significantly more often than German and Dutch smokers. Brown will present data on attitudes to forthcoming/potential future policies, including point of purchase display bans, generic packaging and smoke-free cars; eg 76% UK, 89% French, 82% German and 96% Dutch smokers support bans on smoking in cars with children (Netherlands question concerned pre-school children).

Chairs: Abraham Brown/Ann McNeill

1. Evaluation of smoke-free policies – Romain Guignard, Jean-Louis Wilquin, ITC France team

2. Effectiveness of the text-based EU-tobacco warning labels – Ute Mons/Martina Pötschke-Langer, ITC Germany team

3. Effects of smoke-free policies on smoking cessation – Gera Nagelhout/ Marc Willemsen, ITC Netherlands team

4. Attitudes towards future tobacco control policies – Abraham Brown/Ann McNeill, ITC UK team

Meeroken door kinderen in Nederland door de jaren heen

Probleemstelling
Meeroken door kinderen kan schadelijke gevolgen hebben voor hun gezondheid. Vanaf 1997 is STIVORO daarom gestart met een voorlichtingsprogramma hierover en zijn er diverse tabaksbeleidsmaatregelen ingevoerd. De vraag is wat de huidige stand van zaken is wat betreft het meeroken door kinderen en hoe dit veranderd is in de tijd.

Methode
Sinds 1996 heeft jaarlijks een steekproef van 500 ouders met kinderen van 0-4 jaar gevraagd om een vragenlijst over meeroken en een aantal achtergrondkenmerken ingevuld.

Resultaten
Het meeroken in huis is in de afgelopen jaren sterk gedaald. In 19% van de gezinnen met een kind van 0-4 jaar wordt gerookt in huis en in 10% van de gezinnen in huis in het bijzijn van het kind. In 1996 was dit respectievelijk 64% en 48%. In gezinnen met een hoge SES en in gezinnen met een kind van 1 jaar en jonger is de prevalentie van meeroken in huis in bijzijn van het jongste kind 5%. Meeroken door kinderen komt vaker voor bij gezinnen met oudere kinderen (14%), met een lage SES (29%) en gezinnen met rokers (22%). Direct na de invoering van de rookverboden in 2004 en 2008 is een sterkere daling in het meeroken te zien dan in de jaren daarvoor.

Relevantie voor beleid
Een combinatie van voorlichting en beleidsmaatregelen lijkt er aan bijgedragen te hebben dat het meeroken door jonge kinderen sterk gedaald is. Er zijn echter verschillen tussen groepen te zien.

Conclusies
Ook al is het meeroken gedaald zijn er nog steeds groepen kinderen die regelmatig in de rook zitten. Preventieve programma’s moeten aangepast worden om de daling in het meeroken in deze groepen verder voort te zetten. Activiteiten moeten gericht zijn op de gezinnen met rokers, met oudere kinderen en met een lage SES.

The StopSite: Web-assisted self-help intervention for smoking cessation

Background and objective
To design and evaluate an interactive website (www.destopsite.nl) to help smokers quit and prevent relapse. The intervention is based on cognitive-behavioural therapy and self-regulation theory. The program includes exercises with individually tailored feedback, as well as interactive tools: forum, diary, quitmeter, chatroom, and professional advice on demand. Smokers and ex-smokers can choose from this ‘menu’ of exercises and tools to create a treatment that suits their needs. Nothing is obligatorily.

Methods
Subjects were recruited through advertisements (print and internet). An e-mailed screening questionnaire was used to select subjects who smoked and wanted to quit smoking within the next 3 months. 1190 respondents who fit these criteria were e-mailed a baseline questionnaire, which 1133 subjects completed. These subjects randomly received access either to the StopSite (N=565) or to an online self-help quide (control group; N=568). After 4 months and 7 months (including a 1-month grace period), an online follow-up questionnaire was sent. StopSite use was monitored by a track and trace tool which measured a.o. number of logins and use of interactive tools.

Results
Response to the follow-up after 4 months was 48.3% in the intervention group and 55.3% in the control group. After 7 months, responses were 48.1% and 54.9% respectively. Seven-day abstinence after 7 months in the intervention group was 18.1% compared to 15.5% in the control group (NS). Prolonged abstinence after 7 months was 13.4% for the intervention group, compared to 11.1% for the control group. (NS). Subjects who visited the StopSite more than 5 times were 5.6 times more likely to say that they had not smoked (prolonged abstinence) than those who never visited the StopSite. (p<0.001). Subjects  who visited the StopSite 14 times or more even had 6.4 times more chance on prolonged abstinence (p<0.001). About 20% of the respondents used the StopSite more than 6 weeks.

Conclusions
Our data suggest that visiting an interactive website more than 5 times can help to increase the likelihood that a quit attempt will be successful. The StopSite motivated smokers to return.

Mixed modes in de International Tobacco Control (ITC) Netherlands survey: differences between CAWI and CATI on smoking related questions

Objectives
The ITC Project studies the effects of tobacco control policies in 19 countries. The ITC Netherlands Survey, which began in 2008, differs from other ITC surveys in its use of a mixed mode design. Some respondents were interviewed by random digit dialled telephone methods (CATI), as in other high income countries, but most respondents were interviewed using panel-based computer assisted web interviewing (CAWI). Finding ways to systematically study the effects of mixed mode surveys and account for them in analyses will create new opportunities to enlarge the ITC Project to countries with a limited budget. The objective of this study was to assess the direction and magnitude of several mode effects and to test for possible moderating influences of age, gender, and education.

Methods
Wave 1 of the ITC Netherlands Survey was completed by 404 CATI and 1820 CAWI respondents in March–April 2008. Mode effects were tested using binary logistic regression analyses in which the demographic variables on which the two samples differ significantly and the interaction with gender, age, and education were predictor variables.

Results
In our study, CATI respondents showed more socially desirable responding, extreme responding, acquiescence, consistent answering, recency and primacy effects, and use of the “other” option than did CAWI respondents. CAWI respondents showed more midpoint responding and use of the “don’t know” option. These mode effects were stronger among lower educated respondents. Age and gender also acted as moderators, but these effects were not consistent in direction.

Conclusions
Our analyses suggest that CAWI methods yield responses with more favourable characteristics, compared to CATI. However, the validity of the responses will depend on the representativity of the CAWI panel. As CATI surveys continue to become more difficult and expensive, it is important to test the value of less expensive CAWI methods in tobacco research.

Effectiveness of mood management therapy as an adjunct to a telephone counseling smoking cessation intervention for smokers with a past major depression: a randomised controlled trial

Objective
Smokers with past major depression who attempt to quit smoking have a higher risk of relapsing than smokers without past major depression. This may be attributable to elevations in negative mood and depressive symptoms. These smokers may be able to quit more easily if they can better manage mood swings. Therefore a new intervention was developed. This consisted of proactive telephone counseling with the addition of a self-help mood management manual. The objective of the study was to evaluate the effectiveness of this intervention

Methods
485 smokers with a past major depression were randomly assigned to the mood management intervention (MM) or control intervention (C). The outcome measures were seven-day point prevalence abstinence, prolonged abstinence and depressive symptoms (CES-D), at 6 and 12-months follow-up.

Results
Seven-day point prevalence abstinence rates at 6-month and 12-month follow-up for the MM condition were 37.4% and 27.6%, respectively, and for the C condition were 31.0% and 24.0%. 6-month OR was 1.39 (95%CI 0.95-2.03), 12-month OR was 1.22 (95%CI 0.82-1.86). Prolonged abstinence rates at 6-month and 12-month follow-up for the MM condition were 30.5% and 23.9%, respectively, and for the C condition were 22.3% and 14.0%. 6-month OR was 1.55 (95%CI 1.03-2.34), 12-month OR was 1.96 (95%CI 1.23 – 3.14). In the MM condition, 49.0% and 43.6% of the participants had depressive symptoms at 6-month and 12 month follow-up, respectively. For the C condition this was 39.3% and 41.3%. The 6 month OR was 0.72 (95%CI 0.50-1.03), 12 month OR was 0.97 (95%CI 0.68-1.41).

Conclusion
Mood management therapy as an adjunct to telephonic counseling for smoking cessation seems to increase success rates for smokers with past major depression. Contrary to our expectations, this effect was not mediated by reductions of depressive symptoms.

Het rookverbod in de horeca: resultaten van het International Tobacco Control policy evaluation (ITC) project

Probleemstelling
Sinds 2008 maakt Nederland deel uit van het ITC project. Dit is een internationaal vergelijkende studie naar de impact van tabaksontmoedigingsmaatregelen. In Nederland worden de effecten van het rookverbod in de horeca onderzocht in combinatie met een massamediale campagne en een accijnsverhoging op sociaalpsychologische determinanten bij rokers en rookgedrag. Door Nederlandse resultaten met die uit andere ITC-landen te vergelijken, kan mogelijk worden vastgesteld of een combinatie van beleidsmaatregelen, bijvoorbeeld een rookverbod en een campagne, een groter effect heeft dan de beleidsmaatregelen afzonderlijk.

Methode
Het ITC project is een longitudinaal vragenlijstonderzoek met jaarlijkse metingen. Doordat de methodologie gestandaardiseerd is in alle 19 participerende landen kunnen effecten vergeleken worden tussen landen die een beleidsmaatregel wel of niet invoeren (quasi-experimentele onderzoeksopzet). In Nederland zijn vragenlijsten afgenomen bij maandelijks rokers die minstens 100 sigaretten hebben gerookt in hun leven. De voormeting heeft plaatsgevonden in maart / april 2008, de eerste nameting vindt plaats in november en december 2008. Verder zullen er nog metingen worden gehouden in maart / april 2009, 2010 en 2011.

Resultaten
Tijdens de presentatie zal worden ingegaan op de ITC methodiek, resultaten uit andere landen en eerste resultaten van het Nederlandse project. ITC onderzoek in andere landen heeft onder andere uitgewezen dat rookverboden in publieke gebouwen stoppen met roken stimuleert, dat het rokers helpt om de stoppoging vol te houden en dat het niet leidt tot een verplaatsing van het rookgedrag naar de thuissituatie.

Implicaties
De ITC methodiek -landenvergelijkend, longitudinaal vragenlijstonderzoek- kan ook voor andere gezondheidsthema’s (voeding, alcohol, SOA, bewegen) interessant zijn om effecten van populatiebrede interventies te evalueren. Vanuit de eerste resultaten van het Nederlandse project, worden enkele praktische aanbevelingen gegeven.

Conclusie
Als de nameting afgerond is, kunnen er conclusies worden getrokken over de effecten van de rookvrije horeca, campagne en accijnsverhoging in Nederland.

Targeting low income groups to reduce the exposure to tobacco smoke in infants

Background
Existing studies provide clear evidence of an association between passive smoking in childhood and several adverse health conditions. Therefore STIVORO has implemented the intervention ‘Smoking? Not in the presence of the little one’. Since the start of the campaign the prevalence of passive smoking in young children has been reduced significantly. However, we still see a gap between low income groups and high income groups.

Objectives
The objective is to further lower the percentage of passive smoking in young children, especially in low income groups.

Methods
The intervention is a combination of tailored education from health professionals to parents and mass media campaigns. During the last decade various elements have been introduced to successfully reach low income families. Through further review and qualitative research we have identified additional methods.

Results
Among low income families we see a decrease from 52% in 1998/1999 to 24% in 2006/2007 (compared to 17% in 2006/2007 among the general public). Effective methods to reach low income families have been identified. Examples are: Motivational Interviewing, repetition, training professionals in interviewing techniques (already implemented) use of visuals rather than text, use of incentives, and providing feedback (not yet implemented).

Conclusions
The prevalence of passive smoking in young children of low income families has reduced. Since there is still a gap between low and high income families, it is still necessary to continue looking for even more effective methods.

Ways to implement smoking cessation support by health care practitioners

Background
In the Netherlands, in 2004, the evidence based guideline on tobacco dependence treatment in health care was published. It was developed by a cooperation of scientific institutions and professional organisations. Until 2006 efforts were put into the implementation of very specific smoking cessation interventions for specific patient groups, leading to enormous differences in support given by health care professionals (HP’s). In 2007 we started with a multi-component program to implement the clinical guideline in health care settings.

Program objectives
Increase the number of HP’s that provide smoking cessation support as recommended in the clinical guideline.

Methods
A multi-component implementation strategy was used:
- Increase availability of interventions that provide health professionals with practical directions on how to treat their patients.
- Increase availability of supportive (implementation) tools; manuals, patient materials, skills trainings, overview of effective treatment methods, website.
- Publication of a practical translation of the guideline recommendations by The Dutch College of General Practitioners.
- Media-campaign (print and internet advertisements) for health care professionals, addressing the logic of providing smoking cessation support.
- Newsletters and mailings.
- Presentations on conferences and meetings
- A digital knowledge centre on implementation of smoking cessation support in healthcare settings

Results
The actions mentioned above are expected to increase the number of HP’s that act according to the clinical guideline. Results of a study among HP’s on their supportive behaviour will be available by the end of 2008 and can be presented at the time of the conference.

Conclusion
A multi-component strategy might increase smoking cessation support given by HP’s.

The StopSite: A web-assisted self-help intervention for smoking cessation

Aim was to design and evaluate an interactive website (www.destopsite.nl) to help smokers quit and prevent relapse. The intervention is based on cognitive-behavioural therapy and the principle of self-control. The program includes exercises with individually tailored feedback, as well as interactive tools: a forum, diary, quitmeter, chatroom, and professional advice on demand. Participants can choose from this ‘menu’ of exercises and tools to create a treatment that suits their needs. Nothing is obligatory.

Subjects were recruited through advertisements (print and internet). A screening questionnaire was used to select subjects of 18 years and older who smoked and wanted to quit smoking within the next 3 months. The 1190 respondents who fit these criteria were e-mailed a baseline questionnaire, which 1133 subjects completed (67% female, mean age 43). These subjects randomly received access either to the StopSite (N=565) or to an online self-help quide (control group; N=568). After 4 months and 7 months, a follow-up questionnaire was sent. StopSite use was monitored by a track and trace tool which measured, amongst others, number of logins and use of interactive tools.

Response to the follow-up after 4 months was 48.3% in the intervention group and 55.3% in the control group. After 7 months, responses were 48.1% and 54.9% respectively. Abstinence rates were slightly more positive in the StopSite condition than in the control condition, but differences were not significant. Seven-day abstinence after 7 months in the intervention group was 18.1% compared to 15.5% in the control group (ns). Prolonged abstinence after 7 months was 13.4% for the intervention group, compared to 11.1% for the control group (ns). However, the more often subjects visited the StopSite, the greater the likelihood that their quit attempt was successful. Subjects who visited the StopSite more than 5 times were 5.6 times more likely to say that they had not smoked (prolonged abstinence) than those who never visited the StopSite. (p < .001). Subjects who visited the StopSite 15 times or more even had 6.4 times more chance on prolonged abstinence (p < .001).

Our next step will be to investigate which subjects are attracted by which components of the StopSite. Over-all, stickiness of the StopSite seems high: 75% of the smokers in the StopSite condition paid at least one visit. About 63% returned more than one time, 44% used the stopsite more than one week, and 20% used the StopSite more than 6 weeks. Further analyses will reveal how to further improve the stickiness of the StopSite and of future interventions.

Stoppen met roken in de zorg

Stoppen met roken is niet eenvoudig. Zorgverleners kunnen hierin een belangrijke steun zijn voor de patiënt. Alleen al het advies om te stoppen met roken van de arts verdubbelt de kans dat een roker met succes stopt met roken. Omdat roken een verslaving is, kan verdere ondersteuning door zorgverleners de kans van slagen van een stoppoging nog sterker vergroten. Zorgverleners zien rokers met aan roken gerelateerde aandoeningen vaak als eerste.
De zorgsector is daarom de uitgelezen plek om rokers te stimuleren tot en ondersteunen bij stoppen met roken. De Nederlandse Hartstichting heeft als streven dat elke roker die in aanraking komt met een arts, stoppen met roken begeleiding krijgt aangeboden. 
Stopondersteuning in de zorg is echter nog geen vanzelfsprekendheid. Hieraan liggen diverse knelpunten ten grondslag. In het kader van de doelstelling van het Nationaal Programma Tabaksontmoediging (20% rokers in 2010) is het noodzakelijk knelpunten voor de behandeling van tabaksverslaving in de zorg weg te nemen of tenminste te verminderen. In het najaar van 2007 is onder 1100 zorgverleners, zowel artsen als verpleegkundigen een onderzoek uitgevoerd over stopondersteuning. Knelpunten die zij noemden om rokers niet altijd een stopadvies en/of uitgebreidere begeleiding te geven lagen hoofdzakelijk op het niveau van de patiënt (bv. ongemotiveerd, eerdere pogingen gefaald), maar ook tijdgebrek tijdens het consult werd genoemd.
Daarnaast kwamen uit brainstormsessies met vertegenwoordigers van diverse typen zorgverleners (het partnership Stop met roken) de volgende knelpunten naar voren: gebrek aan vergoeding van stopondersteuning, gebrek aan erkenning van roken als verslaving door zorgprofessionals, gebrek aan overzicht van verwijsmogelijkheden en gebrek aan basiskennis over stopondersteuning.
Om zorgverleners te helpen hun stopondersteuning op een effectieve wijze vorm te geven worden door STIVORO met steun vanuit diverse partijen, zoals de Hartstichting, diverse interventies en trainingen aangeboden. De belangrijkste interventie is de Minimale Interventiestrategie Stoppen met roken (MIS). Dit is een stapsgewijze begeleidingsmethode waarin onder andere de motivatie om te stoppen en de barrieres die iemand ziet en mogelijke oplossingen daarvoor aan de orde komen. Ook is er aandacht voor hulpmiddelen en –methoden waarnaar zorgverleners rokers kunnen verwijzen, zoals nicotinevervangers, medicatie en intensievere gedragsmatige stopondersteuning.

Leesadviezen:
- Handleidingen Minimale Interventiestrategieën op www.stivoro.nl/professionals  > stoppen met roken > patiënten
- www.zorgentabak.nl: website met informatie over het invoeren van stoppen met roken begeleiding in de praktijk
- CBO richtlijn Behandeling van tabaksverslaving, 2004
- Knol e.a. (2005)Tabaksgebruik: Gevolgen en bestrijding

Results from the European Smoking Cessation Helplines Evaluation Research (ESCHER):  The use of quitline call volume data to measure population impact of tobacco control interventions.

Objectives
Most quitlines routinely collect data on the number of callers who seek help. Changes in call volumes can be used as an indicator of the impact of national tobacco control interventions on quitting activity in the population, which is an important precursor of smoking cessation. Interventions that generate a large increase in call volume might have more impact than interventions that have only limited effect on the number of callers. 
We examined how changes in call volumes in 17 EU countries between 2002 and 2006 were related to 1. the introduction of health warnings on cigarette packs featuring quitline telephone numbers in 2003, 2. the EU ‘HELP-For a life without tobacco’ campaign in 2005 and 2006, 3. price increases of tobacco products, and 4. national mass media smoking cessation campaigns. 

Methods
As part of the European Smoking Cessation Helplines Evaluation Research (ESCHER), we collected call volume data from European quitlines. For the period 2003 – 2004 call volumes were collected from 7 quitlines. For the period 2004 - 2006 data were obtained from 14 quitlines. We employed an interrupted time-series design. For each quitline, autoregressive integrated moving average (ARIMA) analysis was used to test for the effect of interventions on call volumes. ARIMA gives estimates of how many extra calls compared to baseline trend levels can be attributed to specific interventions.

Results
The introduction of cigarette packs featuring quitline telephone numbers had very strong immediate impact on the number of callers to quitlines (around 100% increase, with even higher increases in some countries). Price raises had a large impact in the Netherlands, Sweden and France. Promoting the quitline number in national mass media cessation campaigns also had a significant and substantial impact on call volumes. In contrast, the impact of the ‘HELP-For a Life Without Tobacco’ television spots was very limited (mostly less then 1% increase in most countries), and these effects were mostly restricted to the third wave of the HELP campaign only.

Conclusions
The impact of tobacco control interventions can be detected immediately by increases in number of callers to quitlines. Changes in call volumes can be used as a first indicator of population impact of tobacco control measures. Health warnings on cigarette packs, price increases for tobacco, and national mass media campaigns all have large effects on call volumes. The  pan-european HELP campaign generated hardly any extra calls.

Internet-based smoking cessation programmes and quitlines

Introduction
At the population level, success rates of unaided quit attempts are not higher than 3 -7% (Baillie, Mattick & Hall, 1995; West, 2006). During the past decades, several efficacious pharmacotherapies have been developed to support quit attempts, e.g., various forms of nicotine replacement and medication, notably bupropion, nortriptyline, and varenicline (Hughes, Stead & Lancaster, 2004). These are regarded as the cornerstones of effective treatment, due to their well established evidence from clinical trials  (Silagy et al, 2004; West, McNeill, & Raw, 2000; Fiore et al., 1996). For example, NRT approximately doubles the relative likelihood of quitting successfully whether or not behavioural support is provided (Hughes et al. 2003; Silagy et al., 2004). While proper use of pharmacological treatment increases the likelihood of success,  the resulting chances to be not smoking at one year follow-up are still small in absolute terms when a quit attempt is not backed up by psychological (‘behavioural’) support. Combining pharmacological treatment with behavioural support can substantially increase success rates (resulting in success rates in the range of 20-30%). Getting behavioural support therefore is crucial. In practice however, most smokers quit smoking on their own and if they use pharmacological aids, this is rarely accompanied by behavioural support. Physicians are very much reluctant to provide this support and in general are not optimally equipped and trained for this task. Quitters therefore have to look for professional support within their community or contact national organisations such as cancer societies, national tobacco control or public health institutes, and non-governmental organisations. The challenge for these national organisations is to provide effective support to an as large as possible group of smokers and to do so on a continuous basis, so as to have any population impact. Two strategies are especially promising: quitlines and internet services.
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