The Views and Experiences of Smokers Who Quit Smoking Unassisted. A Systematic Review of the Qualitative Evidence.

Background Unassisted cessation – quitting without pharmacological or professional support – is an enduring phenomenon. Unassisted cessation persists even in nations advanced in tobacco control where cessation assistance such as nicotine replacement therapy, the stop-smoking medications bupropion and varenicline, and behavioural assistance are readily available. We review the qualitative literature on the views and experiences of smokers who quit unassisted. Method We systematically searched for peer-reviewed qualitative studies reporting on smokers who quit unassisted. We identified 11 studies and used a technique based on Thomas and Harden’s method of thematic synthesis to discern key themes relating to unassisted cessation, and to then group related themes into overarching concepts. Findings The three concepts identified as important to smokers who quit unassisted were: motivation, willpower and commitment. Motivation, although widely reported, had only one clear meaning, that is ‘the reason for quitting’. Willpower was perceived to be a method of quitting, a strategy to counteract cravings or urges, or a personal quality or trait fundamental to quitting success. Commitment was equated to seriousness or resoluteness, was perceived as key to successful quitting, and was often used to distinguish earlier failed quit attempts from the final successful quit attempt. Commitment had different dimensions. It appeared that commitment could be tentative or provisional, and also cumulative, that is, commitment could be built upon as the quit attempt progressed. Conclusion A better understanding of what motivation, willpower and commitment mean from the smoker’s perspective may provide new insights and direction for smoking cessation research and practice.Funding was provided by the National Health and Medical Research Council (NHMRC), Australia, grant number 1024459. SMC was supported by NHMRC Career Development Fellowship 1032963

Measured, opportunistic, unexpected and naïve quitting: a qualitative grounded theory study of the process of quitting from the ex-smokers’ perspective.

Background To better understand the process of quitting from the ex-smokers’ perspective, and to explore the role spontaneity and planning play in quitting. Methods Qualitative grounded theory study using in-depth interviews with 37 Australian adult ex-smokers (24–68 years; 15 males, 22 females) who quit smoking in the past 6–24 months (26 quit unassisted; 11 used assistance). Results Based on participants’ accounts of quitting, we propose a typology of quitting experiences: measured, opportunistic, unexpected and naïve. Two key features integral to participants’ accounts of their quitting experiences were used as the basis of the typology: (1) the apparent onset of quitting (gradual through to sudden); and (2) the degree to which the smoker appeared to have prepared for quitting (no evidence through to clear evidence of preparation). The resulting 2 × 2 matrix of quitting experiences took into consideration three additional characteristics: (1) the presence or absence of a clearly identifiable trigger; (2) the amount of effort (cognitive and practical) involved in quitting; and (3) the type of cognitive process that characterised the quitting experience (reflective; impulsive; reflective and impulsive). Conclusions Quitting typically included elements of spontaneity (impulsive behaviour) and preparation (reflective behaviour), and, importantly, the investment of time and cognitive effort by participants prior to quitting. Remarkably few participants quit completely out-of-the-blue with little or no preparation. Findings are discussed in relation to stages-of-change theory, catastrophe theory, and dual process theories, focusing on how dual process theories may provide a way of conceptualising how quitting can include elements of both spontaneity and preparation. Keywords Qualitative Grounded theory Smoking cessation Catastrophe theory Stages of change Dual process theoryfunded by an Australian National Health and Medical Research Council grant (NHMRC 1024459)

The Views and Experiences of Smokers Who Quit Smoking Unassisted. A Systematic Review of the Qualitative Evidence.

Background Unassisted cessation – quitting without pharmacological or professional support – is an enduring phenomenon. Unassisted cessation persists even in nations advanced in tobacco control where cessation assistance such as nicotine replacement therapy, the stop-smoking medications bupropion and varenicline, and behavioural assistance are readily available. We review the qualitative literature on the views and experiences of smokers who quit unassisted. Method We systematically searched for peer-reviewed qualitative studies reporting on smokers who quit unassisted. We identified 11 studies and used a technique based on Thomas and Harden’s method of thematic synthesis to discern key themes relating to unassisted cessation, and to then group related themes into overarching concepts. Findings The three concepts identified as important to smokers who quit unassisted were: motivation, willpower and commitment. Motivation, although widely reported, had only one clear meaning, that is ‘the reason for quitting’. Willpower was perceived to be a method of quitting, a strategy to counteract cravings or urges, or a personal quality or trait fundamental to quitting success. Commitment was equated to seriousness or resoluteness, was perceived as key to successful quitting, and was often used to distinguish earlier failed quit attempts from the final successful quit attempt. Commitment had different dimensions. It appeared that commitment could be tentative or provisional, and also cumulative, that is, commitment could be built upon as the quit attempt progressed. Conclusion A better understanding of what motivation, willpower and commitment mean from the smoker’s perspective may provide new insights and direction for smoking cessation research and practice.Funding was provided by the National Health and Medical Research Council (NHMRC), Australia, grant number 1024459. SMC was supported by NHMRC Career Development Fellowship 1032963

Paediatric Track and Trigger Systems: Validity, Reliability and Utility

Paediatric Track and Trigger Systems (PTTS) should alert staff to deteriorating children and accelerate access to resuscitation. The thesis presents a series of linked studies exploring selected aspects of PTTS use. Study 1: Systematic review Fifty-five papers describing 33 PTTS were identified. Implemented without a rapid response team (RRT), PTTS did not demonstrate statistically significant relative reduction in cardiac or respiratory arrest, or mortality. Implemented as part of a RRT PTTS demonstrated a statistically significant reduction in the relative and absolute risk of death in hospital, death on the ward and death following PICU transfer. Study 2: Validity This case-controlled study compared the predictive validity of 18 PTTS using case-controlled methodology. The area under the receiver operator characteristic curve (AUROC) varied (0.62 to 0.89). Three systems demonstrated statistically better performance. Incorporation of evidence-based thresholds for heart and respiratory rate did not improve the AUROC of high-performing systems. Study 3: Reliability This study examined the accuracy and completeness of PTTS documentation and compliance to a monitoring and escalation protocol. Of the 13,816 observation sets, 10,518 (76.1%) had an accurately calculated PTTS. Just 4957 (35.9%) contained all the required parameters. Only 3.3% of patients (20/608) met the required standard for monitoring and escalation. Study 4: Utility This mixed-methods study examined the understanding and experiences of children, young people, parents and nurses surrounding the use of a PTTS. Three main themes emerged: benefits and burdens, watchfulness and wisdom, and collaboration and conflict. Findings indicate that use of a PTTS is complex and greater collaboration between children/young people, families and healthcare professionals is likely to improve their use in clinical practice.  Conclusion: There may be a relationship between validity, reliability and utility which, at present, is poorly understood. Better understanding of this relationship may improve outcomes for children and young peopl

Reflections on the US College Loans System: Lessons from Australia and England

There is wide agreement that the US student loan system faces significant problems. Seven million borrowers are in default and many more are not repaying for reasons such as returning to school, or economic hardship. The stress of repayments faced by many students results at least in part from the design of US student loans. Specifically, loans are organised like a mortgage, with fixed monthly repayments over a fixed period of time, creating a high repayment burden on borrowers with low income. This paper draws on the experience of the income-contingent loan (ICL) systems operating in England and Australia, in which monthly or two-weekly repayments are related to the borrower's income in that period, thus building in automatic insurance against inability to repay during periods of low income. We discuss the design of this type of loan in detail since such an exercise seems to be largely absent in the US literature. Drawing on data from the US Current Population Survey (CPS) we provide two main empirical contributions: a stylised illustration of the revenue and distributional implications of different hypothetical ICL arrangements for the USA; and an illustration of repayment problems faced by low-earning borrowers in the US loan system, including a plausible example of adverse outcomes with respect to Stafford loans. Importantly, we compare repayment burdens under the existing and alternative systems. Our illustrations show how US mortgage-type loans can create financial difficulties for a significant minority of US borrowers, difficulties which an ICL is designed to address. We note also that the current small and ineffective income-based repayment system in the US has few of the characteristics of an ideal ICL

Replicating landmine blast loading in cellular <i>in Vitro</i> models

Trauma arising from landmines and improvised explosive devices promotes heterotopic ossification, the formation of extra-skeletal bone in non-osseous tissue. To date, experimental platforms that can replicate the loading parameter space relevant to improvised explosive device and landmine blast wave exposure have not been available to study the effects of such non-physiological mechanical loading on cells. Here, we present the design and calibration of three distinct in vitro experimental loading platforms that allow us to replicate the spectrum of loading conditions recorded in near-field blast wave exposure. We subjected cells in suspension or in a three-dimensional hydrogel to strain rates up to 6000 s-1and pressure levels up to 45 MPa. Our results highlight that cellular activation is regulated in a non-linear fashion - not by a single mechanical parameter, it is the combined action of the applied mechanical pressure, rate of loading and loading impulse, along with the extracellular environment used to convey the pressure waves. Finally, our research indicates that PO MSCs are finely tuned to respond to mechanical stimuli that fall within defined ranges of loading

Why do smokers try to quit without medication or counselling? A qualitative study with ex-smokers.

Objective When tobacco smokers quit, between half and two-thirds quit unassisted: that is, they do not consult their general practitioner (GP), use pharmacotherapy (nicotine-replacement therapy, bupropion or varenicline), or phone a quitline. We sought to understand why smokers quit unassisted. Design Qualitative grounded theory study (in-depth interviews, theoretical sampling, concurrent data collection and data analysis). Participants 21 Australian adult ex-smokers (aged 28–68 years; 9 males and 12 females) who quit unassisted within the past 6 months to 2 years. 12 participants had previous experience of using assistance to quit; 9 had never previously used assistance. Setting Community, Australia. Results Along with previously identified barriers to use of cessation assistance (cost, access, lack of awareness or knowledge of assistance, including misperceptions about effectiveness or safety), our study produced new explanations of why smokers quit unassisted: (1) they prioritise lay knowledge gained directly from personal experiences and indirectly from others over professional or theoretical knowledge; (2) their evaluation of the costs and benefits of quitting unassisted versus those of using assistance favours quitting unassisted; (3) they believe quitting is their personal responsibility; and (4) they perceive quitting unassisted to be the ‘right’ or ‘better’ choice in terms of how this relates to their own self-identity or self-image. Deep-rooted personal and societal values such as independence, strength, autonomy and self-control appear to be influencing smokers’ beliefs and decisions about quitting. Conclusions The reasons for smokers’ rejection of the conventional medical model for smoking cessation are complex and go beyond modifiable or correctable problems relating to misperceptions or treatment barriers. These findings suggest that GPs could recognise and respect smokers’ reasons for rejecting assistance, validate and approve their choices, and modify brief interventions to support their preference for quitting unassisted, where preferred. Further research and translation may assist in developing such strategies for use in practice.NHMR

Why do smokers try to quit without medication or counselling? A qualitative study with ex-smokers.

Objective When tobacco smokers quit, between half and two-thirds quit unassisted: that is, they do not consult their general practitioner (GP), use pharmacotherapy (nicotine-replacement therapy, bupropion or varenicline), or phone a quitline. We sought to understand why smokers quit unassisted. Design Qualitative grounded theory study (in-depth interviews, theoretical sampling, concurrent data collection and data analysis). Participants 21 Australian adult ex-smokers (aged 28–68 years; 9 males and 12 females) who quit unassisted within the past 6 months to 2 years. 12 participants had previous experience of using assistance to quit; 9 had never previously used assistance. Setting Community, Australia. Results Along with previously identified barriers to use of cessation assistance (cost, access, lack of awareness or knowledge of assistance, including misperceptions about effectiveness or safety), our study produced new explanations of why smokers quit unassisted: (1) they prioritise lay knowledge gained directly from personal experiences and indirectly from others over professional or theoretical knowledge; (2) their evaluation of the costs and benefits of quitting unassisted versus those of using assistance favours quitting unassisted; (3) they believe quitting is their personal responsibility; and (4) they perceive quitting unassisted to be the ‘right’ or ‘better’ choice in terms of how this relates to their own self-identity or self-image. Deep-rooted personal and societal values such as independence, strength, autonomy and self-control appear to be influencing smokers’ beliefs and decisions about quitting. Conclusions The reasons for smokers’ rejection of the conventional medical model for smoking cessation are complex and go beyond modifiable or correctable problems relating to misperceptions or treatment barriers. These findings suggest that GPs could recognise and respect smokers’ reasons for rejecting assistance, validate and approve their choices, and modify brief interventions to support their preference for quitting unassisted, where preferred. Further research and translation may assist in developing such strategies for use in practice.NHMR

Applying a perceptions and practicalities approach to understanding nonadherence to antiepileptic drugs

Summary Objective Nonadherence to antiepileptic drugs (AEDs) is a common cause of poor seizure control. This study examines whether reported adherence to AEDs is related to variables identified in the National Institute for Health and Clinical Excellence (NICE) Medicines Adherence Guidelines as being important to adherence: perceptual factors (AED necessity beliefs and concerns), practical factors (limitations in capability and resources), and perceptions of involvement in treatment decisions. Methods This was a cross-sectional study of people with epilepsy receiving AEDs. Participants completed an online survey hosted by the Epilepsy Society (n = 1,010), or as an audit during inpatient admission (n = 118). Validated questionnaires, adapted for epilepsy, assessed reported adherence to AEDs (Medication Adherence Report Scale [MARS]), perceptions of AEDs (Beliefs about Medicines Questionnaire [BMQ]), and patient perceptions of involvement in treatment decisions (Treatment Empowerment Scale [TES]). Results Low adherence was related to AED beliefs (doubts about necessity: t(577) = 3.90, p < 0.001; and concerns: t(995) = 3.45, p = 0.001), reported limitations in capability and resources (t(589) = 7.78, p < 0.001), and to perceptions of a lack of involvement in treatment decisions (t(623) = 4.48, p < 0.001). In multiple logistic regression analyses, these factors significantly (p < 0.001) increased variance in reported adherence, above that which could be explained by age and clinical variables (seizure frequency, type, epilepsy duration, number of AEDs prescribed). Significance Variables identified in the NICE Medicines Adherence Guidelines as potentially important factors for adherence were found to be related to adherence to AEDs. These factors are potentially modifiable. Interventions to support optimal adherence to AEDs should be tailored to address doubts about AED necessity and concerns about harm, and to overcome practical difficulties, while engaging patients in treatment decisions

The influence of slope and peatland vegetation type on riverine dissolved organic carbon and water colour at different scales

Peatlands are important sources of fluvial carbon. Previous research has shown that riverine dissolved organic carbon (DOC) concentrations are largely controlled by soil type. However, there has been little work to establish the controls of riverine DOC within blanket peatlands that have not undergone major disturbance from drainage or burning. A total of 119 peatland catchments were sampled for riverine DOC and water colour across three drainage basins during six repeated sampling campaigns. The topographic characteristics of each catchment were determined from digital elevation models. The dominant vegetation cover was mapped using 0.5 m resolution colour infrared aerial images, with ground-truthed validation revealing 82 % accuracy. Forward and backward stepwise regression modelling showed that mean slope was a strong (and negative) determinant of DOC and water colour in blanket peatland river waters. There was a weak role for plant functional type in determining DOC and water colour. At the basin scale, there were major differences between the models depending on the basin. The dominance of topographic predictors of DOC found in our study, combined with a weaker role of vegetation type, paves the way for developing improved planning tools for water companies operating in peatland catchments. Using topographic data and aerial imagery it will be possible to predict which tributaries will typically yield lower DOC concentrations and which are therefore more suitable and cost-effective as raw water intakes