Presentation is loading. Please wait.

Presentation is loading. Please wait.

Impediment Profiling for Smoking Cessation: Breaking Down Barriers to Behavioral Goals David L. Katz, MD, MPH, FACPM, FACP Director, Prevention Research.

Similar presentations


Presentation on theme: "Impediment Profiling for Smoking Cessation: Breaking Down Barriers to Behavioral Goals David L. Katz, MD, MPH, FACPM, FACP Director, Prevention Research."— Presentation transcript:

1 Impediment Profiling for Smoking Cessation: Breaking Down Barriers to Behavioral Goals David L. Katz, MD, MPH, FACPM, FACP Director, Prevention Research Center Yale University School of Medicine Art & Science of Health Promotion Conference Las Vegas, NV March 23, 2006

2 Key References- Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001;32:66-72 Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001;32:66-72 Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC. Impediment profiling for smoking cessation. Preliminary experience. Behav Modif. 2003;27:524-37 Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC. Impediment profiling for smoking cessation. Preliminary experience. Behav Modif. 2003;27:524-37 O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan W, Katz DL. Impediment profiling for smoking cessation: results of a pilot study. Am J Health Promot. 2003;17:300-3 O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan W, Katz DL. Impediment profiling for smoking cessation: results of a pilot study. Am J Health Promot. 2003;17:300-3 O'Connell ML, Freeman M, Jennings G, Chan W, Greci LS, Manta ID, Katz DL. Smoking cessation for high school students. Impact evaluation of a novel program. Behav Modif. 2004;28:133-46 O'Connell ML, Freeman M, Jennings G, Chan W, Greci LS, Manta ID, Katz DL. Smoking cessation for high school students. Impact evaluation of a novel program. Behav Modif. 2004;28:133-46 More papers in press More papers in press

3 Modifiable Behaviors & Health The leading causes of death are the results of risk factors The leading causes of death are the results of risk factors Nearly 50% of all deaths in the US each year are premature and related to modifiable behaviors Nearly 50% of all deaths in the US each year are premature and related to modifiable behaviors Tobacco, Diet, and Physical Activity patterns are the leading causes of premature death Tobacco, Diet, and Physical Activity patterns are the leading causes of premature death McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-12 McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-12 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-45 Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-45

4 What Behavior Is The best choice under prevailing circumstances/conditions The best choice under prevailing circumstances/conditions

5 The Challenge of Change Moving out of a desired or valued pattern Moving out of a desired or valued pattern Moving into a rejected, or unknown pattern Moving into a rejected, or unknown pattern

6 Leading Theories Theory of Reasoned Action Theory of Reasoned Action Health Beliefs Model Health Beliefs Model Social Cognitive Theory/Self-efficacy Social Cognitive Theory/Self-efficacy Social Learning Theory/Locus of Control Social Learning Theory/Locus of Control Transtheoretical Model/Stages of Change & Processes of Change Transtheoretical Model/Stages of Change & Processes of Change Institute of Medicine. Health and Behavior: the Interplay of Biological, Behavioral, and Societal Influences. National Academy Press. Washington, D.C. 2001

7 Reasoned Action Consideration of pros and cons Consideration of pros and cons Choice based on options and values Choice based on options and values

8 Health Belief Model Must believe he/she is susceptible Must believe he/she is susceptible Must perceive the potential seriousness Must perceive the potential seriousness Must believe that benefits outweigh the costs and inconvenience Must believe that benefits outweigh the costs and inconvenience Must believe he/she is capable Must believe he/she is capable There must be a cue to action There must be a cue to action

9 Transtheoretical Model Stages of Change Stages of Change Processes of Change Processes of Change

10 Prochaska J, DiClemente C. Psychotherapy: Theory, Res, Pract. 1982;19:276-288 Stages of Change Precontemplation Precontemplation Contemplation Contemplation Preparation Preparation Action Action Maintenance/Lapse Maintenance/Lapse Termination Termination

11 Processes of Change Consciousness Raising Consciousness Raising Dramatic Relief Dramatic Relief Self-Reevaluation Self-Reevaluation Environmental Reevaluation Environmental Reevaluation Self-Liberation Self-Liberation Helping Relationships Helping Relationships Counterconditioning Counterconditioning Contingency Management Contingency Management Stimulus Control Stimulus Control Social Liberation Social Liberation Prochaska JO, Redding CA, Evers KE. The Transtheoretical Model and Stages of Change. In: Glanz K, Lewis FM, Rimer BK (eds). Health Behavior and Health Education. Theory, Research, and Practice. 2 nd edition. Jossey-Bass, Inc. San Fancisco, CA. 1997.

12 Getting There Requires the Right M/O M = maximizing motivation M = maximizing motivation O = overcoming obstacles O = overcoming obstacles Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72

13 Miller WR. Addict Behav. 1996;21:835- 42; Rollnick S. Int J Obes Relat Metabl Disord. 1996;20suppl1:s22-6 Motivational Interviewing General Principles: 1) express empathy / acknowledge ambivalence 1) express empathy / acknowledge ambivalence 2) develop discrepancy 2) develop discrepancy 3) avoid argumentation 3) avoid argumentation 4) roll with resistance 4) roll with resistance 5) support self-efficacy 5) support self-efficacy 6) encourage social contracting 6) encourage social contracting

14 Decision Balance for Physical Activity. Cells in the balance show some hypothetical entries. Increase Physical Activity Advantages Weight loss Better health More energy Disadvantages Hard work Limited time Unsure how Maintain Current Activity Level Advantages Easy Comfortable Avoid risk of injury Avoid sweating Disadvantages No weight loss No health benefits Possible weight gain

15 Motivation can be the sound of one hand clapping…

16 Overcoming Resistance Acknowledge obstacles Acknowledge obstacles Convert obstacles into challenges/opportunities Convert obstacles into challenges/opportunities Identify/surmount universal barriersIdentify/surmount universal barriers Identify/surmount patient-specific barriersIdentify/surmount patient-specific barriers

17 The Inspiration for IP- How stone many walls with no windows or doors does it take to impede your progress? How stone many walls with no windows or doors does it take to impede your progress?

18 Tailored Interventions for Smoking Cessation (TISC)

19 Study Team: PREVENTION RESEARCH CENTER David L. Katz, MD, MPH, FACPM, FACP Project PI Meghan OConnell, MPH Project Coordinator Sean Lucan Research Assistant YSM*4 YSM*4 Ming-Chin Yeh, PhD Research Associate Wendy Chan, MPH Data Analyst *Yale Medical School

20 PURPOSE To establish a reliable means of identifying and quantifying the diverse impediments to smoking cessation in an individual To establish a reliable means of identifying and quantifying the diverse impediments to smoking cessation in an individual To demonstrate that smoking cessation interventions tailored to individual To demonstrate that smoking cessation interventions tailored to individual impediment profiles increase one and two- year quit rates impediment profiles increase one and two- year quit rates

21 BACKGROUND Cigarette smoking is the leading cause of preventable death in the U.S. Cigarette smoking is the leading cause of preventable death in the U.S. The literature suggests that there are 7 commonly identified impediments to smoking cessation: nicotine dependence; stress; anxiety; depression; chemical codependency;concern about weight gain; and the presence of at least one smoker in the household The literature suggests that there are 7 commonly identified impediments to smoking cessation: nicotine dependence; stress; anxiety; depression; chemical codependency;concern about weight gain; and the presence of at least one smoker in the household

22 METHODS Survey Design Comprehensive screening tools were developed to identify and quantify impediments by fusing items from existing and newly developed questionnaires Comprehensive screening tools were developed to identify and quantify impediments by fusing items from existing and newly developed questionnaires Validated instruments were located for nicotine dependence, stress, anxiety, and depression. Validated instruments were located for nicotine dependence, stress, anxiety, and depression. Multi-item questionnaires for assessing chemical dependency and concern about weight gain were developed from surveys used in clinical practice. Multi-item questionnaires for assessing chemical dependency and concern about weight gain were developed from surveys used in clinical practice. A single, direct question used to assess the presence of household members who smoke A single, direct question used to assess the presence of household members who smoke

23 Long Impediment Profiler: Fusion Of Instruments

24 Recruitment Recruitment Inclusion criteria: -smoking history > 1 year -current smoking > 15 cigarettes per day -resident of Lower Naugatuck Valley, CT. -> 18 years of age Exclusion criteria: -current use of nicotine replacement products -allergy to study medications, history of seizures -participation in other cessation program -uncompensated medical problems

25 SUBJECTS

26 Intervention Applications Nicotine dependence Nicotine dependence Subjects meeting criteria on the Fagerstrom scale were given bupropion, for a total of 12 weeks started 2 weeks prior to target quit dateSubjects meeting criteria on the Fagerstrom scale were given bupropion, for a total of 12 weeks started 2 weeks prior to target quit date Subjects received transdermal nicotine replacement therapy for 10 weeks starting on the quit date (2 weeks into program)Subjects received transdermal nicotine replacement therapy for 10 weeks starting on the quit date (2 weeks into program) Co-morbid chemical dependencies Co-morbid chemical dependencies -Subjects meeting CAGE score criteria were evaluated by an addictions specialist and referred to a Chemical Dependency Program-Subjects meeting CAGE score criteria were evaluated by an addictions specialist and referred to a Chemical Dependency Program

27 Intervention Applications, Cont. Anxiety Anxiety Subjects meeting criteria on the Beck Anxiety Inventory received the anxiolytic, buspirone, for 8 weeks. Therapy started 2 weeks prior to quit date.Subjects meeting criteria on the Beck Anxiety Inventory received the anxiolytic, buspirone, for 8 weeks. Therapy started 2 weeks prior to quit date. Depression Depression Subjects meeting Beck Depression Inventory criteria were referred for psychiatric evaluation, with treatment on the basis of professional discretion.Subjects meeting Beck Depression Inventory criteria were referred for psychiatric evaluation, with treatment on the basis of professional discretion. Smoking by household member Smoking by household member Subjects with family/household members who smoke were invited to family group counseling dinner meetings.Subjects with family/household members who smoke were invited to family group counseling dinner meetings.

28 Intervention Applications, Cont. Stress Stress Subjects meeting criteria on the Simple Stress and Tension Test were enrolled in a stress- management program consisting of yoga, guided relaxation, and meditation conducted weekly throughout the year-long program.Subjects meeting criteria on the Simple Stress and Tension Test were enrolled in a stress- management program consisting of yoga, guided relaxation, and meditation conducted weekly throughout the year-long program. Weight management Weight management Subjects meeting Smoking Situations Scale criteria enrolled in four 1-hour dietary counseling sessions.Subjects meeting Smoking Situations Scale criteria enrolled in four 1-hour dietary counseling sessions. Organized walking groups met 3 times per week for 20 minutes, for a period of one month.Organized walking groups met 3 times per week for 20 minutes, for a period of one month. Discounted membership to YMCA for subsequent 3 months.Discounted membership to YMCA for subsequent 3 months.

29 RESULTS N=19 Percentage of subjects with impediments:

30

31 Results, Cont. No significant difference in the proportions of participants that quit smoking between males and females at the significance level of 0.05. (p=0.9) No significant difference in the proportions of participants that quit smoking between males and females at the significance level of 0.05. (p=0.9) Insufficient evidence to suggest that any single impediment predicts quit status Insufficient evidence to suggest that any single impediment predicts quit status

32 Participation/intervention Ratings

33 Conclusions This novel approach resulted in 42% and 26% quit rates at one and two years respectively, a significant improvement over best quit rates reported in literature. This novel approach resulted in 42% and 26% quit rates at one and two years respectively, a significant improvement over best quit rates reported in literature. Targeting therapies for each of the 7 commonly reported impediments to quitting smoking may have resulted in the high quit rates achieved in the study. Targeting therapies for each of the 7 commonly reported impediments to quitting smoking may have resulted in the high quit rates achieved in the study.

34 Conclusions, Cont. Independent of quit rate, profiling impediments to smoking cessation served to identify otherwise ignored health problems meriting treatment in their own right. Independent of quit rate, profiling impediments to smoking cessation served to identify otherwise ignored health problems meriting treatment in their own right. The further study of impediment profiling as a smoking cessation adjunct in larger, longer, and randomized trials is warranted. The further study of impediment profiling as a smoking cessation adjunct in larger, longer, and randomized trials is warranted.

35 Worksite Study- To replicate the promising results of a pilot study using an approach to smoking cessation termed impediment profiling in the worksite setting

36 Background Cigarette smoking is the leading cause of preventable death in the U.S. 1 Cigarette smoking is the leading cause of preventable death in the U.S. 1 The CDCs Community Guide to Preventive Services recommends smoking cessation interventions be made available 2 The CDCs Community Guide to Preventive Services recommends smoking cessation interventions be made available 2 Worksites as an important venue 3 Worksites as an important venue 3 Potential benefits to both employees and employers 3 Potential benefits to both employees and employers 3 Novel Impediment Profiling methods applied in a community hospital setting Novel Impediment Profiling methods applied in a community hospital setting

37 Methods PLANNING Community hospital/PRC partnership for planning and implementation Community hospital/PRC partnership for planning and implementation administration, human resources, outpatient psychiatry, dietary, volunteer services depts.administration, human resources, outpatient psychiatry, dietary, volunteer services depts. Promotion of program for manager/supervisor buy-in Promotion of program for manager/supervisor buy-in Hospital/PRC resource sharing Hospital/PRC resource sharing

38 Methods (contd) RECRUITMENT All smoking employees were invited to participate via internal email, flyers, informational sessions for each department, information provided with employee benefits package, letters sent to all employees All smoking employees were invited to participate via internal email, flyers, informational sessions for each department, information provided with employee benefits package, letters sent to all employees

39 Methods (contd.) IMPLEMENTATION Use of Impediment Profiling (IP) instrument (previously validated) for barrier identification Use of Impediment Profiling (IP) instrument (previously validated) for barrier identification Assignment to interventions as indicated by measurement scales: Assignment to interventions as indicated by measurement scales: NRT; treatment for anxiety/depression; dietary counseling and PA for weight gain prevention; stress reduction; family support groups; referral to treatment of chemical co- dependenciesNRT; treatment for anxiety/depression; dietary counseling and PA for weight gain prevention; stress reduction; family support groups; referral to treatment of chemical co- dependencies

40 Methods (contd.) Specific intervention components were… Specific intervention components were… Self-reported quit status was verified with measurement of carbon monoxide (CO) concentration in expired air Self-reported quit status was verified with measurement of carbon monoxide (CO) concentration in expired air Smoking cessation was defined as CO reading of < 10ppm. Smoking cessation was defined as CO reading of < 10ppm.

41 Results 55 enrolled 4 dropped out prior to study commencement, resulting in sample of 51 employees 88% of participants had previously attempted to quit Stages of Change survey indicated subjects were in the following stages at baseline: 8% precontemplative 69% contemplative 23% action

42 Subjects

43 Percentage of subjects with impediments :

44 Participation

45

46

47 Conclusions This study achieved a 39% one-year quit rate, replicating pilot findings indicating that IP and tailoring of interventions results in a dramatic improvement over quit rates reported in the literature This study achieved a 39% one-year quit rate, replicating pilot findings indicating that IP and tailoring of interventions results in a dramatic improvement over quit rates reported in the literature Seventy-seven percent of participants were in either the precontemplative or contemplative stage of change at enrollment, suggesting that providing individualized assistance may be highly effective at increasing/maintaining motivation to quit Seventy-seven percent of participants were in either the precontemplative or contemplative stage of change at enrollment, suggesting that providing individualized assistance may be highly effective at increasing/maintaining motivation to quit

48 Conclusions (contd) Independent of quit rate, profiling impediments to smoking cessation served to identify otherwise ignored health problems meriting treatment in their own right Independent of quit rate, profiling impediments to smoking cessation served to identify otherwise ignored health problems meriting treatment in their own right Further study of impediment profiling as a smoking cessation adjunct in larger, longer, and randomized trials is warranted Further study of impediment profiling as a smoking cessation adjunct in larger, longer, and randomized trials is warranted

49 Conclusions (contd) The study demonstrated the feasibility of applying IP methods in a worksite setting The study demonstrated the feasibility of applying IP methods in a worksite setting Hospitals in particular are ideal settings for smoking cessation interventions. By capitalizing on existing resources and involving stakeholders, creative programs can be implemented to benefit the entire workforce Hospitals in particular are ideal settings for smoking cessation interventions. By capitalizing on existing resources and involving stakeholders, creative programs can be implemented to benefit the entire workforce

50 I have a dream… Impediment profiling for all: web-based Impediment profiling for all: web-based Mapping individualized paths to behavior change Mapping individualized paths to behavior change Application to eating/weight control… Application to eating/weight control…

51 Bibliography 1. Centers for Disease Control. (2000). Reducing Tobacco Use: A Report of the Surgeon General. MMWR, 49(RR16), 1-27. 2. Cohen, S. (1983). The Perceived Stress Scale: A Global Measure of Perceived Stress. Journal of Health and Social Behavior, 24, 385-396. 3. Creamer, M., Foran, J., & Bell, R. (1995). The Beck Anxiety Inventory in a Non-Clinical Sample. Behavioral Research and Therapy, 33(4), 477-485. 4. French, S., Jeffrey, R., Klesges, L., & Forster, J. (1995). Weight Concerns and Change in Smoking Behavior Over Two Years in Working Population. American Journal of Public Health, 85, 720-722. 5. Freund, M. (1992). Predictors of Smoking Cessation: The Framingham Study. American Journal of Epidemiology, 135, 957-964. 6. Ginsberg, D., Hall, S., & Rosinski, M. (1991). Partner Interaction and Smoking Cessation: A Pilot Study. Addictive Behaviors, 16, 195-202. 7. Glassman, A., Helzer, J., Covey, L., Cottler, L., Stetler, J., Tipp, J., & Johnson, J. (1990). Smoking Cessation and Major Depression. JAMA, 264, 1546-1549. 8. Heatherton, T., Kozlowski, L., Frecker, R., & Fagerstrom, K. (1991). The Fagerstrom Test for Nicotine Dependence: A Revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction, 86, 1119-1127. 9. Hilleman, D., Mohiuddin, S., Core, M. D., & Sketch, M. (1992). Effect of Buspirone on Withdrawal Symptoms Associated with Smoking Cessation. Archives of Internal Medicine, 152, 350-352. 10. Jeffery, R., Hennrikus, D., Lando, H., Murray, D., & Liu, J. (2000). Reconciling Conflicting Findings Regarding Post-Cessation Weight Concerns and Success in Smoking Cessation. Health Psychology, 19(3), 242-246.

52 Bibliography, cont. 11. Keuthen, N., Niaura, R., Borrelli, B., Goldstein, M., DePue, J., Murphy, C., Gastfriend, D., Reiter, S.R., & Abrams, D. (2000). Comorbidity, Smoking Behavior and Treatment Outcome. Psychother Psychosom, 69(5), 244-250. 12. Niaura, R, Shadel W. Response to social stress, urge to smoke, and smoking cessation. Addict Behav,27(2),241-50. 13. Roski, J., Schmid, L., & Lando, H. (1996). Long-Term Associations of Helpful and Harmful Spousal Behaviors With Smoking Cessation. Addict Behav, 21(2), 173-185. 14. Saitz, R., Lepore, M., Sullivan, L., Amaro, H., & Samet, J. (1999). Alcohol Abuse and Dependence in Latinos Living in the United States: Validation of the CAGE (4M) Questions. Arch Intern Med, 159(7), 718-724. 15. Weekley, C. (1992). Smoking as a Weight-Control Strategy and its Relationship to Smoking Status. Addict Behav, 17(3), 259-271. 16. Whisman, M., Perez, J., & Ramel, W. (2000). Factor Structure of the Beck Depression Inventory-Second Edition (BDI-II) in a Student Sample. J Clin Psychol, 56(4), 545-551.

53 Bibliography, cont. 17. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs-August 1999. Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, August 1999. 18. Wasserman, M.P. 2001. Guide to Community Preventive Services: State and local opportunities for tobacco use reduction. American Journal of Preventive Medicine: 20 (S2) pp 8-9. 19. Centers for Disease Control and Prevention. Making Your workplace Smoke-free: A decision makers guide. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Wellness Councils of America and American Cancer Society.

54 Bibliography 1. Centers for Disease Control. (2000). Reducing Tobacco Use: A Report of the Surgeon General. MMWR, 49(RR16), 1-27. 2. Cohen, S. (1983). The Perceived Stress Scale: A Global Measure of Perceived Stress. Journal of Health and Social Behavior, 24, 385-396. 3. Creamer, M., Foran, J., & Bell, R. (1995). The Beck Anxiety Inventory in a Non-Clinical Sample. Behavioral Research and Therapy, 33(4), 477-485. 4. French, S., Jeffrey, R., Klesges, L., & Forster, J. (1995). Weight Concerns and Change in Smoking Behavior Over Two Years in Working Population. American Journal of Public Health, 85, 720-722. 5. Freund, M. (1992). Predictors of Smoking Cessation: The Framingham Study. American Journal of Epidemiology, 135, 957-964. 6. Ginsberg, D., Hall, S., & Rosinski, M. (1991). Partner Interaction and Smoking Cessation: A Pilot Study. Addictive Behaviors, 16, 195-202. 7. Glassman, A., Helzer, J., Covey, L., Cottler, L., Stetler, J., Tipp, J., & Johnson, J. (1990). Smoking Cessation and Major Depression. JAMA, 264, 1546-1549. 8. Heatherton, T., Kozlowski, L., Frecker, R., & Fagerstrom, K. (1991). The Fagerstrom Test for Nicotine Dependence: A Revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction, 86, 1119-1127. 9. Hilleman, D., Mohiuddin, S., Core, M. D., & Sketch, M. (1992). Effect of Buspirone on Withdrawal Symptoms Associated with Smoking Cessation. Archives of Internal Medicine, 152, 350-352. 10. Jeffery, R., Hennrikus, D., Lando, H., Murray, D., & Liu, J. (2000). Reconciling Conflicting Findings Regarding Post-Cessation Weight Concerns and Success in Smoking Cessation. Health Psychology, 19(3), 242-246.

55 Bibliography, cont. 11. Keuthen, N., Niaura, R., Borrelli, B., Goldstein, M., DePue, J., Murphy, C., Gastfriend, D., Reiter, S.R., & Abrams, D. (2000). Comorbidity, Smoking Behavior and Treatment Outcome. Psychother Psychosom, 69(5), 244-250. 12. Niaura, R, Shadel W. Response to social stress, urge to smoke, and smoking cessation. Addict Behav,27(2),241-50. 13. Roski, J., Schmid, L., & Lando, H. (1996). Long-Term Associations of Helpful and Harmful Spousal Behaviors With Smoking Cessation. Addict Behav, 21(2), 173-185. 14. Saitz, R., Lepore, M., Sullivan, L., Amaro, H., & Samet, J. (1999). Alcohol Abuse and Dependence in Latinos Living in the United States: Validation of the CAGE (4M) Questions. Arch Intern Med, 159(7), 718-724. 15. Weekley, C. (1992). Smoking as a Weight-Control Strategy and its Relationship to Smoking Status. Addict Behav, 17(3), 259-271. 16. Whisman, M., Perez, J., & Ramel, W. (2000). Factor Structure of the Beck Depression Inventory-Second Edition (BDI-II) in a Student Sample. J Clin Psychol, 56(4), 545-551.

56 Bibliography, cont. 17. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs-August 1999. Atlanta GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, August 1999. 18. Wasserman, M.P. 2001. Guide to Community Preventive Services: State and local opportunities for tobacco use reduction. American Journal of Preventive Medicine: 20 (S2) pp 8-9. 19. Centers for Disease Control and Prevention. Making Your workplace Smoke-free: A decision makers guide. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Wellness Councils of America and American Cancer Society.

57 May you be inspired often (and expire late). Thank you. Yale Prevention Research Center 130 Division St. Derby, CT 06418 (203) 732-1265 David.katz@yale.edu www.davidkatzmd.com


Download ppt "Impediment Profiling for Smoking Cessation: Breaking Down Barriers to Behavioral Goals David L. Katz, MD, MPH, FACPM, FACP Director, Prevention Research."

Similar presentations


Ads by Google