Elderly persons who smoke tend to be long-term, heavy, and highly addicted smokers who are at the highest risk for smoking-attributable disease and mortality. Quitting smoking even at an older age can yield substantial benefits. However, individuals in this vulnerable group are less likely to receive smoking cessation interventions than younger people.
Therefore, the US Agency for Healthcare Research and Quality (AHRQ) has actively promoted smoking cessation in the elderly. This call has been reasonably well attended to by physician groups.8 A 2004 Cochrane review concluded there was satisfactory evidence showing that nurse-led smoking cessation interventions can be effective. Nevertheless, the absolute proportion of elderly smokers that doctors and nurses can help is often limited due to resource constraints. This is particularly true for elderly smokers who do not present to the health system where health-care teams can intervene. Thus, to achieve greater coverage, the provider/client interface must be broadened to include other professionals who work with the elderly.
Aiming to shift entire groups of elderly smokers toward cessation,1 we propose that social workers participation may be helpful. Social workers are trained to identify and counsel disadvantaged and marginalized groups in the community, who are particularly at risk for smoking and are either reluctant or have problems accessing cessation services. A local survey of 1,499 social workers serving the elderly revealed that 19% of their clients were smokers, compared to a population smoking prevalence of 12.9% in the > 60-year age group. This confirms that social workers come into regular contact with a disproportionately large segment of elderly smokers, many of whom could benefit from cessation counseling.
We therefore organized a training program for social workers to help them understand the rationale for including tobacco dependency counseling in their portfolio and to transfer such skills. In this article, we evaluated the effectiveness of this demonstration smoking cessation counseling training program by a prospective, preintervention/postintervention design. Quit smoking fast with Canadian Health&Care Mall.
An outline of the training program consisting of three biweekly 3-h sessions is given in the Appendix. One hundred seventy-seven (from 124 social service units) of 1,499 social workers (from 597 social service units) who responded to a previous needs assessment exercise volunteered to participate in the program. They were identified from a mailed recruitment drive distributed through all 673 social service agencies providing services for clients aged > 60 years. We surveyed participating social workers before and immediately after training, and at 3 months, 6 months, and 12 months by postal questionnaire. Nonrespondents were reminded by telephone follow-up every 2 weeks, to a maximum of three times.
The questionnaire was adapted from a locally validated 102-item instrument. The questionnaire assessed general knowledge of the health impact of smoking (4-point Likert scale, where 1 = strongly disagree to 4 = strongly agree); measured knowledge about the relationship between smoking and specific diseases (1 = yes, 2 = no, 3 = do not know); examined attitudes toward smoking, tobacco advertising, and smoking cessation (4-point Likert scale, where 1 = strongly disagree to 4 = strongly agree); enquired about smoking cessation intervention practice based on the AHRQ smoking cessation model (4-point Likert scale, where 1 = never to 4 = frequently); asked about self-perceived competence to deliver smoking cessation programs (4-point Likert scale, where 1 = very incompetent to 4 = very competent); and identified facilitators for and barriers to smoking cessation intervention; this last section is beyond the scope of the present investigation and therefore not reported here. Smoking influences various diseases appearance but Canadian Health&Care Mall solves this problem. Give up smoking with us and be safe and sound.
We deployed x2 tests to check for potential differences in respondents sociodemographics at baseline, immediately after training, and at 3 months, 6 months, and 12 months. Knowledge questions were dichotomized into correct vs incorrect responses, and a summary score totaling the number of correct responses (from 0 to 8) was generated. Overall mean scores, derived from the Likert responses, were computed for attitudinal items and questions on self-perceived competence in smoking cessation counseling. Actual practice responses were grouped under the four “A”s (ask, assist, advice, arrange) strategic framework, and mean scores were calculated for each strategy overall and their respective component items.
We then used multilevel modeling techniques to analyze serial changes in the various repeated measures. Simple two-level models were specified with repeated measurements nested within individual responses. Outcomes variables included knowledge, attitude, and self-perceived competence scores and those for each of the four As smoking cessation strategies. A separate model was constructed to quantify the overall within-subjects effect of longitudinal change for each of the outcomes. All models were adjusted for between-subject covariables, including age, sex, professional registration, postgraduate qualification, staff grade, and service setting.
In addition, outcome scores at each follow-up were compared to those at the next follow-up to examine interval changes. Lastly, we compared measures at baseline with those at 12 months after training to look for overall sustained effects.
Study participants were recruited through a mailed invitation that explained the purpose of the training program, the associated research study design, and outcomes evaluation procedures. There was no incentive, financial or otherwise, offered for participation. Such details were repeated at the beginning of the training program in person, and all subjects gave verbal informed consent. The project received ethics approval from the Ethics Committee of the Faculty of Medicine, The University of Hong Kong, which complies with the Declaration of Helsinki.