Here, I summarize the methodology behind integrating de novo assemblies and genetic linkage maps, outline the current challenges, review the available software tools, and discuss new mapping technologies.Modern high-throughput DNA sequencing has made it possible to inexpensively produce genome sequences, but in practice many of these draft genomes are fragmented and incomplete. Genetic linkage maps based on recombination rates between physical markers have been used in biology for over 100 years and a linkage map, when paired with a  De novo genome sequences are fueling a scientific revolution. Biologists are in a position to answer questions that were unimaginable 30 years ago, and new technologies and resources are generating new questions. However, many of these draft genomes contain thousands of individual sequences with no information on how these pieces are assembled into chromosomes. This is problematic both for molecular and developmental studies as individual genes may end up fractured and incorrectly annotated , and scaffolds, sequences that contain regions with unknown nucleotides . Next-generation sequencing-by-synthesis has shrunk the price of a million bases of sequenced DNA from $2400   assemblies have always suffered from the same limitations, and short read lengths have amplified these problems  can be established from parental crosses and used for genetic mapping  while 10 genetic markers can be ordered in 1.8 million different ways. The necessary marker density depends on assembly contiguity, and fragmented genome sequences require dense maps for anchoring and orientation. Grouping, ordering and spacing dense marker sets is a central computational challenge and efficient algorithms are still under development  and sequencing. Sequencing coverage can be uneven across both genomic regions and alleles at one locus due to local GC content. This can result in different data missing from each individual and a negative relationship between sample sizes for markers and individuals.de novo assembly containing thousands of scaffolds and thousands of genetic markers, this quickly becomes time-consuming and subject to error.Map-assembly integration can proceed in two different ways. For sequence-based mapping genetic markers are aligned to the draft assembly and these markers are used to construct a map, while for array-based mapping the map is constructed first and genetic markers aligned second. For both procedures multiply-mapped markers and loci must be excluded from the final map. However, there is no software to perform either of these processes and it requires custom scripting. Mis-assembled scaffolds can be identified through marker segregation patterns, but in practice identifying and correcting these errors must be done manually. For a typical de novo assembly, and efficient methods and algorithms are spread across different packages. My goal is to describe the benefits and limitations of each package so biologists can choose which to implement in their own work. For a review of older software, see Cheema and Dicks  but can not be used to accurately reconstruct chromosome-scale relationships. An integrated approach to de novo genome assembly and genetic linkage mapping could utilize the information in each to build a high-quality reference sequence. These methods are just now beginning to appear in computational tools  (Adey et al., de novo assembly with linkage mapping is a powerful way to produce a high-quality reference genome. Map estimation was originally developed as a genetic tool over 100 years ago (Sturtevant, Coupling de novo assembly alone and every genome project that can reasonably be coupled with a linkage map, should be coupled with a linkage map.Dense linkage maps can both orient and order assembled sequences and identify the genetic basis of phenotypic traits. Linkage maps are therefore one of the most important tools we have in genetics. Establishing a mapping population takes time, and undertaking a mapping project is a significant investment of resources. However, linkage maps provide high-quality sequences that can not result from The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Recently, the development of new biomarkers as prognostic and predictive markers in prostate cancer has been crucial.This study was aimed to determine whether serum vascular endothelial growth factor (VEGF) levels would be a prognostic marker or risk assessment factor in patients with prostate cancer and to investigate whether it could differentiate cancerous tissue from benign prostate hyperplasia (BPH).We enrolled 44 patients with prostate cancer, 57 patients with BPH, and 57 healthy individuals. Serum VEGF levels was measured by ELISA and was compared among all groups; then, its correlation with PSA and Gleason score in cancerous group was assessed. In addition, by using receiver operating characteristic (ROC) curve and area under curve (AUC), we determined the sensitivity and specificity of VEGF as well as combined variable of VEGF and PSA as a diagnostic marker of prostate cancer.Serum VEGF level was significantly higher in patients with prostate cancer in comparison to the other groups ; however, it was not different between BPH and control groups. Only in cancerous group a significant correlation between VEGF and PSA was found . Assessing the risk of prostate cancer, we found a powerful correlation between the VEGF alone as well as the combination of VEGF and PSA with prostate cancer.VEGF may be a diagnostic biomarker of prostate cancer. In addition, it may differentiate the cancerous tissue from BPH. We suggest that VEGF combined with PSA may be used as a screening test of prostate cancer. Prostate cancer is the fourth cause of death in men worldwide (9.2%) being surpassed only by lung cancer 18%). Due to the magnitude of the impact over public health, strong efforts have been made aiming the prevention, early diagnosis, and treatment of this disease , which is expressed at elevated levels in several tumor types, is an important hypoxia-inducible proangiogenic protein and a potent inducer of endothelial cell growth , 5. The On the other hand, some studies revealed that the expression of VEGF was not correlated with any clinicopathological parameters among prostate cancer specimens . It was For the first time in Iranian population, we aimed to compare the serum levels of VEGF in patients with prostate cancer with the levels in patients with BPH as well as healthy people and to determine whether it would be a prognostic marker as well as differentiating factor in such patients.This study was performed under KAUMS  Ethics Committee-approved protocol and written informed consent was obtained from all participants. The study protocol conformed to the ethical guidelines of the 1975 Helsinki Declaration. Exclusion criteria consisted of prior surgery or any other treatment of prostate cancer or BPH as well as any active infection or inflammatory process. From May 2011, serum samples were collected from 158 men. Forty-four of them were new cases of prostate cancer with no history of surgical or medical procedures at the time of sampling, 57 men were new cases of BPH based on clinical and sonographic criteria . We recruited 57 age-assimilated healthy control men without any complaint or sign of inflammatory/noninflammatory diseases. In those with an abnormal rectal exam and a prostate-specific antigen (PSA) > 4, we proved the diagnosis of cancer by biopsy. We considered just new cases without any surgical procedures to assess TMN; therefore, it was impossible to evaluate the staging of the patients. Five patients with BPH attended with a mildly elevated PSA levels; therefore, we confirmed no evidence of malignancy in them with histological findings on the biopsy specimens.All patients and controls had a blood sample drawn into a tube with no anticoagulant. In BPH, patients’ blood samples were taken after the diagnosis and before any treatment, and in cancer suspects  before prostatic biopsy. Blood samples of biopsy-confirmed cancerous patients were enrolled in the study. Therefore, nobody had any surgical and medical treatment at the time of sampling. The serum stored at −20°C until analysis. Concentration of serum VEGF was measured using a quantitative immunoassay technique, namely enzyme-linked immunosorbent assay (ELISA), by a commercially available ELISA kit , according to the manufacturer’s instruction. Samples were analyzed twice and mean VEGF levels reported in picogram per milliliter in each group. All data were analyzed by SPSS v.17  using descriptive statistics, namely chi-square and fissure exact tests. Analytical data were analyzed via ANOVA and student t-test. We used a logistic regression model to assess the effective factors on prostate cancer risk. Then the impact of all factors on VEGF was studied simultaneously by covariance analytic model. Using receiver operating characteristic (ROC) curve and area under curve (AUC), we tried to determine the sensitivity and specificity of VEGF as a diagnostic marker of prostate cancer. Moreover, using analysis of the principle components, we calculated linear combination of VEGF and PSA variables with equal co-efficiencies. Finally, we calculated the specificity, sensitivity and AUC of combined variable to predict prostate cancer.Using ROC curve and area under curve (AUC) , we deteMorphology-based approaches, especially Gleason scoring, combined to clinical parameters of PSA and T stage have provided clinicians some important prognostic information about prostate cancer. Recent successes have served to cultivate the growing interest in discovering more molecular-based prognostic factors . Such biIn line with Soulitzis et al. , we showOur study had some advantages. First, relatively proper sample size and associated standard deviations yielded a proper power to detect differences in subgroup analyses. Second, all of our patients were newly diagnosed and there were no essential factors affecting the comparability of the groups including using different kinds of medical or surgical treatments. Such uniformity of the patients especially in the cancerous arm was seen less in other studies. In a case-control study, Vancleave et al.  showed t


Nucleic acids display remarkable properties beyond information storage and propagation. The well-understood base pairing rules have enabled nucleic acids to be assembled into nanostructures of ever increasing complexity. Although nanostructures can be constructed using other building blocks, including peptides and lipids, it is the capacity to evolve that sets nucleic acids apart from all other nanoscale building materials. Nonetheless, the poor chemical and biological stability of DNA and RNA constrain their applications. Recent advances in nucleic acid chemistry and polymerase engineering enable the synthesis, replication, and evolution of a range of synthetic genetic polymers (XNAs) with improved chemical and biological stability. We discuss the impact of this technology on the generation of XNA ligands, enzymes, and nanostructures with tailor-made chemistry. Natural nucleic acids, DNA and RNA, are uniquely suited to their information storage role as they allow accurate propagation of chemical information through specific base pairing during replication. DNA and RNA are composed of a limited set of four chemically analogous monomers – the nucleosides adenosine, guanosine, cytidine, and thymidine (or uridine for RNA). The natural nucleosides are composed of three chemical moieties – an aromatic nucleobase, a conformationally flexible ribofuranose, and the anionic phosphate diester linkage between monomers. Nucleic acids can thus be viewed as aperiodic polymers composed of these tripartite nucleotide building blocks.Although all three moieties contribute to the physicochemical properties of the final nucleic acid polymer, there is a dominant contribution by the polyanionic phosphodiester backbone The polyanionic nature of the backbone also favours an extended conformation in low ionic conditions through charge repulsion. Nevertheless, single-stranded DNA and RNA can both fold into defined structures, which allow nucleic acid ligands (aptamers) and catalysts  We focus on some of the recent advances in nucleic acid-based materials, particularly enzymes and nanostructures, and on the new possibilities that synthetic genetic polymers can bring to the field.It is challenging to develop complex function from conventional polymers because their rational design imposes huge demands: understanding of the molecular basis of the desired function, knowledge of the polymer molecular structure required for function, and tight control of polymer synthesis with the desired structure. These challenges remain largely unresolved, but significant progress has been made not only in nucleic acids, but also in peptides and proteins 14 variants in nucleic acid selections) for complex phenotypes, such as ligand binding and catalysis, bypassing current limitations of rational design approaches.The capacity for replication sets nucleic acids apart from other polymers: replication enables evolution and the iterative optimisation of function. Cycles of sequence diversification and purifying selection enable the systematic search of vast populations , however, have limited chemical diversity and poor chemical and biological stability, limiting their suitability for many applications. Although many modifications of the natural chemical moieties or even introduction of novel chemical functionalities are possible, the challenge is that these are frequently incompatible with replication and hence evolution .In nature, nucleic acid replication is carried out by complex, highly dynamic enzymes called polymerases, through the sequential incorporation of activated monomers (nucleotide triphosphates) against a single strand of nucleic acid template. DNA polymerases have evolved stringent specificity mechanisms to exclude noncognate substrates from their active site and, as a result, the range of the chemical modifications that can be incorporated and/or replicated with DNA polymerases is limited Recent research has therefore focused on identifying strategies to circumvent the restrictions imposed by the narrow polymerase substrate spectrum. These efforts can be broadly summarised by three complementary strategies: the chemical optimisation of unnatural substrates improving their uptake by natural polymerases Systematic exploration of the chemical neighbourhood of natural nucleotides has identified a significant number of modifications that are well tolerated by natural polymerases, notably: substitutions to N7 in purines and C5 in pyrimidines , unnatural base pairs (that retain or mimic the geometric shape of the cognate pairs), and a few phosphate backbone modifications (that retain the negative charge). These optimised substrates can be incorporated efficiently as partial substitutions, either as a mixture with the natural substrate for very low density labelling or with one of the nucleotides fully replaced by the modified counterpart.A number of small non-fluorescent substitutions identified by Famulok and colleagues could even be introduced at ‘full’ substitution , and allowed direct amplification (by PCR) of the modified nucleic acid, resulting in a double-stranded polymer with significantly altered structural and physicochemical properties (fDNA) 2+-dependent DNAzyme with RNAse activity. Such modifications increase the chemical diversity in nucleic acids and have been further explored by Perrin and colleagues, who identified other possible nucleobase substitutions to generate DNAzymes, harbouring two  Although DNAzymes with RNAse activity had been previously reported Eaton and colleagues successfully introduced methyl pyridyl modifications to the C5 position of uridine through a rigid carboxamide linker that is well tolerated by natural RNA polymerases and reverse transcriptases Other chemical functionalities have been introduced to deoxyuridine through a similar carboxamide linker and deployed particularly in the selection of aptamers in situ hybridisation (FISH). The steric bulk of the large hydrophobic dyes limits their incorporation by polymerases to sparse incorporations. However, directed evolution through compartmentalised self-replication Polymerase engineering also allows more diverse modifications to be accessed, such as fluorescent dye-labelled nucleotides, with applications in next-generation sequencing, arrays, and fluorescent Extended efforts by the Benner Chemical modification of nucleobases does not alter the nucleic acid backbone and therefore generally does not greatly improve resistance to degradation by exo- and endo-nucleases, or the pH-dependent decomposition of the polymers. By contrast, modification of the nucleic acid backbone can dramatically alter its chemical and biological stability. However, until recently, efficient enzymatic synthesis of synthetic nucleic acid polymers (XNAs) with fully altered backbone chemistries had not been possible.kcat/Km = 3.7 × 106/M/min) at physiological conditions and was stable in human serum .Partial substitution, through the incomplete replacement of the natural nucleic acid backbone with synthetic alternatives, provides significant gains in stability and has been used to isolate aptamers and RNAzymes with increased resistance to nuclease degradation. Beigelman and colleagues substituted pyrimidine ribonucleotides for 2′-amino-2′-deoxyribonucleotides to select an RNAzyme with RNA nuclease activity Notably, pioneering work on the rational design of RNA polymerases by Padilla and Sousa Directed evolution and rational design of DNA polymerases has recently enabled our lab to synthesise and replicate eight different XNAs in which the canonical five-membered ribofuranose ring of DNA and RNA is replaced by various congeners, including hexitol nucleic acids (HNA), cyclohexenyl nucleic acids (CeNA), locked nucleic acids (LNA), threose nucleic acids (TNA), arabinonucleic acids (ANA), fluoroarabinonucleic acids (FANA), 2′-azido-2-deoxyribonucleic acids, and 2′-fluoro-2′-deoxyribonucleic acids Modifications of the phosphodiester backbone itself are also possible, but provide an even bigger challenge for polymerase engineering. Conservative replacement of one of the non-bridging α-oxygens with sulfur (phosphorothioates) or borano (boranophosphates) moieties has been shown to allow synthesis of the modified nucleic acid at full replacement Due to the programmable nature of interactions through Watson–Crick base pairing, nucleic acids are an attractive substrate for the construction of a wide variety of 2D and 3D nanostructures and devices.Broadly, there are three strategies currently available for the design and assembly of DNA nanostructures: rational-designed DNA oligonucleotides, DNA origami, and DNA bricks.Seeman and colleagues pioneered the rational design of oligonucleotides to assemble DNA nanostructures DNA origami consists of using short oligos (‘staples’) to guide the folding of a long (‘scaffold’) strand. It was originally developed by Rothemund Complex nanostructures such as gated transmembrane channels have been assembled by DNA origami, highlighting the potential of the method ® brick.Recently, Yin and colleagues have reported a third approach for the design of complex 3D DNA structures based on the assembly of short oligonucleotides (without a scaffolding strand) termed DNA bricks DNA nanostructure conformation and assembly can be controlled by the addition of extra DNA strands (DNA fuel) Correct folding can be a limiting factor in the assembly of large DNA nanostructures. Although simple polyhedra can achieve correct assembly yields as high as 90% Investigating the effect of temperature on the rate of folding of DNA origami, Dietz and colleagues report that folding is a non-equilibrium process that is also highly cooperative Church and colleagues used the equivalent of DNA falsework, a temporary framework that is used to support construction but that can be subsequently removed, to improve the yields of their DNA box in the desired ‘closed’ conformation Synthetic nucleic acids like PNA can be used for efficient removal of falsework Similarly, nucleic acid nanostructures are not limited to the well-defined assemblies described above but rather can form large 2D or 3D assemblies including nanoparticles and hydrogels with potential biological applications Nucleic acid nanoparticles were originally described by Mirkin and colleagues as gold nanoparticle cores densely coated with oligonucleotides  or spherical nucleic acids (SNAs) in vivo stabilities and fluorescence yields.The high density of oligonucleotides in SNAs also affects the thermodynamic properties of annealing to complementary nucleic acid sequences – much sharper transitions between single- and double-stranded nucleic acids are observed. Despite this change, the melting profile of SNAs still correlates with the underlying coating oligo and target. Synthetic nucleic acids, such as LNA, which are known to increase duplex stability, can be introduced on the coating oligos, changing the SNA melting temperature (while keeping the sharp transition) 6 copies of the siRNA hairpin per cell in vivo but in both cases, the reports highlight that large or at least structured nucleic acid molecules may be able to enter cells efficiently via lysosomal uptake pathways Hammond and colleagues demonstrated that RNA particles, made from long RNA transcripts harbouring multiple copies of hairpins generated by rolling circle transcription, could be used for cellular delivery of siRNAs. The long transcripts were reported to self-assemble into RNA particles that could be further condensed with polyamines creating a nucleic acid nanoparticle that could be efficiently uptaken and processed by cells in culture, delivering an estimated 10Nucleic acids have shown to be a remarkably versatile source of novel materials and nanodevices. Design and evolution combined with the sub-angstrom resolution offered by nucleic acid scaffolds may enable not only the assembly of intricate structures but also confer them with properties such as tight ligand binding, catalytic activity, and different conformational states .in vivo and that can be used in diagnostic applications capitalizing on fluorescence or catalytic properties. Given the limited chemical and biological stability of DNA and RNA, it may also be possible to use DNA and RNA nanostructures as formwork (moulds) for the synthesis/condensation and assembly of other polymer-based structures and materials.Chemical modification of nucleic acids, and in particular wholesale replacement of the natural framework with synthetic genetic polymers (XNAs) capable of evolution, has the potential to create novel structures and devices as well as greatly extend their functionalities – for instance, generating XNA devices that are stable Modifications that extend the chemical repertoire available to nucleic acids will also enable a wider range of properties to be accessed, depending on the chemical functionality introduced and on the density of the substitution. Ongoing work in our labs to expand the chemistry that is compatible with enzymatic synthesis and evolution will add to the ever growing palette of XNAs available for the construction of XNA nanostructures and devices enabling novel functions and improved performance in challenging environments and conditions.


The central representation of numerical cognition is commonly considered an abstract magnitude representation serving as one key precursor for higher mathematical thinking. However, recent research indicates that the representation might not be purely abstract. In fact, accumulating evidence suggests that numerical representations are rooted in and shaped by specific motor activities and sensory-bodily experiences and, therefore, are influenced by so-called embodied numerical representations. If we want to understand how numerical understanding develops, it is crucial to elucidate the basic cognitive tools with which we develop a sense of number. We argue that it is necessary to address this issue on both a behavioral and a neural level.Contrasting the view of functional magnetic resonance imaging (fMRI) being the generally preferable neuroimaging technique, we argue that particularly in embodied cognition, restrictions and benefits of different imaging methods should guide the chosen research question. In our opinion, near-infrared spectroscopy (NIRS) is optimally suited to investigate embodied cognition paradigms that explicitly involve motion. In the following, recent research will be outlined showing that numerical cognition is not purely abstract, but influenced by embodied representations. NIRS will then be introduced as a feasible technique for the investigation of embodied cognitions. Since research in this domain is largely restricted to the perception of embodied experiences, but fails to address motion itself, we will finally argue that NIRS offers a good opportunity to fill this research gap.Embodied cognition refers to the idea that, throughout our lifespan, we consistently associate specific motor activities and sensory-bodily experiences with more abstract concepts such as words or numbers  automatic  of associations of finger- as well as hand-related and numerical magnitude representations have been studied in perceptual studies. FMRI studies demonstrated that cortical areas related to number magnitude processing are in close proximity to areas activated when fingers/hands are used. Additionally, it has been shown that applying transcranial magnetic stimulation (TMS) to the left angular gyrus resulted in a disruption of finger schema and number processing . Following the idea that the coactivation of a corresponding embodied-spatial representation of number might promote the development of the numerical magnitude representation, training studies were designed aiming at enriched training conditions that use (full) body movements and are congruent with a left-to-right orientation of the mental number line. Indeed, first studies indicate that such embodied-spatial numerical trainings are more effective than non-embodied control trainings and even show specific transfer effects  with its high sampling rate allows for a precise investigation of temporal processes. Both are prone to motion artifacts and rely on a rather restrictive measurement setting—not a major problem for most paradigms, but an enormous limitation for some. Therefore, the investigation of processes inherently relying on motion or body postures remains a challenge. To address research questions that involve motoric and sensory (embodied) processes underlying seemingly abstract numerical cognition, we argue that NIRS is a good alternative.NIRS measures cortical oxygenation by emitting near-infrared light to the brain using optical properties of oxy- and deoxygenated hemoglobin, thus providing an optical blood-oxygen-level dependent (BOLD) signal  depending on the distance between optodes. Therefore, studies asking for a fine-grained topological resolution of a particular region (e.g., Harvey et al., Considering new evidence in research in embodied numerical cognition as well as technological developments, we are convinced that NIRS will add to a more elaborated picture of neurocognitive underpinnings of embodied cognition and to a broader understanding of the basis of numerical cognition as well.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


It is long known that immune response is energydemanding. It has become clear in recent years  that preIncreased energy consumption by immune cells requires a metabolic adaptation of the whole organism. During trauma or infection, the organism vitally depends on the immune system, which is therefore privileged in energy/nutrient allocation. According to Rainer Straub , insulinWe have recently demonstrated a selfish behavior of the immune system during defense of Drosophila larva against parasitoid wasp infection . The wasExtracellular adenosine can be produced in extracellular space from ATP, which for example leaks out from damaged tissues. Alternatively, when demand for ATP exceeds supply in a cell, the decreasing ATP level results in an increased level of AMP that can either activate AMPK and thus can suppress energy consuming processes within the cell or AMP can be converted to adenosine by cytosolic 5′-nucleotidase ; adenosiCan adenosine play a similar role in higher organisms including humans? Adenosine is produced, for example, by activated neutrophils and its systemic level is increased during sepsis. Adenosine generally suppresses energy-consuming processes; this can be observed both at the cellular level, e.g. inhibiting cell growth, and at the systemic level. The systemic suppression effects of adenosine are observed in torpor/hibernation and are important for anoxia-tolerant organisms. Adenosine is known to suppress neuronal firing and to induce sleep; caffeine is the most famous adenosine receptor antagonist. Increased plasma levels of adenosine were associated with chronic fatigue syndrome and adenosine was shown to mediate an exercise-induced fatigue . FatigueHow would this role of adenosine go together with its well-established anti-inflammatory role in the mammalian immune system ? The keyIt would be interesting to test if adenosine, produced during immune response, influences the metabolism of non-immune tissues, activity and wakefulness, regulating thus the energy allocation in higher organisms. How important would such metabolic regulation be for the effectivity of immune response? It might be difficult to study these complex roles of adenosine but purinergic signaling is an important target for new drugs, for example to treat inflammatory diseases , and thu


Reviews recommend controlling alcohol availability to limit alcohol-related harm. However, the translation of this evidence into policy processes has proved challenging in some jurisdictions.This paper presents a critical review of empirical spatial and temporal availability research to identify its features and limitations for informing alcohol availability policies. The UK is used as an example jurisdiction. It reviews 138 studies from a 2008 systematic review of empirical availability research and our update of this to January 2014. Data describing study characteristics  were extracted and descriptively analysed.Important limitations in current evidence were identified: (i) outlet-level temporal availability was only measured in three studies, and there has been little innovation in measurement of spatial availability; (ii) empirical analyses focus on acute harms with few studies of longer-term harms; (iii) outlets are typically classified at aggregated levels with little empirical analysis of variation within outlet categories; (iv) evidence comes from a narrow range of countries; and (v) availability away from home, online availability and interactions between availability, price and place are all relatively unexamined.Greater innovation in study and measure design and enhanced data quality are required. Greater engagement between researchers and policy actors when developing studies would facilitate this.Research and data innovations are needed to address a series of methodological gaps and limitations in the alcohol availability evidence base, advance this research area and enable findings to be translated effectively into policy processes.  Controlling the spatial and temporal availability of alcohol has been identified as a key approach for reducing alcohol-related harm The limited powers afforded to local authorities for controlling or managing alcohol availability in the UK mean it provides a useful example of the difficulties faced by practitioners in bringing evidence from availability research to bear at different stages in the policy process. These difficulties should be understood in the context of an evolving policy landscape. In the mid-20th century, the decline of temperance, the development of harm models focusing on individual problem drinkers and the increasing influence of deregulatory models of market governance led to moves away from a regulatory focus on outlet density The focus on individual drinkers and outlets meant translation of empirical evidence on the public health consequences of spatial and temporal availability was limited in these policy processes until the 1990s. Where public health concerns were present, licensing authorities in England and Wales could, in principle, rely on their own discretion in deciding whether an area had a ‘need’ for more alcohol outlets Previous reviews have examined the findings of the empirical evidence base et al.'s and are reported in full in Appendix S1 alongside search results information. In brief, we searched Ovid Medline, Psycinfo, CiNAHL, Web of Knowledge and Embase using search terms relating to both spatial and temporal availability, alcohol consumption and alcohol-related harm. Studies were included in the final sample if they were English language, empirical primary studies conducted in Organisation for Economic Co-operation and Development countries between 2009 and January 2014, used measures of spatial availability or temporal availability as exposure measures, and quantified the association between these exposures and one or more alcohol-related outcome. Studies which did not objectively measure availability (e.g. perceived availability) were excluded as were before and after evaluation studies which measured impacts on outcome measures of a policy without measuring impacts on availability.Two main datasets were used to assess the evidence base. The first was 59 studies included in a systematic review conducted in December 2008 of empirical spatial and temporal availability research, hereafter the Popova review For each study, data on research design and setting, availability measures, and outcome measures were extracted. These data were used to define exactly which availability and outcome measures were being studied and to review study designs and analyses to identify research gaps and future priorities.Of 138 studies reviewed, 32 from the Popova review did not directly or objectively measure availability. This includes evaluations of policy interventions where resultant changes in availability were not measured. The remaining 118 studies contained 136 measures of spatial availability and three of temporal availability . Individual exposures are likely to vary markedly across these areas, creating the potential for ecological biases For temporal availability, most studies evaluated policy changes affecting trading hours and provided no outlet-level measure. The only three outlet-level measures came from a single dataset identifying which Australian outlets had extended trading permits 29–31.On-trade and off-trade outlet availability may have different impacts as may the different types of outlets within that dichotomy (e.g. bars vs. restaurants). Although only 40 availability measures grouped all outlets into a single category, just 36 disaggregated on-trade outlet types , and only nine disaggregated off-trade outlet types (supermarkets vs. liquor stores or government vs. private stores).The outcome measures analysed for associations with availability in the empirical literature tend to focus on acute health and social outcomes and heavy alcohol consumption Table . The 138n = 35), the USA as a whole (n = 91) and, more recently, Australia (n = 20) , meaning, there is a lack of clarity as to whether observed relationships apply to all outlet types. Attributing negative effects to broad outlet categories overlooks the wide diversity of outlets those categories contain, including sleepy pubs, crowded modern bars, supermarkets and 24-h booze stores. These distinctions feature in policy processes with Scottish licensing boards being encouraged to take account of different outlet types when developing their overprovision statements and, in England and Wales, a number of local authorities having sought to tailor cumulative impact policies to tackle ‘vertical drinking outlets’ while encouraging the establishment of food-led or family-oriented outlets , social indicators  or clustering of problematic drinkers (e.g. in assortative drinking theories) which facilitate violence and other criminality via increased consumption or other mechanisms 38–40. Excepting the two more sophisticated measures above Four further related problems were identified: (i) only a small number of studies have used direct measures of alcohol availability when evaluating the potential effectiveness of specific licensing approaches, such as lockout policies or discrete shifts in licensing laws 45–47. Instead, policy evaluations tend to use before and after research designs to evaluate changes in outcome measures without examining the degree of outlet-level change 47–52. In combination with the empirical focus on outlet density, this leads to the valid conclusion that reducing general availability is effective, but specific recommendations for strategies to manage local availability profiles or achieve desirable patterns of availability which policy makers can seek to implement within their own policy structures are lacking. (ii) Existing measures artificially separate temporal and spatial availability. No study combined these into a single measure (e.g. 24-h outlet proximity or late license bar density). (iii) Similarly, whether exposure to both high outlet density and high outlet proximity confers additive or multiplicative risks has not been explored, and investigation of composite indices of availability is required. (iv) Current measures do not address concerns regarding the presence, as opposed to number or proximity, of individual outlets or outlet types, such as living near a ‘bad bar’ or 24-h store or having an outlet within walking distance. This reflects an assumption that the relationships between availability and outcomes are continuous and linear rather than discrete or curvilinear. Few studies explore this assumption Even acknowledging the linguistic limitations of our search, the relative lack of studies from outside the USA and Australia is problematic as other English-speaking nations have different outlet types and different norms, expectations, and values around them. For example, UK outlets are found in significant numbers wherever there are people. Almost all supermarkets and convenience stores sell alcohol and even small villages will typically have at least one pub which has traditionally been viewed as a hub of community life. Therefore, in important respects, the UK policy setting is different to the USA and Australia. UK policy makers may query the validity of empirical findings if they are explained by theory suggesting such commonplace outlets, even in large numbers, indicate social disorganisation. Some authors note that it is specific outlet types in specific areas, rather than outlets per se, which are problematic et al. Recent evidence suggests alcohol availability within an individual's residential area is not correlated with their actual exposure to alcohol outlets due to their additional exposure while outside the home et al., Reboussin et al., Chilenski et al. 58–60) and US ethnic groups , the impacts of availability on population subgroups of interest are rarely explored. Similarly, analysis of multiple consumption dimensions, such as frequency, average and heavy episodic consumption, which feature heavily in policy debate and drinking guidelines, is rarely a focus of study 64–66. For research to provide maximum utility to policy makers, demonstrating that interventions are well targeted and complement existing policy is crucial.Research designs appear poorly linked with the specifics of policy concerns, such as the need to avoid penalising the ‘responsible majority’, an argument deployed extensively by UK industry lobbyists when challenging legislation on both price and availability Little research to date has explored the relationships between availability, price and place 67–70. Increased price competition is a product of high availability contexts The role of the Internet in changing alcohol availability has received little attention. Online retailers deliver alcohol as part of weekly grocery shopping or convenience purchases, provide access to bulk or specialised product purchases, and supply or restock parties. In all instances, availability has increased beyond the detection of the spatial maps used in most analyses, and to date, it is unclear what the extent or focus of policy concern around internet sales should be. New data detailing online purchasing behaviours are emerging from the International Alcohol Control Study The overarching finding of this review is that although a large body of research exists on the impacts of spatial and temporal alcohol availability, this evidence base is somewhat generic and high level in terms of the research settings, the availability and outcome measures used, and the conclusions individual studies can offer. Although recommendations to control alcohol availability remain valid, specific guidance on the forms of availability which should be addressed, the effective controls which should be applied or the full range of intervention outcomes which may be expected is difficult to derive. This lack of specificity has concrete policy implications in countries such as the UK where, for example, legal appeals against licensing restrictions often hinge on the validity of evidence linking density to harm.et al. have noted similar studies often yield contradictory findings et al. et al. This review has several imitations. First, it excluded non-English language studies for practical reasons, and this may have excluded relevant literature from European countries in particular. Second, the primary focus was on studies measuring alcohol availability, and in the updated systematic review, this excluded literature evaluating policy interventions without directly measuring resultant changes in availability. Third, we have not sought to systematically analyse whether different availability measures are consistently associated with particular outcomes. As with other reviews to date, we have found such analyses are hindered by substantial heterogeneity in data quality, analytical techniques and outcome measures. On this topic, Livingston The UK alcohol licensing system has provided an example context in this review for discussing questions of translation of research into practice. The limited scope provided by this system for the strategic control of alcohol availability centres on the facility for English licensing authorities to develop cumulative impact policies and the requirement for Scottish licensing boards to provide statements on over-provision and consider public health within licensing decisions. In both countries, public health- or social order-oriented decisions have been challenged in the courts by highly specialist licensing lawyers leading to other authorities abandoning plans under threat of challenge Our recommendation for greater analytic innovation should not be interpreted as suggesting research has stood still. Availability analyses have developed to explore, for example, the relative effects of environmental and individual factors on outcomes Current evidence supports conclusions that controlling the spatial and temporal availability of alcohol is a key intervention for reducing alcohol consumption and related harms. However, this review has identified a series of methodological gaps and limitations in the existing evidence base. These hinder the translation of research into evidence-based policy recommendations. Research stakeholders should focus resources on resolving data needs and better integration of theory, empirical analysis and policy practice to facilitate a step change in availability research.


Tobacco use has reached epidemic levels around the World, resulting in a world-wide increase in tobacco-related deaths and disabilities. Hospitalization presents an opportunity for nurses to encourage inpatients to quit smoking. This qualitative descriptive study was aimed to explore nurse-counsellors’ perspectives of facilitators and barriers in the implementation of effective smoking cessation counselling services for inpatients. In-depth interviews were conducted with 16 nurses who were qualified smoking cessation counsellors and who were recruited from eleven health promotion hospitals that were smoke-free and located in the Greater Taipei City Area. Data were collected from May 2012 to October 2012, and then analysed using content analysis based on the grounded theory approach. From nurse-counsellors’ perspectives, an effective smoking cessation program should be patient-centred and provide a supportive environment. Another finding is that effective smoking cessation counselling involves encouraging patients to modify their lifestyles. Time constraints and inadequate resources are barriers that inhibit the effectiveness of smoking cessation counselling programs in acute-care hospitals. We suggest that hospitals should set up a smoking counselling follow-up program, including funds, facilities, and trained personnel to deliver counselling services by telephone, and build a network with community smoking cessation resources. Tobacco use has reached epidemic levels in many developing countries and steady use has continued in some developed nations ,2,3. ConThere is a worldwide appeal to improve nurses’ involvement in tobacco control, particularly in cessation interventions . CompareThe Taiwanese Health Promotion Administration (THPA) reported that there were approximately 4.8 million smokers in Taiwan, and that approximately 47% of them had considered quitting at least once. The success rate of quitting smoking, however, is less than 5% . QuittinAn analysis of the 2004–2007 Taiwan Adult Tobacco Surveys showed that 71% of doctors in Taiwan had failed to offer smoking cessation counselling to patients, a rate that was higher than those reported in the United Kingdom (59%) and the United States (39%) . BecauseThe THPA implemented the New Smoking Cessation Policy on the 1st of March 2012 to expand smoking cessation counselling services to both outpatient and inpatient settings. The new policy is based on the following three evidence-based premises: (i) non-physician providers  have an essential role in providing smoking cessation counselling; (ii) increasing the intensiveness of counselling services may improve the success rate of smoking cessation; and (iii) inpatient settings may facilitate intensive smoking cessation counselling. Hospitals that participate in the inpatient smoking cessation program send qualified employees, most of them nurses, to receive training to become smoking cessation counsellors. As a result of the expansion of smoking cessation counselling to inpatient settings and inclusion of nurses in the provision of cessation counselling services, the new policy has broadened the scope of effort to identify smoking patients when they are most receptive to tobacco cessation intervention as well as increased the range of patient-provider interface to allow patients be served by trained nurse-counsellors.Previous research in the education sector showed that the perceptions of school nurses had a significant influence on school administrators and parents in the promotion of student health education . However(i)From the nurse-counsellors’ viewpoint, what were the factors that facilitate the provision of smoking cessation counselling services to inpatients?(ii)From the nurse-counsellors’ viewpoint, what were barriers in the provision of smoking cessation counselling services to inpatients?In this study, we employed a qualitative study design and interviewed nurse-counsellors to elucidate their perspectives on smoking cessation counselling, as well as their perceptions on the facilitators and barriers of smoking cessation programs. Specifically, the following research questions were addressed:The findings of this study may assist health care providers implementing smoking cessation programs and provide a reference for the development of effective training programs for smoking cessation counsellors.The aim of the study was to explore the perspectives of nurse-counsellors regarding the facilitators and barriers to implementing effective smoking cessation counselling services for inpatients.This qualitative descriptive study employed a grounded theory approach. We conducted in-depth interviews to explore the perspectives of nurse-counsellors regarding the environment of hospitals in which inpatient smoking cessation programs were implemented as well as their experiences in delivering inpatient smoking cessation counselling services. Previous studies have asserted that qualitative research methodologies are effective for examining novel research topics because they can assist in soliciting information from service users or providers to develop and improve health interventions through in-depth probing with questions that are meaningful and context-specific to key informants ,23. It cThe participants in this study were nurses who had (i) provided cessation counselling services to inpatients, (ii) received at least one of three-levels of training workshop on smoking cessation, and (iii) received counselling certification from the THPA. Nurses who meet these three criteria are called nurse-counsellors and the smoking cessation counselling services they provide are eligible for reimbursement by THPA.Beginning in May 2012, we approached directors of departments that were responsible for the delivery of smoking cessation services at 25 smoke-free health promotion hospitals in the Greater Taipei City Area (including Taipei City and new Taipei City) in northern Taiwan and asked them to recommend nurse-counsellors. Seventeen directors agreed to our request and indicated that their hospital had one or two nurse counsellors that were eligible as study participants in accordance to our selection criteria. We contacted those nurse-counsellors to invite their participation, and 16 agreed to be interviewed. We arranged an interview at a time and a place convenient to those who agreed. By October 2012, we had interviewed all 16 nurse-counsellors at 11 health promotion hospitals and determined that the information we obtained had reached saturation. These 16 nurse-counsellors from 11 health promotion hospitals constituted the study sample.For the in-depth interviews, we developed semi-structured open-ended questions based on field observations and a review of extant literature. The questions were designed to investigate (i) facilitating factors that the nurses considered effective in helping patients to quit smoking, and (ii) barriers that nurse-counsellors experienced while delivering smoking cessation services. The interviews were conducted by two authors (CYC was a PhD candidate and YQJ had a master degree) with relevant experience in qualitative research methods and interviewing. Prior to collecting the data, one of the investigators (YCC) led a pilot study with the two interviewers (CYC & YQJ) to test the interview guide and questions. The results of the pilot test were discussed among the members of the research team and subsequently applied to improve the interview guide .Within three days of completing each interview, the recorded interviews were transcribed verbatim by one of the interviewers, and the transcripts were reviewed by the other one to eliminate errors. Information that was considered ambiguous was clarified with the participants. i.e., strategy, effectiveness, and barriers). Third, the categories were divided into subthemes and themes, which were independently compared and reconciled by three of the authors. Finally, the authors discussed the main themes that emerged from their analyses, and compared the categories to resolve discrepancies. The review and comparison process was iterative, involving the review of specific transcripts in their entirety.We conducted a content analysis using the principles of the grounded theory approach. Grounded theory is an inductive research approach; it involves the discovery of theory from ground up, through the analysis of in-depth interview data . The anaThroughout the data analysis, the authors worked collaboratively and iteratively to develop and revise the codes and categories. Following the process of reflection and discussion, a consensus was reached on the appropriate and meaningful approach to sorting and grouping the codes, as well as formulating the categories into subthemes and main themes.There are four issues of trustworthiness that demand attention in qualitative research: credibility, transferability, dependability, and conformability . To incrThe research protocol was approved by the Institutional Review Board at National Yang-Ming University in Taiwan. The IRB approval number is 2012-07-036 BCY. Prior to conducting the interviews, we informed the participants regarding the research purpose and procedures, as well as their rights. All of the participants signed an informed consent form, with an understanding that their participation was entirely voluntarily. We also had the participants’ permission to audio-record the interview. To assure anonymity, we used a unique numeric identifier to replace the name of each participant on the documents of study and the citations of results.Participant characteristics are reported in Hospitalization is a crucial moment or occasion that triggers patients’ motivation to quit smoking. The following facilitators emerged from the interviews with nurse-counsellors: (i) building work teams to create a supportive smoking cessation environment; (ii) shifting the focus to the modification of smokers’ lifestyles; (iii) selecting an appropriate time to initiate counselling; (iv) providing patient-centred counselling; and (v) referring patients to other resources when necessary.If all hospital staff—including professional health workers, paraprofessionals, and volunteers—who meet with the patients emphasize that smoking has caused their illness and [if the staff] inform them that quitting smoking would be beneficial for treating their diseases, the patients would have the strongest motivation to quit smoking.’ (Counsellor B)‘When a patient comes to the hospital reporting chest pain, a doctor could ask them if they [smoke]. If they confirm that they [smoke], the doctor should [inform] the patient of the correlation between chest pain and smoking…afterward, the pathology staff may ask these patients whether they [smoke], and then advise them to quit during the process of physical examination.’ (Counsellor A)‘When health professionals work cooperatively in emphasizing the benefits of quitting smoking to patients during patient interactions, they are more effective at promoting smoking cessation counselling and motivating patients to quit smoking. This assessment, exemplified by the following responses, was shared among all of the interviewed nurse-counsellors:For patients to quit smoking, they require a whole team of health professionals to support and assist them.’ (Counsellor N)‘Collaboration is the best strategy for all hospital health professionals, including physicians, nurses, medical equipment operators, pharmacists, and even health volunteers and priests because a positive and supportive smoking cessation environment helps inpatients quit [smoking].’ (Counsellor D)‘Moreover, the majority of the interviewed counsellors emphasized the importance of employing a team approach to creating a cessation-oriented environment in order to effectively help patients to quit smoking:[It is crucial] to contact smokers as quickly as possible when they are admitted [to] the hospital…frontline nurses and physicians should immediately provide advice if the patients report that they are smokers during the admission assessment of [newly] admitted patients…, which gives them the best opportunity to provide counselling services for smokers.’ (Counsellor A)‘If primary nurses inquire about the patients’ smoking history when they are admitted, then physicians should also tell them that [whether their condition] is related to smoking, offer advice on quitting, and refer [them] to [smoking] cessation counsellors. That would improve the patients’ intention to use cessation service.’ (Counsellor J)‘If we have good timing, then patients are more likely to be willing to quit.’ (Counsellor D)‘Usually, we contact [newly] admitted patients within 24 hours after their primary nurses have marked them as smokers... if we do not [attend to smokers] punctually, they will be discharged soon. Then, we [would miss a] good chance [to intervene].’ (Counsellor B)‘To improve the success rate of patients quitting smoking, the nurse-counsellors indicated that the timing for initiating counselling services was a crucial aspect of effective smoking cessation strategies:Smoking is not only a physiological dependency but is also a psychological dependency. [Moreover], the psychological dependency is the primary reason that smokers continue [to smoke]; even when they have [been provided] the necessary advice, health information, and motivation to [modify their behaviour], it is easy for them to relapse if they do not change their lifestyle... Smokers must adjust [their] behaviour and lifestyle to cope with the stress [associated with quitting]. Moreover, they require a therapist for psychological treatment.’ (Counsellor F)‘Healthcare providers should not only emphasize how crucial quitting smoking is for promoting patient’s health, but they should also shift their emphasis to other health-promoting behaviours such as exercising, maintaining a healthy diet, and managing stress.’ (Counsellor D)‘To assist smokers in quitting, it is critical that healthcare providers promote a healthful lifestyle that includes regular exercise, a healthy balanced diet, and stress management. Several of the nurse-counsellors reported the following observations:It is useless if the counsellors educate smokers on quitting based only on their professional knowledge and do not assess smokers’ specific needs and difficulties.’ (Counsellor P)‘[Quitting smoking], I think, is an individual experience. The situation varies among patients…There are different stages for smoking cessation. Healthcare providers need to provide different patients with different things; you need to help them identify better ways [to quit] by providing patients with the appropriate information for their stage [of quitting].’ (Counsellor A)‘Providing patients with various educational materials that [are] relevant to the patient’s stage of quitting…Some patients are still hesitant; they need to [be more determined]…Those who have decided to quit should go directly to the process [commence counselling immediately]; that is, the patient needs information on how to quit smoking and the type of problems they [will] face.’ (Counsellor D)‘Although the time constraint appeared to be universal, the interviewed nurse-counsellors advocated that the intervention approach—specifically, providing patients with information and education on quitting smoking—must be individualized and patient-centred to address each patient’s specific needs.When I encountered something I did not know, I did not answer the patients; rather, I provided a hotline for quitting smoking.’(Counsellor M)‘When there are some problems we do not know the answers to, we try to find an answer. I often read a research paper or ask professionals.’(Counsellor O)‘Professional counsellors must learn constantly and accumulate experience to become more confident and capable of identifying solutions and resources [that can] assist their patients. If they are [neither confident nor capable], then they have to make a referral.’ (Counsellor K)‘Consistent with the patient-centred approach, the interviewed nurse-counsellors recognized that patients may have special needs that could be better addressed elsewhere or with alternative resources. Thus, referrals to other appropriate smoking cessation resources are necessary when a counsellor feels unqualified to address a specific question or the personnel, knowledge, or resources in the hospital are limited:The nurse-counsellors were confronted with substantial organizational-level barriers, including a lack of full support from the hospital administration, a lack of commitment from other professionals, as well as a shortage of time and personnel.The cost of providing this type of counselling service for smoking cessation, which is allocated by the administrators, is very low.’ (Counsellor H)‘If an administrator always mentions the smoking cessation program during the hospital meeting and [informs the] physicians to advise patients to quit, then the program can go on providing service to patients well and the program will succeed.’ (Counsellor O)‘Just a little more support [for the smoking cessation program] from the managers would be sufficient.’ (Counsellor E)‘Although it is recognized that the promotion of a supportive smoking cessation environment in hospitals can improve the successful delivery of smoking cessation counselling services, the nurse-counsellors indicated that there was a lack of complete support from hospital administration:Because we are short of staff, the nurses are already [overloaded] with tasks. It is impossible to provide patients with all of their health education needs. [The trained nurse-counsellors] really do not have time to persuade patients not to smoke.’ (Counsellor H)‘Most of the counsellors in hospitals have several duties. We not only need to follow various cases and [manage] new cases, but we must also provide regular care to other inpatients... Usually, we feel unwilling to do this because we are not full-time counsellors.’ (Counsellor O)‘Because we lack a sufficient number of nursing staff, we often work for many [consecutive] days. We sometimes need to work night shifts, and we occasionally work for more than 12 hours... It is really difficult to allocate time to do this. In fact, it is a difficult job.’ (Counsellor L)‘If [counsellors were employed] full-time, [then they would] do a much better job. We can follow the cases after we discharge the patients from the hospital to provide health education and guidance on how to prevent them from relapsing…’ (Counsellor N)‘The nurse-counsellors reported that their time and effort were stretched thin.The advice provided by doctors is very useful for helping smokers to quit. However, not every doctor has the incentive to advise smokers… [Similarly], primary care nurses typically do not think they are responsible for advising patients on smoking cessation and do not consider advising patients to be a part of their duty.’ (Counsellor F)‘Most physicians are not interested in providing smoking cessation service—even brief advise… they won’t receive any [funding] from National Health Insurance [for offering these services], so they lack the financial incentive.’ (Counsellor C)‘Consistent with the aforementioned subthemes, other hospital health professionals, such as doctors, social workers, nutritionists, and pharmacists, were unaware of how crucial and effective their advice was for smokers during hospitalization. Consequently, the following nurse-counsellors’ reports indicated that there was a general lack of clear commitment from these health professionals:This is the first study in Taiwan to understand from nurse-counsellors’ perspective facilitators and barriers for smoking cessation counselling services in inpatient settings. A total of sixteen trained nurse-counsellors from 11 acute hospitals participated in this study. They proposed several facilitators to effectively promote and implement smoking cessation counselling programs: collaborate with other health professionals in hospitals to create a supportive cessation-oriented environment, visit smoking inpatients and provide them counselling services as quickly as they are admitted, modify smokers’ behaviours to promote a healthy lifestyle, apply patient-centred techniques in smoking cessation counselling services, and refer hospitalized smokers to other counselling resources when they are discharged from hospitals. From nurse-counsellors’ perspectives, barriers to implement smoking cessation services include the lack of full support from hospital administration, insufficient time and personnel support, and lack of commitment from other health professionals in hospitals.Although hospitalization provides a window of opportunity for smoking cessation ,17, deliet al. [et al. [From nurse-counsellors’ perspective, a comprehensive counselling program must include lifestyle modifications , rather than providing only health education and pharmacotherapy for physiological dependence. This idea is consistent with other studies. May et al. , Kotz et [et al. , and Cha [et al.  have con [et al. ,32. Hosp [et al. . However [et al. ,17. Thiset al. [et al.’s study, the barriers identified by nurses involved in providing smoking cessation services included a lack of competence, referral options, and resources, as well as time constraints. Two other studies showed that nurses felt competent and were effective at assisting smokers to quit when they were able to commit full time to providing smoking cessation services [The interviewed nurse counsellors all reported feeling frustrated as a result of several barriers, all of which were directly or indirectly related to the lack of support and resources for delivering smoking cessation services in hospitals. Consequently, the nurse-counsellors reported having insufficient time and inadequate competence to provide these services, which supported the findings reported by Sarna et al. . In Sarnservices ,33. A meservices . Having The interviewed nurse-counsellors reported concerns regarding the commitment of other healthcare providers to providing inpatient smoking cessation services. Physicians, for example, did not consider offering advice to patients on quitting smoking as a part of their duty, partially because they were doubtful of the effect of their advice and their patients’ receptivity. Another reason could be that the assessment of their patients’ smoking status had not been incorporated into routine care processes . A studyBased on comments of the interviewed nurse-counsellors, future administrative support and resources must be invested to: (i) educate healthcare providers, (ii) implement a hospital-wide smoking cessation policy that incorporates the assessment of smokers into routine care practices, (iii) develop health education materials for patients, (iv) allow sufficient time for healthcare professionals to provide smoking cessation counselling to their patients, and (v) establish a referral system for patients to receive smoking cessation services. Furthermore, follow-up counselling services are needed to reduce relapse of smoking patients after their discharge from the hospital. A Cochrane review on studies of hospitalized smokers suggests that interventions need to last at least one month post-discharge to have a statistically detectable effect . An alteSeveral features of this study design need to be discussed. First, the study sample is small. Considering the exploratory nature of the study, the small sample size may be justifiable. Second, the interviewed nurse-counsellors were from different hospitals, which may influence nurse-counsellors’ perceptions of smoking cessation programs. It is important to note, however, all the programs served similar patient groups and were located in hospitals that shared the same mission of health promotion. To the extent that organizational attributes of hospitals affected the implementation and effectiveness of smoking cessation counselling services, a high degree of consistency in the perceptions and recommendations of nurse-counsellors interviewed suggests that findings of the study are robust and have good generality to other hospitals in Taiwan. Finally, the nurse-counsellors interviewed in the study were referred by their supervisor in the hospital. They were likely to be highly motivated and actively involved in the inpatient smoking cessation counselling program. Our findings may be limited by not including nurse-counsellors who were not fully committed to the counseling program and who may have provided useful information that highlight additional barriers that prevent their active involvement in the smoking cessation counselling program.Hospitalization provides a unique opportunity for nurses to deliver smoking cessation counselling services. There is a broad consensus among nurses-counsellors who provide smoking cessation counselling that more emphasis should be placed on lifestyle changes than on pharmacotherapy. Nurse-counsellors believe that a supportive environment, teamwork, and provision of patient-centred care are key elements of successful smoking cessation programs for inpatients. Barriers to smoking cessation services exist primarily at the organizational level; they include the lack of full support from hospital administration level, insufficient time and personnel support, and lack of commitment from other health professionals in hospitals.The study has several practice implications. First, nurse-counsellors must assess the needs of smokers throughout the cessation process by using more advanced technology like electronic medical records. Second, to increase the involvement of other healthcare professionals, they need to be informed on the smoking cessation program and its effectiveness. Third, nurse-counsellor training programs should include modules on health education and behavioural modification to improve their competence in helping smokers to quit. Finally, increasing the reimbursement for smoking cessation services might encourage hospital administrators to allocate additional resources to smoking cessation programs. For hospital administrators, they may consider the provision of follow-up counselling services to discharged patients. Establishment of a network with community smoking cessation resources is another strategy to continue the smoking cessation services post-discharge.A report issued by the Health Behaviour Export Panel of the American Academy of Nursing (AAN) advocated efforts to increase nurses’ visibility and influence in tobacco control services . The inpAnother important finding of the study is recognition among nurse counsellors that inpatient smoking cessation services are but the beginning of a patient’s long journey of ridding a hardwired habit. The occasion of hospitalization opens a window of opportunity. The opening is slim, however, and it is likely to become smaller as cost-cutting efforts in many countries are reducing the length of hospital stays. Continuing interventions that extend beyond the hospital stay are needed and they would require the investment of hospitals in follow-up services and in building collaboration with outpatient clinical settings and community-based social service agencies and advocacy groups.Based on the study findings, we urge that hospitals, community organizations, nursing organizations, and governmental funding agencies work together to ensure that nurse-counsellors be involved in tobacco control network. Smoking cessation training program should provide nurse-counsellors the skills to mobilize community resources. We also recommend future research to examine the various designs of inpatient smoking cessation counselling. An example of such research is the application of electric medical records in smoking cessation programs, which may enhance the identification and recruitment of smoking inpatients and improve the coordination of nurse-counsellors with other health professionals.