Health Education Research Advance Access originally published online on December 20, 2006
Health Education Research 2008 23(1):1-9; doi:10.1093/her/cyl157
The challenge of embracing a smoke-free lifestyle: a neglected area in smoking cessation programs
1 Cancer Control Research Institute
2 The Victorian Smoking and Health Program (Quit Victoria), The Cancer Council Victoria, 1 Rathdowne St, Carlton, Victoria 3053, Australia
3 Program Evaluation Unit, School of Population Health, University of Melbourne, Parkville, Victoria 3010, Australia
* Correspondence to: C. J. Segan. E-mail: csegan{at}unimelb.edu.au
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Abstract |
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 Top Abstract IntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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Relapse prevention theory and practice has focussed on teaching coping skills to deal with withdrawal and temptations to relapse with the result that treatments appear to be effective in reducing relapse over the short term, but not over the longer term. Once cravings subside ex-smokers face a further task of adjusting to a smoke-free lifestyle that involves learning to think and act like a non-smoker. To highlight this task, we operationalized a new conceptual framework that describes three tasks of quitting (the 3Ts): (i) making a quit attempt; (ii) learning to effectively deal with cravings and withdrawal; and (iii) adapting to a smoke-free lifestyle. This was introduced to the Quitline service in Victoria, Australia, in preparation for a randomized controlled trial aimed at testing whether a program of four to six extra callbacks could help ex-smokers with the third task and as a result reduce rates of relapse compared with Quitline's standard callback program. This paper describes the conceptual framework (focussing on the third task) and initial reactions to it from both Quitline advisors and callers. The conceptual framework is now integrated in the service and appears to have changed the way Quitline operates and the apparent expectations of its clients.
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Introduction |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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Tobacco smoking is recognized as a chronic relapsing condition, with relapse being the most common outcome of any given quit attempt. While relapse is most common in the days after quitting [1], it can happen for years afterwards [2]. Current smoking cessation treatments, both cognitive-behavioural and pharmacological, appear to be effective in reducing rates of relapse in the early days after cessation, but there is little evidence that they affect longer term relapse [3, 4]. Improving the capacity of therapies to reduce smoking relapse while they are being provided and developing strategies that will continue to work after the termination of therapy are significant challenges that are common to smoking cessation programs as well as programs targeting other addictive behaviours.
We have taken up this challenge within the context of research into and delivery of a Quitline callback service established in 1992 in the state of Victoria, Australia (population 4.9 million and 19% smoking rate [5]). Between 2001 and 2005 there were 
23 500 calls to the service per year. The vast majority of calls is prompted by mass media campaigns (television, radio and print) designed to attract calls from across the state. Health professionals, e.g. general practitioners, also promote the service and are encouraged to use fax-referral forms that prompt a call to their patient from a Quit advisor.
Quitline callers are offered free self-help materials and access to a trained advisor (there are 25 of them) who can respond to the caller's immediate needs and help direct them to the most appropriate evidence-based assistance, e.g. Quitline callback counselling, Quit group courses and Quit web-based programs. Nicotine-dependent smokers are encouraged to use effective smoking cessation pharmacotherapy [6] along with the behavioural assistance and are directed to their pharmacist or doctor as appropriate. Typically between one-third and one-half of callers requested advice beyond provision of self-help materials. Routine data collection by Quit advisors from these callers indicates that 57% were women and that 6% were under age 20, 73% were 20–49 and 21% were 50+. In all, 63% were planning to quit, 7% thinking about it and 30% recent ex-smokers. Quality control procedures include regular follow-ups of callers to the service [7–9] as well as monitoring of counsellors by shift supervisors and quarterly professional development sessions for counsellors.
Between 2001 and 2005 5000 people per year used the Quitline callback service. This service offers up to two pre-quitting and four post-quitting callbacks. Pre-quitting calls aim to enhance client motivation and confidence and, once a decision to quit is made, help formulate and carry out a quitting plan. Post-quitting calls focus on teaching coping skills to deal with withdrawal and everyday temptations to relapse. Calls are scheduled in consultation with the client but with recommendation for more frequent calls close to cessation, particularly the first week after quitting when relapse rates peak. This gives a pattern similar to the relapse-sensitive schedule of Zhu and Pierce [10].
A randomized controlled trial we conducted of the callback service in the late 1990s found that it was effective in reducing relapse in the short term, but had no effect on relapse beyond 3 months [7]. At the time of the trial, most relapse prevention advice was provided in response to problems identified by the caller. Callers typically felt they had no further need for help after 2–3 weeks of being successfully quit. It was at this point that callbacks typically ceased, with callers being congratulated and encouraged to call in should difficulties arise. However, the finding of high rates of relapse suggested that staying quit over the longer term requires additional strategies.
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Conceptualizing two major tasks of staying quit |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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At the conceptual level, we believe that it is useful to distinguish two sets of tasks that ex-smokers must successfully perform if they are to become a stable non-smoker. First, learning to effectively cope with common high-risk situations (the focus of relapse prevention in most programs) and second, learning the skills associated with being a fully functional non-smoker. These two tasks correspond with the two forms of relapse prevention of Marlatt and Gordon [11], i.e. specific cognitive and behavioural coping strategies to manage specific high-risk situations and lifestyle interventions designed to reduce or eliminate underlying causes of temptations.
To date, most work on relapse prevention has been based on the cognitive-behavioural Abstinence Violation Effect model of Marlatt and Gordon [11] which focusses on the first task of managing temptations. Marlatt and Gordon acknowledged the lack of attention to lifestyle change and noted that evidence regarding its effectiveness in preventing relapse was sparse, a sentiment reiterated 15 years later in a review by Ockene et al. [12] We believe it is time for renewed focus on the second task of adjusting to a smoke-free lifestyle, i.e. helping ex-smokers to psychologically position themselves in ways that reduce the occurrence of temptations to smoke in the first place.
It is useful to examine the two tasks of staying quit within the context of stage theories of behaviour change. The popular Transtheoretical Model [13] postulates a homogenous Action stage that spans the first 6 months of abstinence; however, it is evident from our and others' observations [14] that the challenges of surviving the first few days are very different to those of staying quit 3–6 months later. As a result, we hypothesize, in a manner similar to Shiffman [14], alternative post-cessation stages which correspond to the two main tasks of staying quit.
The first stage, Implementation, begins the first days after quitting, which are typically marked by acute withdrawal symptoms, such as constant cravings. Most ex-smokers are in survival mode at this stage and need high levels of motivation and of anticipatory and immediate coping activity because risk of relapse is high. Typically, after the first week or so, daily cravings tend to become more episodic and identified with particular situations.
The next stage, Integration, involves adjusting to a smoke-free lifestyle. A drop in frequency of cravings from daily to less than daily may be the best way to mark this boundary and our observations indicate that this often occurs around a month after quitting. As a result of cravings becoming occasional, vigilance and coping activity decline and risk of sudden relapse increases, even though people clearly have the capacity to cope with cravings and generally report feeling better than when they smoked. During this phase, replacements for the functions served by smoking need to be found, in order to reduce the appeal of returning to smoking, and any unfounded residual beliefs about the value of smoking need to be challenged.
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Evidence for the two major tasks of staying quit |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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There is a small, but growing body of evidence for distinguishing between the two major tasks or stages (Implementation versus Integration) of staying quit, namely findings of non-linearities in rates and predictors of relapse in the months after quitting. In stage theories, discontinuity in prediction is recognized as the defining characteristic of a stage boundary [15].
Borland [16] found that rates of relapse following an initial slip up initially fell after the first day of cessation, but subsequently rose again around a month after cessation. Related to this, Piasecki and colleagues [17] found evidence that for some quitters the frequency and intensity of temptations to smoke actually become higher 3 weeks after cessation, typically after some modest decline. More recently, we found differences in measures that predict relapse at around the same time. A drop in frequency of cravings from daily to non-daily among Quitline clients was associated with self-efficacy and related variables reversing their predictive value for quitting success [18]. High self-efficacy predicted continued abstinence among ex-smokers with daily cravings, but surprisingly predicted relapse among ex-smokers with non-daily cravings. This finding suggested that ex-smokers might become overconfident once cravings drop in frequency, leaving them prone to relapse, perhaps because they believe that the task of staying quit is over. Alternatively, the upsurge in and changes in predictors of relapse might be due to the occurrence of post-decisional regret [19]. This could occur if the ex-smoker came to believe that there were permanent losses associated with quitting. Research demonstrates that stronger residual beliefs about the benefits of smoking predict relapse among ex-smokers [20, 21]. In another study we found that frequency of use of behavioural coping strategies changed predictive value according to whether a person had been quit for less than versus more than 1 month [22]. More frequent coping predicted relapse among those quit for less than a month, perhaps because it indicates difficulties with staying quit, while levels of coping were unrelated to relapse after 1 month, perhaps due to cravings becoming occasional. Clearly, there are significant changes occurring at 1 month after cessation.
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Translating ideas into practice: informing smokers of the three tasks of quitting |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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These research findings, in particular the suggestion that overconfidence may be leading to relapse among ex-smokers who succeed until strong urges to smoke decline, complemented by the experiences of some senior Quitline counsellors, who believe that the integration of quitting experiences into a non-smoking identity is fundamental to quitting success, suggested that it was important to communicate to smokers the longer term tasks of quitting without undermining the need for crisis management strategies in the short term. To this end, a new conceptual framework was postulated that describes the three main tasks smokers face when quitting (see Table I). The first task is to stop smoking (a task we do not consider in detail here) and the second and third are the two tasks of staying quit. As identification of the third task is the most novel aspect of three tasks of quitting (the 3Ts) approach, we now elaborate on it.
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The challenge of embracing a smoke-free lifestyle
Figure 1 illustrates the conceptual framework of what is involved in the third task of embracing a smoke-free lifestyle. The aim is to help ex-smokers move as far as possible towards the point where they think and feel like a non-smoker, i.e. someone who sees no use for cigarettes. If ex-smokers find they are enjoying life more and coping better than when they were smoking and cannot think of any important situation where they would be better off reaching for a cigarette, it is unlikely that they will relapse. To achieve this, ex-smokers need to break their psychological as well as physiological dependence on cigarettes. This is a challenge as smoking is often perceived as a valuable tool that fulfilled important emotional, social and temporal roles. For example, smokers report that cigarettes help them to relax, socialize, concentrate, control their weight and moods, cope when things are not going well, etc. [23, 24].
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Once recent quitters no longer get frequent cravings to smoke, it is common for them to perceive that they have successfully quit, but that in doing so they may have lost some things they value. They seem to assume that these current experiences of being a new non-smoker are typical of what they will continue to experience, i.e. rather than seeing a new set of challenges before them (the process of adapting to being a non-smoker), they often assume a stable outcome (that it will always be like this) and so they do not necessarily recognize the need to find replacements for smoking.
Figure 1 shows that embracing a smoke-free lifestyle involves both cognitive and behavioural tasks: learning to think as well as act like a non-smoker. The core cognitive component involves evaluation of beliefs about the value of smoking and of testing or challenging these beliefs. Now that staying quit is no longer a daily focus, ex-smokers have the opportunity to appraise life without cigarettes. Can they can relax, socialize, etc., as well as when they used to smoke? If yes, it is easy to challenge residual beliefs that smoking is needed. In areas where losses are identified, behavioural strategies need to be found to enable these needs to be met in healthier ways. This approach is consistent with the behavioural economics framework [25] that emphasizes that the reward value of a reinforcer is not an intrinsic property, but varies depending on the availability of alternative reinforcers. Once viable replacements are found, these new behaviours need to be adopted as lifestyle changes, i.e. they need to become habitual, so that the person does them without needing to think about it.
The other behavioural mechanism involves ex-smokers hastening the process of extinction of the addictive habit by preparing for and successfully facing old ‘smoking situations’. The situational nature of addiction means that cravings to smoke will occur in all situations people used to smoke in until they have re-experienced them several times without smoking. This explains why some ex-smokers experience occasional strong cravings years after stopping. Preparing for and confronting smoking situations, including those judiciously avoided in the early days of a quit attempt, reduces the risk of ex-smokers unexpectedly finding themselves tempted to smoke. Those using cessation pharmacotherapies also need to prove to themselves that they can get through situations without this assistance.
Together, implementation of these strategies should speed up adaptation to a smoke-free lifestyle and reduce the potential for enduring regret or perceived sacrifice as a result of quitting. Consistent with principles of cognitive-behavioural theory, the strategies aim to alter the position of smoking in the dynamic interplay between behaviour, cognition and the environment [26]. For a stable transition to a new behaviour, the new set of behaviours must become habitual, the old habits need to be extinguished—lose their tendency to be triggered by thoughts or cues in the environment—and the person needs to come to value the new set of behaviours and see no important areas of his/her life where he/she has lost out, or could lose out, if circumstances change. For example, ex-smokers may remain stopped and deal with stress using alternatives until a very stressful event, which is likely to trigger urges to smoke, and if the person believes smoking works better than their newer coping strategies, they are likely to relapse. Relapse in these cases is triggered both by the context triggering an urge to smoke, i.e. a habit of smoking when stressed is re-ignited (something that the person cannot control at the time), and by a belief that the cigarette might help (something they can potentially control if they have previously challenged this belief). On the other hand, if the person no longer believes in the benefit of smoking and understands the genesis of the urge (that it is normal to still get cravings in situations where they used to smoke and that resisting the cravings will change this), they are far more likely to resist, thus furthering the extinction of their habit as well as remaining smoke free.
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Introducing the 3Ts to the Quitline service |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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The 3T framework was introduced to Quitline counsellors at a routine professional development session as part of preparations for a randomized trial to test whether extra callbacks could assist ex-smokers with the third task and as a result reduce rates of longer term relapse. We anticipated two major benefits of counsellors routinely describing the 3Ts to callers and incorporating it into their counselling. First was that it would provide smokers with more realistic expectations of the quitting process (i.e. that quitting is not over once cravings diminish) and thus address the problem of overconfidence leading to relapse. Second was that once the trial commenced, it would increase the likelihood of callers accepting extra callbacks at a time when, because cravings are only occasional, staying quit is not perceived as a major challenge.
Counsellors responded positively to the 3Ts framework at the session and were enthusiastic about trying it out with callers. Over the following month the project manager (C.J.S.) sought qualitative feedback on implementation of the 3Ts. All counsellors were encouraged to contact her directly with feedback. In addition, in order to gauge views from as many counsellors as possible, the eight Quitline shift supervisors were provided with five open-ended questions about implementation of the 3Ts and led small group discussions with other counsellors on their shifts. In all, 19 of the 25 counsellors participated in such a discussion. Summary responses of supervisors (either written or verbal) were recorded and collated along with the individual feedback. Responses were then analyzed thematically. Each of the quotations below came from a different counsellor.
It was quickly apparent that both counsellors and callers received considerable value from the 3Ts framework. Counsellors commented that it was a useful tool for concisely and concretely mapping out to smokers what the quitting process involves, ‘It gives a snap-shot understanding and helps the quitter to take control of their own quitting journey as they immediately see where they're up to, as well as the journey ahead, the light at the end of the tunnel’. Another commented, ‘I always congratulate recent quitters on already finishing the first task of making a quit attempt—it really gives them a boost’. Many responses indicated that explanation of the third task reinforced to counsellors, as well as to callers, that there was more to quitting than learning to cope with cravings: ‘It's also about the caller internalizing the behaviour change, integrating their quitting experiences into their sense of self’. Use of the 3Ts also meant that the issues of adapting to a smoke-free lifestyle were now routinely and overtly addressed, ‘Before, these were background issues, but now, using the 3Ts, they're raised upfront and we do more to anticipate and circumvent problems’.
Some counsellors pointed out that the 3Ts were particularly valuable for callers who voiced concerns about relapse down the track, or who presented with a history of relapse after staying quit for some time: ‘For these callers, it's all about Task 3, I point out to them that they can already do Tasks 1 & 2’. In this way, the 3Ts framework helped to alert counsellors and callers to situations where it was appropriate to focus more on the third task, even if the caller had not yet reached that stage within their current quit attempt.
Use of the 3Ts framework also changed the nature of the final callback of the standard service, in that the upcoming task of adapting to life as a non-smoker was now routinely anticipated and discussed. Counsellors had previously tended to focus on congratulating callers and had varied in the extent to which they provided advice about longer term relapse prevention. Where advice had been provided, it had been done without the conceptual framework to make it seem important, and so advice tended to be fragmented and brief, consisting mostly of asking callers to think hypothetically about how they might cope. We think it likely that this lack of systematic acknowledgement of longer term quitting issues by counsellors and ex-smokers alike contributed to our finding that many recent quitters became overconfident as strong cravings declined, and that this contributed to subsequent relapse. Introducing the 3Ts framework thus appears to have resulted in a number of positive changes to Quitline operations as well as to the expectations of its clients.
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Can an extended callback service to help ex-smokers with the third task of adopting a smoke-free lifestyle reduce relapse? |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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Most cessation services, including Victoria's Quitline callback service, have contact with ex-smokers up to a month after quitting. Any efforts programs put into encouraging lifestyle change are either designed to be enacted beyond the period of contact or are introduced as something to do between dealing with temptations. It is possible that more progress would be made if the issue of lifestyle change were addressed more centrally and it may be more effective later in the quit attempt, i.e. once daily cravings have subsided, so that ex-smokers can relate the advice to their current experiences. We are currently conducting what we believe to be the first randomized controlled trial to test this hypothesis. The control condition is Quitline's standard callback service which offers up to four post-quitting callbacks over a period of about a month that focus on helping ex-smokers to cope with daily cravings and withdrawal. The intervention condition builds on the standard callback service by offering a further four to six extra Integration callbacks designed to help ex-smokers through the subsequent task of adapting to life as a non-smoker. An overview of the extended Integration callback program is provided in Table II and full details of the program are available upon request. The results of the trial are not yet available.
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Our initial plan was that the control condition would be the ‘original’ standard callback service, in which counsellors did not use the 3Ts framework to describe the process of quitting and hence did not systematically raise the challenges of adopting a smoke-free lifestyle. In this way, only participants in the intervention condition would be exposed to the 3Ts framework as well as being offered the extra calls to assist them with the third task. However, it became clear from counsellors' rapid uptake of the 3Ts framework that it would not be possible to stop them from introducing some form of this conceptual model with clients randomized to the standard callback service (control condition). Hence, we agreed that the 3Ts framework could be raised with all participants. The control condition was thus defined as helping ex-smokers through to the end of the second task of dealing with daily cravings and withdrawal and then signposting for them the third task of adopting a smoke-free lifestyle and encouraging them to work on these issues alone now that the callbacks were concluding.
Given the responses of counsellors and callers to the 3Ts framework, we believe its introduction is likely to have improved the relapse prevention capacity of the standard callback service (control condition). In this way the intervention tested in the trial was weakened as it now consisted purely of the extra Integration calls designed to help ex-smokers adjust to a smoke-free lifestyle, whereas we had originally intended that it consist of both the extra calls plus the 3Ts conceptual framework.
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Implementation of the extended Integration program of extra callbacks |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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Feedback from counsellors (obtained systematically at quarterly professional development sessions as well as incidentally) was collected throughout the 2-year implementation of the extended program of extra callbacks. Implementation was initially demanding on counsellors as they adjusted to the proactive role that arises from working with ex-smokers with less than daily cravings, became familiar with program content and process, and integrated this with their own counselling styles. Following program implementation, their feedback was overwhelmingly positive. They appreciated the opportunity to explore issues in greater depth and at a later stage of the quitting process. Caller response to the program was also positive. Of the 352 eligible callers, 74% took up the program and received four extra callbacks on average. This demonstrates that many ex-smokers who have sought assistance are willing to accept further intervention after cravings subside.
A number of insights into the quitting process were gained from program delivery. Counsellors reported that many ex-smokers viewed quitting as a real benefit, not only in terms of their long-term prospects but also more immediately in their day-to-day lives. For example, many mentioned newfound confidence, and some reported significantly reduced stress levels as a result of dealing with issues directly rather than avoiding them by smoking.
In tracking ex-smokers beyond 1 month, it also became apparent that some experience a post-quitting lull. This appears to manifest in multiple ways, from feeling a bit out of sorts for a week or so, to strong feelings of unexplained sadness. In extreme cases, quitting had many features of bereavement, with cigarettes typically viewed as the loss of a best friend or inability to express key aspects of self, e.g. rebellion. Challenging such deep-felt beliefs is not easy. Our impression was that while cognitive reframing exercises could temporarily change people's perspectives, they did not result in fundamental changes. Quitting success in these cases seemed dependent on the person committing to a rational decision to quit.
The pervasiveness of ‘just one’ thoughts was also apparent. Many aspired to smoking occasionally or being a ‘one a day’ smoker although they differed sharply in their expectations of whether this was possible. At this point, the utility of our attempts to resolve these barriers to staying quit is unclear.
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Conclusion |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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To date, most relapse prevention programs have focussed primarily on helping ex-smokers deal with temptations rather than also actively addressing the challenges ex-smokers face once cravings subside. Clarifying that there is a subsequent task of adjusting to a smoke-free lifestyle has proven valuable for both Quitline counsellors (in their explanations of what quitting involves and what the service can offer) and callers (who can now attribute past longer term relapses to not mastering the task of adjusting to life as a non-smoker). Implementation of extra callbacks to facilitate adaptation to a smoke-free lifestyle was well received by both counsellors and callers. These calls have shed new light on what is involved in becoming a non-smoker, but at this point we need to wait for the results of our trial to see whether the extra calls have been successful in reducing rates of longer term relapse. The 3Ts conceptualization is now central to the routine delivery of Quitline's standard callback service.
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Conflicts of interest |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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All authors have been involved in the development, implementation and evaluation of the extended Quitline counselling program based on the ideas described in this article.
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Acknowledgements |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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We are most grateful to all Quitline program staff, in particular Anton Provan, Sunil Bhar, Elham Foroughi, Pat Kee, Linda Steel and Lisa Allwood. We also thank David Dunt for helpful comments on an earlier draft of this article. The development of these ideas and implementation of the extended callback program was supported by Australia's National Health and Medical Research Council Project Grant 180707 and by The Victorian Smoking and Health Program (Quit Victoria). The Cancer Council Victoria's Human Research Ethics Committee approved the project (Project No HREC 0008).
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References |
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TopAbstractIntroductionConceptualizing two major tasks...Evidence for the two...Translating ideas into practice:...Introducing the 3Ts to...Can an extended callback...Implementation of the extended...ConclusionConflicts of interestAcknowledgementsReferences |
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Received on April 6, 2006; accepted on October 5, 2006
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