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Original Research: Tobacco Cessation and Prevention |

Long-term Effects of a Program to Increase Physical Activity in SmokersEffects of a Physical Activity Program in Smokers FREE TO VIEW

Leandro C. Mantoani, MSc; Karina C. Furlanetto, MSc; Demétria Kovelis, MSc; Mahara Proença, MSc; Juliana Zabatiero, MSc; Gianna Bisca, MSc; Andréa Morita, PT; Fabio Pitta, PhD
Author and Funding Information

From the Laboratório de Pesquisa em Fisioterapia Pulmonar, Departamento de Fisioterapia, Universidade Estadual de Londrina, Londrina, Paraná, Brazil.

CORRESPONDENCE TO: Fabio Pitta, PhD, Departamento de Fisioterapia – CCS, Hospital Universitário de Londrina, Rua Robert Koch, 60 – Vila Operária, 86038-350 – Londrina, Paraná, Brazil; e-mail: fabiopitta@uol.com.br


Part of this article has been presented in abstract form (Mantoani LC, Furlanetto KC, Kovelis D, et al. Am J Respir Crit Care Med. 2013:A3813).

FUNDING/SUPPORT: This work was supported by Fundação Araucária/Paraná, Ministry of Health (Ministério da Saúde) – SUS (Brazil), the National Council for Scientific and Technological Development (CNPq/Brazil), and CAPES/Brazil [MSc Grants to Mss Furlanetto and Zabatiero].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(6):1627-1632. doi:10.1378/chest.14-0459
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BACKGROUND:  Programs aimed at increasing physical activity in daily life (PADL) have generated growing interest to prevent the deleterious effects of physical inactivity. Recent literature has shown that a short-term protocol using pedometers increased PADL in smokers with normal lung function. However, the long-term effects of such a protocol were not yet studied. The objective of this study was to evaluate the results of 1-year follow-up after a program aimed at increasing PADL in smokers with normal lung function.

METHODS:  Twenty-four smokers were followed (15 men; mean [interquartile range (IQR)], 51 [41-57] years of age; BMI, 26 [22-29] kg/m2; 20 [20-30] cigarettes/d). Subjects were assessed at baseline, immediately after completion of the program, and 1 year later for PADL, lung function, 6-min walking distance (6MWD), smoking habits, quality of life, anxiety, and depression. The 5-month program used pedometers and informative booklets as interventions.

RESULTS:  The gains achieved after the program were maintained in the long term: steps/d (postprogram vs 1-year follow-up, mean [IQR]: 10,572 [9,804-12,237] vs 10,438 [9,151-12,862]); 6MWD (625 [530-694] m, 88 [81-97] % predicted vs 609 [539-694] m, 89 [81-96] % predicted), anxiety (34 [26-41] points vs 35 [36-47] points) and depression (6 [2-9] points vs 5 [2-11] points) (P > .05 for all). One year after the program, 20% of the subjects had quit smoking.

CONCLUSIONS:  In smokers with normal lung function, improvements in daily physical activity, exercise capacity, anxiety, and depression obtained through a 5-month program aimed at increasing physical activity are sustained 1 year after completion of the program. Furthermore, such a program can contribute to smoking cessation in this population.

Figures in this Article

Lifestyle, including physical inactivity in daily life and smoking, has a marked impact on morbidity and mortality rates. Smoking is currently considered a chronic disease caused by nicotine dependence and regarded as a major avoidable cause of death in the world.1 Furthermore, the concept that regular physical activity may prevent or delay the development of various chronic diseases has solid scientific support.2,3 As an example, a prospective study published by Garcia-Aymerich et al4 showed that a moderate-to-high level of regular physical activity in smokers is associated with a reduction in the long-term decline in lung function and consequently also with lower risk of developing COPD. Therefore, in addition to interventions aimed at smoking cessation, initiatives to promote regular physical activity in smokers are welcome to prevent the combined deleterious effects of physical inactivity and smoking.

Scientific evidence5 revealed that subjects who perform at least 8,000 to 10,000 steps/d generally achieve 30 min/d of moderate physical activity, which is the minimum level of daily physical activity recommended by the American College of Sports Medicine.3 The number of steps/d performed by an individual can be quantified by using a pedometer, which is a small, light, portable, and low-cost type of motion sensor. The use of pedometers has been highlighted in the literature as one of the strategies to monitor and improve physical activity in daily life (PADL) in several populations.2,616

Our research group has studied the benefits of using pedometers to promote physical activity in smokers with normal spirometry.10,15 Both in the short term (1 month)10 and in the medium term (5 months),15 physically inactive smokers improve their PADL when submitted to a protocol based on the use of pedometers. Moreover, the more inactive the subject was, the larger the increment in his/her daily physical activity. Although these previous results clearly support the use of pedometers to increase PADL in this population, one important question is still unanswered: Are the gains obtained through such a program maintained in the long term, without any formal incentive provided to the subject? Thus, the present study is a follow-up of the studies of Kovelis et al10 and Zabatiero et al15 and aimed at evaluating the long-term effects (1 year) after completion of a program that used pedometers to promote the increase of daily physical activity in smokers with normal lung function.

Recruitment

Participants were recruited through announcements in the media, buses, and health centers. Forty-nine smokers were included because they were interested in taking part in a program to promote improvement of physical activity in daily life. The program took place at the Laboratory of Research in Respiratory Physiotherapy from the State University of Londrina, Brazil. Inclusion and exclusion criteria for this follow-up study were the same as in the article by Kovelis et al,10 with the only difference being that only the participants who completed all the phases of the physical activity program were analyzed in the present article (see Study Design).

The program had as its primary aim to increase PADL and not smoking cessation; therefore, no professional counseling or pharmacological support for smoking cessation was offered to the participants, since this could introduce bias to the specific effects of the physical activity program itself. The study was approved by the institution’s Ethics Committee in Research (number 007/07) and data were collected from June 2008 to September 2012. All subjects signed an informed consent before taking part in the study.

Study Design and Assessment Methods

The design of this longitudinal prospective study is described in Figure 1.15 The randomization and allocation process, as well as a detailed explanation about the study design, assessment methods, and the physical activity program can be found in the study by Zabatiero et al.15 Smokers who fulfilled the inclusion criteria were submitted to an initial assessment (A1) that included lung function test (spirometry), functional exercise capacity test, smoking habits, nicotine dependence, health-related quality of life, levels of anxiety and depression, and quantification of PADL with a pedometer (steps/d).

Figure Jump LinkFigure 1 –  Study design. A1 = assessment moment 1; A2 = assessment moment 2; A3 = assessment moment 3; A4 = assessment moment 4; A5 = assessment moment 5; G1 = pedometer + booklet group (GP + B); G2 = booklet + pedometer group (GB + P). For a more detailed description of the protocol, see Reference 15.Grahic Jump Location

After A1, subjects were randomized into one of two groups: group booklet + pedometer (GB + P), who initially received a booklet with information about the benefits of walking regularly and were stimulated to walk as much as possible in daily life during 1 month, although they did not receive pedometers and had no written control of their physical activity; and group pedometer + booklet (GP + B), who initially received a pedometer and were instructed and stimulated to perform at least 10,000 steps/d during 1 month. This group was also provided with a logbook where they could record the number of steps in each day during this period of 1 month. After this initial 1-month period, a reassessment (A2) was performed with the same procedures as A1, and the interventions were then crossed over for another 1-month period. Then, another reassessment period (A3) similar to the previous ones was performed, and immediately after that both groups wore pedometers every day during 3 months, aiming to reach the 10,000 steps/d goal. After this 3-month intervention, a final reassessment (A4) was performed with the same procedures as the previous assessment periods.

One year after completion of the physical activity enhancement program (A4), participants were invited to perform a new assessment moment (A5), which comprised the same tests performed in other assessment moments of the study (A1, A2, A3, and A4). In this period of 1 year after completion of the program, none of the subjects received any type of formal incentive to encourage or promote physical activity in daily life (pedometer, informative booklet, or any other), but they were verbally instructed to maintain as physically active as possible. Each assessment moment (A1-A5) lasted 1 week: 6 days of activity monitoring with the pedometer and 1 day to perform all the other tests. To achieve the aims of this study without redundancy with the two previous articles,10,15 the focus of the present article was specifically directed to assessment moments A1, A4, and A5. A detailed description of the methodology involved in the assessment of PADL, lung function (spirometry), exercise capacity (6-min walking test), anxiety, depression, quality of life, and smoking habits can be found in the two related previous articles published by the present group of researchers.10,15

Statistical Analysis

The statistical software used in the analysis was SPSS 19.0 (IBM) and GraphPad Prism 5 (GraphPad Software, Inc). The normality in data distribution was evaluated by the Shapiro-Wilk test. Because the majority of the variables presented nonnormal distribution, nonparametric tests were used, and results were presented as median (interquartile range [IQR, 25%-75%]). The multiple imputation method was used specifically on missing data at 1 year after completion of the physical activity program (A5) to impute the values missed completely at random according to Little’s Missing Completely at Random test. There were no differences in the results obtained with (n = 49) and without (n = 24) the multiple imputation method, and, therefore, we have chosen to present only the results of subjects with all assessments (ie, without imputed values) (n = 24).

To analyze changes among the different assessment moments (A1, A4, and A5), the Friedman test (with Dunn post hoc test) was applied. The χ2 test was used to analyze categorical data. Correlations were studied by the Spearman coefficient correlation. Statistical significance was set at P < .05 for all analysis.

Forty-nine subjects who fulfilled the inclusion criteria took part in the study. Twenty-four subjects completed the program (A4) and returned to perform the 1-year follow-up assessment (A5).

Characteristics of the studied subjects in the relevant assessment moments (A1, A4, and A5) are described in Tables 1 and 2. Table 1 shows that the sample was composed of subjects from both sexes with normal lung function (spirometry) and characterized as normal weight to slightly overweight in terms of body composition. From baseline to 1-year follow-up there was a statistically significant reduction in the number of cigarettes smoked per day (20 [20-30] vs 16 [3-20]) and an increase in maximal voluntary ventilation (89 [82-98] % predicted vs 100 [85-110] % predicted; P < .02 for both). The other lung function parameters and body composition variables did not change throughout the study. Table 2 describes some of the main findings of the study. At completion of the study (A4), there was a significant increase in PADL (steps/d) and 6-min walking distance (6MWD) and reductions in nicotine dependence, anxiety, and depression. Furthermore, there was long-term maintenance of the gains obtained after completion of the program in the following variables: number of steps/d (postprogram [A4] vs 1-year follow-up [A5]: 10,572 [9,804-12,237] steps/d vs 10,438 [9,151-12,862] steps/d) (Fig 2), 6MWD (625 [530-694] m vs 609 [539-694] m and 88 [81-97] % predicted vs 89 [81-96] % predicted), levels of anxiety (34 [26-41] points vs 35 [36-47] points), depression (6 [2-9] points vs 5 [2-11] points), and nicotine dependence (5 [2-6] points vs 4 [3-5] points) (P > .05 for all). Furthermore, 76% of the subjects who started the program increased their level of PADL.

Table Graphic Jump Location
TABLE 1 ]  Characteristics of the Studied Subjects

Data are expressed as median (25%-75% interquartile range). P value refers to the differences evaluated by the Friedman test. A1 is baseline, A4 is immediately after completion of the 5-mo program aimed at increasing daily physical activity, and A5 is 1 y after completion of the program. A1 = assessment moment 1; A4 = assessment moment 4; A5 = assessment moment 5; MVV = maximum voluntary ventilation.

a 

P < .05 vs A1 using Dunn posttest.

Table Graphic Jump Location
TABLE 2 ]  Comparison of Physical Activity in Daily Life, Exercise Capacity, Degree of Nicotine Dependence, Anxiety, Depression, and Quality of Life in the Different Assessment Moments

Data are expressed as median (25%-75% interquartile range). P value refers to the differences evaluated by the Friedman test. The domains functional capacity, physical activity, pain, general health status, vitality, social aspects, emotional aspects, and mental health refer to the Short Form 36 questionnaire. 6MWD = 6-min walking distance; Fagerström = Fagerström Tolerance Questionnaire for nicotine dependence. See Table 1 legend for expansion of other abbreviations.

a 

P < .05 vs A1 using Dunn posttest.

b 

P < .05 vs A4 in Dunn posttest.

Figure Jump LinkFigure 2 –  Comparison of physical activity in daily life (number of steps/day) among subjects (n = 24) in different time points. *P < .05 vs A1. See Figure 1 legend for expansion of abbreviations.Grahic Jump Location

Concerning quality of life, Table 2 shows that there were no significant differences in the domains of functional capacity, pain, vitality, emotional aspects, and mental health throughout the study. There was significant improvement in general health status after completion of the protocol (74 [67-86] points vs 87 [77-97] points); however, after 1 year of follow-up, this quality-of-life domain no longer presented difference in comparison with baseline (72 [68-92] points). One year after completion of the protocol, improvement in social aspects was observed in comparison with baseline (81 [66-100] points vs 100 [75-100] points), whereas worsening of the physical aspects domain was observed in comparison with A4 (100 [100-100] points vs 100 [75-100] points, respectively) (P < .05 for all).

There was no significant correlation of Δ (A5-A4) steps/d either with variables assessed at baseline or with the changes (Δ A5-A4) observed in any variable. Moreover, 1 year after completion of the program, 20% of the smokers had quit smoking for > 3 months.

This study showed that smokers with normal spirometry assessed 1 year after completion of a program aimed at encouraging increase in daily physical activity, despite receiving no formal incentive during this 1-year period, are able to maintain the gains in daily physical activity, exercise capacity, nicotine dependence, and levels of anxiety and depression obtained with the program. Furthermore, the increase in PADL level may contribute to smoking cessation in a portion of this population. Hence, the present work was not restricted to studying the immediate benefits of enhancing physical activity in smokers, but it also brings an unprecedented proposal of a program to encourage physical activity in smokers, which resulted in positive and long-lasting effects, in addition to presenting an apparently very good cost-effectiveness ratio. This model of intervention might be extremely useful for the development of public policies aimed at counteracting the deleterious combination of smoking and physical inactivity.

Beyond the immediate gains of the program previously published by our group,10,15 this study adds an important finding for clinical research involving physical activity in smokers: the maintenance of the gains for at least 1 year after completion of the intervention with pedometers, even without any formal incentive to maintain physical activity. To our knowledge this is the first study in smokers with promising results indicating not only a successful program in the short and medium term in increasing physical activity but also a change in lifestyle over the long term in this population. A hypothesis for this change and maintenance in lifestyle (especially regarding PADL improvement) (Fig 2) may be the simplicity and familiarity of the intervention proposed in the program, since a relatively simple activity of daily life (ie, walking) was used to increase the level of daily physical activity. Possibly, these individuals kept these benefits in the long term by acquiring a healthier daily living habit in the short and medium term.

The impact of the program in the improvement and maintenance of quality-of-life gains in the long term showed much less consistent results. Although Klavestrand et al17 showed an association between higher levels of physical activity and better scores in quality of life in healthy adults, most domains of quality of life did not improve throughout the present study. Additionally, the physical aspects of self-reported quality of life worsened throughout the study, despite the obvious improvement and further maintenance of PADL quantified by pedometers. This is possibly because of the different nature of these assessments (objective quantification of PADL and subjective assessment of quality of life).18

The present results also showed a reduction in the daily consumption of cigarettes 20 [20-30] vs 16 [3-20]) and a smoking cessation rate of 20% 1 year after completion of the program. The percentage of smoking cessation success found in this study is somewhat higher than achieved 1 year after programs that used transdermal patches (14%), nicotine chewing gum (18%), and nicotine inhaler (17%).19 In studies involving nonpharmacologic interventions, such as simple medical advice, individual counseling, and group therapy, the percentages of smoking cessation success 1 year after completion of the program ranges from 3.7% to 9.1% compared with rates of 2.05% to 6.02% of the control groups (no warning or simple warning).20 Our findings, therefore, showed a much higher success rate in comparison with those other nonpharmacologic interventions,20 which reinforces the idea that a program only using pedometers to increase daily physical activity is effective in changing and maintaining healthier habits in smokers and may be helpful in the fight against tobacco. In addition, the combination of pharmacotherapy and interventions aimed at increasing daily physical activity clearly deserves to be studied in depth.

Studies aiming to evaluate economic outcomes, such as the cost-effectiveness ratio of certain interventions, are useful for implementing public policies. In a study published by a Korean group,21 the cost of an intervention for smoking cessation performed in a government-subsidized clinic (staff salaries, medication, educational material, advertisement, and so forth) was US$212.00 per individual who used the service to achieve a smoking cessation rate of 28.1% in a year. Our study, in turn, despite not having assessed economic outcomes, possibly presented a very good cost-effectiveness ratio by using a simple and relatively inexpensive tool (approximately US$73.00) and was able to help a considerable portion of the smokers involved (20%) to quit smoking.

The high drop-out rate at A5 (1 year after completion of the program) might be considered one of the limitations of the present study. However, this type of loss is common in this population, even in programs targeting specifically smoking cessation,22,23 which was not our case. Furthermore, some care should be taken when interpreting our findings because of our small sample size at 1-year follow-up (n = 24). Even though we have also tried a valid and reliable statistical method for managing missing values (multiple imputation), it has shown no differences between results with (n = 49) or without (n = 24) the imputation, which indicates reliable statistical results. Because results were identical, we have chosen to present only the “real” results (ie, those without imputed values; n = 24). Moreover, the study sample was composed of subjects who were not taking part in smoking-cessation programs and responded to public announcements inviting them for a program of physical activity enhancement, therefore, demonstrating the will to increase their daily physical activity level, which may partially limit the generalization of our results. Finally, it is not possible to determine, based on this study, what would be the added benefit of a smoking cessation program to this protocol. Future research in this area is promising and welcome.

In conclusion, in smokers with normal spirometry, the gains obtained with a 5-month program aimed at encouraging increase in physical activity by using pedometers are maintained 1 year after completion of the program, even without any formal incentive to maintain regular physical activity. Moreover, such a program can contribute to smoking cessation in this population.

Author contributions: L. C. M. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. F. P. assumes full responsibility for the integrity of the submission as a whole, from inception to published article. L. C. M. and F. P. contributed to the conception, design, subject recruitment, data collection, analysis and interpretation of data, and writing of the manuscript; K. C. F., D. K., M. P., J. Z., G. B., and A. M. contributed to the conception, design, subject recruitment and data collection; and L. C. M., K. C. F., D. K., M. P., J. Z., G. B., A. M., and F. P. contributed to the revision of the article.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Other contributions: We thank our colleagues from the Laboratory of Research in Respiratory Physiotherapy for their contributions, especially the undergraduate students.

6MWD

6-min walking distance

A1

assessment moment 1

A2

assessment moment 2

A3

assessment moment 3

A4

assessment moment 4

A5

assessment moment 5

PADL

physical activity in daily life

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2011: Warning About the Dangers of Tobacco. Geneva, Switzerland: World Health Organization; 2011.
 
Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007;298(19):2296-2304. [CrossRef] [PubMed]
 
Garber CE, Blissmer B, Deschenes MR, et al; American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359. [CrossRef] [PubMed]
 
Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Antó JM. Regular physical activity modifies smoking-related lung function decline and reduces risk of chronic obstructive pulmonary disease: a population-based cohort study. Am J Respir Crit Care Med. 2007;175(5):458-463. [CrossRef] [PubMed]
 
Tudor-Locke C, Leonardi C, Johnson WD, Katzmarzyk PT, Church TS. Accelerometer steps/day translation of moderate-to-vigorous activity. Prev Med. 2011;53(1-2):31-33. [CrossRef] [PubMed]
 
Araiza P, Hewes H, Gashetewa C, Vella CA, Burge MR. Efficacy of a pedometer-based physical activity program on parameters of diabetes control in type 2 diabetes mellitus. Metabolism. 2006;55(10):1382-1387. [CrossRef] [PubMed]
 
Chan CB, Ryan DA, Tudor-Locke C. Health benefits of a pedometer-based physical activity intervention in sedentary workers. Prev Med. 2004;39(6):1215-1222. [CrossRef] [PubMed]
 
Gardner PJ, Campagna PD. Pedometers as measurement tools and motivational devices: new insights for researchers and practitioners. Health Promot Pract. 2011;12(1):55-62. [CrossRef] [PubMed]
 
Houle J, Doyon O, Vadeboncoeur N, Turbide G, Diaz A, Poirier P. Innovative program to increase physical activity following an acute coronary syndrome: randomized controlled trial. Patient Educ Couns. 2011;85(3):e237-e244. [CrossRef] [PubMed]
 
Kovelis D, Zabatiero J, Furlanetto KC, Mantoani LC, Proença M, Pitta F. Short-term effects of using pedometers to increase daily physical activity in smokers: a randomized trial. Respir Care. 2012;57(7):1089-1097. [CrossRef] [PubMed]
 
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Zabatiero J, Kovelis D, Furlanetto KC, Mantoani LC, Proença M, Pitta F. Comparison of two strategies using pedometers to counteract physical inactivity in smokers. Nicotine Tob Res. 2014;16(5):562-568. [CrossRef] [PubMed]
 
Furlanetto KC, Mantoani LC, Bisca G, et al. Reduction of physical activity in daily life and its determinants in smokers without airflow obstruction. Respirology. 2014;19(3):369-375. [CrossRef] [PubMed]
 
Klavestrand J, Vingård E. The relationship between physical activity and health-related quality of life: a systematic review of current evidence [published retraction appears inScand J Med Sci Sports. 2010 Apr;20(2):366]. Scand J Med Sci Sports. 2009;19(3):300-312. [CrossRef] [PubMed]
 
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Figures

Figure Jump LinkFigure 1 –  Study design. A1 = assessment moment 1; A2 = assessment moment 2; A3 = assessment moment 3; A4 = assessment moment 4; A5 = assessment moment 5; G1 = pedometer + booklet group (GP + B); G2 = booklet + pedometer group (GB + P). For a more detailed description of the protocol, see Reference 15.Grahic Jump Location
Figure Jump LinkFigure 2 –  Comparison of physical activity in daily life (number of steps/day) among subjects (n = 24) in different time points. *P < .05 vs A1. See Figure 1 legend for expansion of abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Characteristics of the Studied Subjects

Data are expressed as median (25%-75% interquartile range). P value refers to the differences evaluated by the Friedman test. A1 is baseline, A4 is immediately after completion of the 5-mo program aimed at increasing daily physical activity, and A5 is 1 y after completion of the program. A1 = assessment moment 1; A4 = assessment moment 4; A5 = assessment moment 5; MVV = maximum voluntary ventilation.

a 

P < .05 vs A1 using Dunn posttest.

Table Graphic Jump Location
TABLE 2 ]  Comparison of Physical Activity in Daily Life, Exercise Capacity, Degree of Nicotine Dependence, Anxiety, Depression, and Quality of Life in the Different Assessment Moments

Data are expressed as median (25%-75% interquartile range). P value refers to the differences evaluated by the Friedman test. The domains functional capacity, physical activity, pain, general health status, vitality, social aspects, emotional aspects, and mental health refer to the Short Form 36 questionnaire. 6MWD = 6-min walking distance; Fagerström = Fagerström Tolerance Questionnaire for nicotine dependence. See Table 1 legend for expansion of other abbreviations.

a 

P < .05 vs A1 using Dunn posttest.

b 

P < .05 vs A4 in Dunn posttest.

References

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2011: Warning About the Dangers of Tobacco. Geneva, Switzerland: World Health Organization; 2011.
 
Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007;298(19):2296-2304. [CrossRef] [PubMed]
 
Garber CE, Blissmer B, Deschenes MR, et al; American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359. [CrossRef] [PubMed]
 
Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Antó JM. Regular physical activity modifies smoking-related lung function decline and reduces risk of chronic obstructive pulmonary disease: a population-based cohort study. Am J Respir Crit Care Med. 2007;175(5):458-463. [CrossRef] [PubMed]
 
Tudor-Locke C, Leonardi C, Johnson WD, Katzmarzyk PT, Church TS. Accelerometer steps/day translation of moderate-to-vigorous activity. Prev Med. 2011;53(1-2):31-33. [CrossRef] [PubMed]
 
Araiza P, Hewes H, Gashetewa C, Vella CA, Burge MR. Efficacy of a pedometer-based physical activity program on parameters of diabetes control in type 2 diabetes mellitus. Metabolism. 2006;55(10):1382-1387. [CrossRef] [PubMed]
 
Chan CB, Ryan DA, Tudor-Locke C. Health benefits of a pedometer-based physical activity intervention in sedentary workers. Prev Med. 2004;39(6):1215-1222. [CrossRef] [PubMed]
 
Gardner PJ, Campagna PD. Pedometers as measurement tools and motivational devices: new insights for researchers and practitioners. Health Promot Pract. 2011;12(1):55-62. [CrossRef] [PubMed]
 
Houle J, Doyon O, Vadeboncoeur N, Turbide G, Diaz A, Poirier P. Innovative program to increase physical activity following an acute coronary syndrome: randomized controlled trial. Patient Educ Couns. 2011;85(3):e237-e244. [CrossRef] [PubMed]
 
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