Promoting cessation resources through cigarette package warning labels: a longitudinal survey with adult smokers in Canada, Australia and Mexico

INTRODUCTION

Health warning labels (HWLs) on tobacco packaging can be used to provide smoking cessation information, but the impact of this information is not well understood.

METHODS

Online consumer panels of adult smokers from Canada, Australia and Mexico were surveyed in September 2012, January 2013 and May 2013; replenishment was used to maintain sample sizes of 1000 participants in each country at each wave. Country-stratified logistic Generalised Estimating Equation (GEE) models were estimated to assess correlates of citing HWLs as a source of information on quitlines and cessation websites. GEE models also regressed having called the quitline, and having visited a cessation website, on awareness of these resources because of HWLs.

RESULTS

At baseline, citing HWLs as a source of information about quitlines was highest in Canada, followed by Australia and Mexico (33%, 19% and 16%, respectively). Significant increases over time were only evident in Australia and Mexico. In all countries, citing HWLs as a source of quitline information was significantly associated with self-report of having called a quitline. At baseline, citing HWLs as a source of information about cessation websites was higher in Canada than in Australia (14% and 6%, respectively; Mexico was excluded because HWLs do not include website information), but no significant changes over time were found for either country. Citing HWLs as a source of information about cessation websites was significantly associated with having visited a website in both Canada and Australia.

CONCLUSIONS

HWLs are an important source of cessation information.

Smokers' reactions to the new larger health warning labels on plain cigarette packs in Australia: findings from the ITC Australia project

OBJECTIVES

This study examined whether larger sized Australian cigarette health warning labels (HWLs) with plain packaging (PP) were associated with increased desirable reactions towards the HWLs postimplementation.

METHODS

Data were from the International Tobacco Control (ITC) longitudinal cohort survey assessing Australian smokers one wave prior to the policy change in 2011 (n=1104) and another wave after the policy change in 2013 (n=1093). We assessed initial attentional orientation (AO) to or away from warnings, plus other reactions, including cognitive reactions towards the HWLs and quit intentions.

RESULTS

As expected, AO towards the HWLs and reported frequency of noticing warnings increased significantly after the policy change, but not more reading. Smokers also thought more about the harms of smoking and avoided the HWLs more after the policy change, but frequency of forgoing cigarettes did not change. The subgroup that switched from initially focusing away to focusing on the HWLs following the policy change noticed and read the HWLs more, and also thought more about the harmful effects of smoking, whereas the subgroup (5.4%) that changed to focusing away from the HWLs showed opposite effects. We tested the mediational model of Yong et al and confirmed it for predicting quit intentions, with larger effects post-policy.

CONCLUSIONS

Increasing the size of HWLs and introducing them on PP in Australia appears to have led to an overall increase in desired levels and strength of some reactions, but evidence of reactance was among a small minority.

Impact of a brief telephone referral on quitline use, quit attempts and abstinence

Quitline use can prompt quit attempts and promote abstinence among smokers, but rates of use are low and outcomes of brief quitline referrals unclear. In this study, a brief intervention was delivered to smokers who expressed motivation to quit in the next 30 days (N = 221) to encourage use of their state quitline. Correlates of quitline use were examined, and quitline callers versus non-callers were compared on the following outcomes at 2-month follow-up: cessation medication use, quit attempts and abstinence. Of the 221 smokers given a quitline referral, 34% called the quitline. Baseline motivation alone distinguished quitline callers from non-callers. Quitline use was positively associated with use of cessation medication, an association that remained robust even after adjusting for baseline motivation to quit. A trend was observed in which callers were marginally more likely than non-callers to report both a 24-h quit attempt and 7-day point prevalence abstinence. Relative to non-callers, callers also endorsed greater confidence to quit and increased self-efficacy to resist smoking temptations at follow-up. This study demonstrates a minimal intervention can promote acceptance of quitlines and favorable cessation outcomes among smokers motivated to quit.

Use of stop-smoking medications in the United States before and after the introduction of varenicline

AIMS

To evaluate trends in use of stop-smoking medications (SSMs) before and after varenicline (Chantix™) was introduced to the market-place in the United States, and to determine whether varenicline reached segments of the population unlikely to use other SSMs.

DESIGN

Cohort survey.

SETTING

United States.

PARTICIPANTS

A nationally representative sample of adult smokers in the United States interviewed as part of the International Tobacco Control Four Country Survey between 2004 and 2011. Primary analyses used cross-sectional data from 1737 smokers who attempted to quit (∼450 per wave).

MEASUREMENTS

Reporting an attempt to quit smoking; use of each of the following types of SSMs for the purpose of quitting smoking: nicotine gum, nicotine patch, other nicotine replacement therapy, bupropion and varenicline.

FINDINGS

There was a significant increase in the rate of use of any SSM among quit attempters across the study period [odds ratio (OR) = 1.15, 95% confidence interval (CI) = 1.10-1.21 per year]. This increase was largest after varenicline was introduced (OR = 1.16, 95% CI = 1.07-1.26 per year); however, there was a decline in nicotine patch use during this time (OR = 0.87, 95% CI = 0.76-0.99 per year). Varenicline users were generally similar to users of other SSMs but differed from those who did not use any SSMs, in that they tended to be older (OR = 5.46, P = 0.024), to be white (OR = 2.33, P = 0.002), to have high incomes (OR = 1.85, P = 0.005), to have high nicotine dependence prior to quitting (OR = 2.40, P = 0.001) and to have used medication in the past (OR = 3.29, P < 0.001).

CONCLUSIONS

The introduction of varenicline in the United States coincided with a net increase in attempts to quit smoking and, among these, a net increase in use of stop-smoking medications. The demographic profile of varenicline users is similar to the profile of those who use other stop-smoking medications and different from the profile of those who attempt to quit without any medication.

The U.S. National Tips From Former Smokers Antismoking Campaign: Promoting Awareness of Smoking-Related Risks, Cessation Resources, and Cessation Behaviors

OBJECTIVE

Evaluate the second flight of the U.S. Tips From Former Smokers (Tips) campaign.

METHOD

Data were analyzed from an online consumer panel of U.S. adult smokers before (n = 1,404) and after (n = 1,401) the 2013 Tips campaign launch. Generalized estimating equation models assessed whether the Tips advertisement recall was associated with knowledge about smoking-related risks in the Tips advertisements, awareness and use of a toll-free quitline and cessation websites, and quit attempts.

RESULTS

Seventy-one percent of participants at Wave 2 reported that they recalled seeing at least one Tips advertisement. Smokers who recalled seeing a Tips advertisement were more likely to (a) show increases over baseline in knowledge of health risks such as amputation: 65% versus 34%, p < .001; blindness: 27% versus 12%, p < .001; and (b) to be aware of a quitline (41% vs. 30%, p < .001) and cessation website (28% vs. 20%, p < .001). Recall of Tips advertisements was also associated with greater likelihood of reporting having visited cessation websites (odds ratio [OR] = 1.62, 95% confidence interval [CI] = 1.27-2.06), having called a quitline (OR = 2.28, 95% CI = 1.61-3.24), and having made a quit attempt (OR = 1.18, 95% CI = 1.00-1.39), although these results were only statistically significant in the unadjusted models.

CONCLUSIONS

The 2013 Tips campaign was successful in increasing knowledge of health risks and awareness of tobacco cessation resources.

Efficacy of High-Efficiency Particulate Air Filtration in Preventing Aspergillosis in Immunocompromised Patients With Hematologic Malignancies

Objectives:

To describe and investigate the cause of an outbreak of 10 cases of nosocomial invasive infection withAspergillus flavusin a hematologic oncology patient care unit.

Design:

A retrospective cohort study.

Setting:

The hematologic oncology unit of a comprehensive cancer center.

Patients:

Ninety-one patients admitted to the hematologic oncology service between January 1 and December 31,1992, for 4 or more consecutive days were included in the study.

Results:

Ten (18%) of 55 patients admitted from July to December 1992 were diagnosed as having invasive aspergillosis compared with 0 (0%) of 36 patients admitted from January to June 1992 to the same patient care units. Patient characteristics, mortality rate, autopsy rate, and admitting location did not change significantly during the course of the year to result in a sudden increase in the number of aspergillosis cases. The source of the outbreak was the high counts ofAspergillusconidia determined from air sampling in the non–bone marrow transplant wing during the outbreak. After high-efficiency particulate air (HEPA) filters were installed as an infection control measure, there were only two additional cases of nosocomial aspergillosis in the 2 years following the outbreak.

Conclusions:

This outbreak occurred among hematologic oncology patients with prolonged granulocytopenia housed in an environment with neither HEPA filters nor laminar air flow units. Our data demonstrate that in the setting of an outbreak of aspergillosis, HEPA filters are protective for highly immunocompromised patients with hematologic malignancies and are effective at controlling outbreaks due to air contamination withAspergillusconidia.

Nosocomial Infection Rates at an Oncology Center

Nosocomial infection rates were computed for 5,031 patients at an oncology center during a 20-month period. Twelve percent of the patients developed nosocomial infections, accounting for a total of 802 infections. The overall incidence of nosocomial infections during this study period was 6.27 infections per 1,000 patient days. The highest incidence of nosocomial infections was found in patients having acute myelogenous leukemia (30.49 infections per 1,000 patient days); bone and joint cancer (27.27 infections per 1,000 patient days); and liver cancer (26.58 infections per 1,000 patient days). The respiratory tract was the most common site of infection, followed by blood-stream, surgical wound, and urinary tract infections. Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and coagulase-negative staphylococci were most frequently implicated as pathogens. The distribution of specific types of infection according to underlying malignancy was also tabulated. These data provide nosocomial infection rates, common pathogens, and sites of infection for cancer patients, thus assisting in directing appropriate therapy for these patients.

Awareness, trial, and current use of electronic cigarettes in 10 countries: Findings from the ITC project

Background: In recent years, electronic cigarettes (e-cigarettes) have generated considerable interest and debate on the implications for tobacco control and public health. Although the rapid growth of e-cigarettes is global, at present, little is known about awareness and use. This paper presents self-reported awareness, trial and current use of e-cigarettes in 10 countries surveyed between 2009 and 2013; for six of these countries, we present the first data on e-cigarettes from probability samples of adult smokers. Methods: A cross-sectional analysis of probability samples of adult (≥ 18 years) current and former smokers participating in the International Tobacco Control (ITC) surveys from 10 countries. Surveys were administered either via phone, face-to-face interviews, or the web. Survey questions included sociodemographic and smoking-related variables, and questions about e-cigarette awareness, trial and current use. Results: There was considerable cross-country variation by year of data collection and for awareness of e-cigarettes (Netherlands (2013: 88%), Republic of Korea (2010: 79%), United States (2010: 73%), Australia (2013: 66%), Malaysia (2011: 62%), United Kingdom (2010: 54%), Canada (2010: 40%), Brazil (2013: 35%), Mexico (2012: 34%), and China (2009: 31%)), in self-reports of ever having tried e-cigarettes (Australia, (20%), Malaysia (19%), Netherlands (18%), United States (15%), Republic of Korea (11%), United Kingdom (10%), Mexico (4%), Canada (4%), Brazil (3%), and China (2%)), and in current use (Malaysia (14%), Republic of Korea (7%), Australia (7%), United States (6%), United Kingdom (4%), Netherlands (3%), Canada (1%), and China (0.05%)). Conclusions: The cross-country variability in awareness, trial, and current use of e-cigarettes is likely due to a confluence of country-specific market factors, tobacco control policies and regulations (e.g., the legal status of e-cigarettes and nicotine), and the survey timing along the trajectory of e-cigarette awareness and trial/use in each country. These ITC results constitute an important snapshot of an early stage of what appears to be a rapid progression of global e-cigarette use.

Australian smokers' support for plain or standardised packs before and after implementation: findings from the ITC Four Country Survey

BACKGROUND

Plain packaging (PP) for tobacco products was fully implemented in Australia on 1 December 2012 along with larger graphic health warnings. Using longitudinal data from the Australian arm of the ITC Four Country Survey, we examined attitudes to the new packs before and after implementation, predictors of attitudinal change, and the relationship between support and quitting activity.

METHODS

A population-based cohort study design, with some cross-sectional analyses. Surveys of Australian smokers assessed attitudes to PP at four time points prior to implementation (from 2007 to 2012) and one post-implementation wave collected (early/mid-2013).

RESULTS

Trend analysis showed a slight rise in opposition to PP among smokers in the waves leading up to their implementation, but no change in support. Support for PP increased significantly after implementation (28.2% pre vs 49% post), such that post-PP more smokers were supportive than opposed (49% vs 34.7%). Multivariate analysis showed support either before or after implementation was predicted by belief in greater adverse health impacts of smoking, desire to quit and lower addiction. Among those not supportive before implementation, having no clear opinion about PP (versus being opposed) prior to the changes also predicted support post-implementation. Support for PP was prospectively associated with higher levels of quitting activity.

CONCLUSIONS

Since implementation of PP along with larger warnings, support among Australian smokers has increased. Support is related to lower addiction, stronger beliefs in the negative health impacts of smoking, and higher levels of quitting activity.

Hospital admissions for acute myocardial infarction before and after implementation of a comprehensive smoke-free policy in Uruguay: experience through 2010

BACKGROUND

Comprehensive smoke-free laws have been followed by drops in hospitalisations for acute myocardial infarction (AMI), including in a study with 2 years follow-up for such a law in Uruguay.

METHODS

Multiple linear and negative binomial regressions for AMI admissions (ICD-10 code 121) from 37 hospitals for 2 years before and 4 years after Uruguay implemented a 100% nationwide smoke-free law.

RESULTS

Based on 11 135 cases, there was a significant drop of -30.9 AMI admissions/month (95% CI -49.8 to -11.8, p=0.002) following implementation of the smoke-free law. The effect of the law did not increase or decrease over time following implementation (p=0.234). This drop represented a 17% drop in AMI admissions following the law (IRR=0.829, 95% CI 0.743 to 0.925, p=0.001).

CONCLUSIONS

Adding two more years of follow-up data confirmed that Uruguay's smoke-free law was followed by a substantial and sustained reduction in AMI hospitalisations.

Trends in E-Cigarette Awareness, Trial, and Use Under the Different Regulatory Environments of Australia and the United Kingdom

INTRODUCTION

E-cigarettes (ECs) have gained significant attention in recent years. They have been introduced in jurisdictions with divergent existing laws that affect their legality. This provides the opportunity for natural experiments to assess effects of such laws in some cases independent of any formulated government policy. We compare patterns of EC awareness and use over a 3 year period in Australia where laws severely restrict EC availability, with awareness and use in the United Kingdom where ECs are readily available.

METHODS

Data analyzed come from Waves 8 and 9 (collected in 2010 and 2013, respectively) of the International Tobacco Control surveys in Australia and the United Kingdom (approximately 1,500 respondents per wave per country).

RESULTS

Across both waves, EC awareness, trial, and use among current and former smokers were significantly greater in the United Kingdom than in Australia, but all 3 of these measures increased significantly between 2010 and 2013 in both countries, and the rate of increase was equivalent between countries. Seventy-three percent of U.K. respondents reported that their current brands contained nicotine as did 43% in Australia even though sale, possession and/or use of nicotine-containing ECs without a permit are illegal in Australia. EC use was greater among smokers in both countries, at least in part due to less uptake by ex-smokers.

CONCLUSIONS

EC awareness and use have risen rapidly between 2010 and 2013 among current and former smokers in both Australia and the United Kingdom despite different EC regulatory environments. Substantial numbers in both countries are using ECs that contain nicotine.

The prevalence of brand switching among adult smokers in the USA, 2006-2011: findings from the ITC US surveys

BACKGROUND

Recent studies have suggested that about 1 in 5 smokers report switching brands per year. However, these studies only report switching between brands. The current study estimated the rates of switching both within and between brand families and examining factors associated with brand and brand style switching.

METHODS

Data for this analysis are from the International Tobacco Control 2006-2011 US adult smoker cohort survey waves 5-8 (N=3248). A switch between brands was defined as reporting two different cigarette brand names for two successive waves, while switching within brand was defined as reporting the same brand name, but a different brand style. Repeated measures regression was used to determine factors associated with both switch types.

RESULTS

A total of 1475 participants reported at least two successive waves of data with complete information on brand name and style. Overall switching increased from 44.9% in 2007-2008 to 58.4% in 2010-2011. Switching between brand names increased from 16% to 29%, while switches within the same brand name to a different style ranged from 29% to 33%. Between-brand switching was associated with younger age, lower income, non-white racial group and use of a discount brand, whereas, within-brand switching was associated with younger age and the use of a premium brand cigarette.

CONCLUSIONS

Nearly half of smokers in the USA switched their cigarette brand or brand style within a year. Switching between brands may be more price motivated, while switching within brands may be motivated by price and other brand characteristics such as product length.

Evaluating the effect of access to free medication to quit smoking: a clinical trial testing the role of motivation

INTRODUCTION

Although the majority of smokers are ambivalent about quitting, few treatments specifically target smokers lacking motivation to quit in the near future. Most existing interventions are instead predicated on the belief that active treatments should only be distributed to smokers interested in quitting, a largely untested assumption.

METHODS

In the current clinical trial (N = 157), motivated smokers wanting to quit in the next 30 days were given a 2-week nicotine replacement therapy (NRT) sample and a referral to a quitline (Group MNQ), while unmotivated smokers were randomized to receive the same treatment (Group UNQ) or a quitline referral only (Group UQ). Participants were tracked via telephone for 3 months to assess quitting behaviors and smoking reduction.

RESULTS

Groups significantly differed across all comparisons with regard to incidence of any quit attempt (MNQ: 77%, UNQ: 40%, UQ: 18%, p < .05) and any 24-hr quit attempts (62%, 32%, 16%, p < .05). Clinically meaningful differences emerged in the rates of floating (19%, 17%, 6%) and point prevalence abstinence (17%, 15%, 5%). Compared to participants in Group UQ (11%), a greater proportion of participants in Group MNQ (48%, p = .01) and Group UNQ (31%, p = .01) reduced their daily cigarette consumption by at least half. Proxy measures of cessation readiness (e.g., motivation) favored participants receiving active forms of treatment.

CONCLUSIONS

Providing NRT samples engaged both motivated and unmotivated smokers into the quitting process and produced positive changes in smoking outcomes. This suggests that motivation should not be considered a necessary precondition to receiving treatment.

Mediational pathways of the impact of cigarette warning labels on quit attempts

OBJECTIVE

To test and develop, using structural equation modeling, a robust model of the mediational pathways through which health warning labels exert their influence on smokers' subsequent quitting behavior.

METHOD

Data come from the International Tobacco Control Four-Country Survey, a longitudinal cohort study conducted in Australia, Canada, the United Kingdom, and the United States. Waves 5-6 data (n = 4,988) were used to calibrate the hypothesized model of warning label impact on subsequent quit attempts via a set of policy-specific and general psychosocial mediators. The finalized model was validated using Waves 6-7 data (n = 5065).

RESULTS

As hypothesized, warning label salience was positively associated with thoughts about risks of smoking stimulated by the warnings (β = .58, p < .001), which in turn were positively related to increased worry about negative outcomes of smoking (β = .52, p < .001); increased worry in turn predicted stronger intention to quit (β = .39, p < .001), which was a strong predictor of subsequent quit attempts (β = .39, p < .001). This calibrated model was successfully replicated using Waves 6-7 data.

CONCLUSION

Health warning labels seem to influence future quitting attempts primarily through their ability to stimulate thoughts about the risks of smoking, which in turn help to raise smoking-related health concerns, which lead to stronger intentions to quit, a known key predictor of future quit attempts for smokers. By making warning labels more salient and engaging, they should have a greater chance to change behavior.

Trends in cigarette pricing and purchasing patterns in a sample of US smokers: findings from the ITC US Surveys (2002-2011)

OBJECTIVE

This paper examines trends in cigarette prices and corresponding purchasing patterns over a 9-year period and explores characteristics associated with the quantity and location of cigarettes purchased by adult smokers in the USA.

METHODS

The data for this paper come from a nationally representative longitudinal survey of 6669 adult smokers (18 years and older) who were recruited and surveyed between 2002 and 2011. Telephone interviews were conducted annually, and smokers were asked a series of questions about the location, quantity (ie, single vs multiple packs or cartons) and price paid for their most recent cigarette purchase. Generalised estimating equations were used to assess trends and model characteristics associated with cigarette purchasing behaviours.

RESULTS

Between 2002 and 2011, the reported purchase of cigarette cartons and the use of coupons declined while multipack purchases increased. Compared with those purchasing by single packs, those who purchased by multipacks and cartons saved an average of $0.53 and $1.63, respectively. Purchases in grocery and discount stores declined, while purchases in tobacco only outlets increased slightly. Female, older, white smokers were more likely to purchase cigarettes by the carton or in multipacks and in locations commonly associated with tax avoidance (ie, duty free shops, Indian reservations).

CONCLUSIONS

As cigarette prices have risen, smokers have begun purchasing via multipacks instead of cartons. As carton sales have declined, purchases from grocery and discount stores have also declined, while an increasing number of smokers report low tax sources as their usual purchase location for cigarettes.

Cigarette smokers' use of unconventional tobacco products and associations with quitting activity: findings from the ITC-4 U.S. cohort

INTRODUCTION

The purpose of this study was to evaluate the prevalence and correlates of use of nicotine-containing tobacco products such as cigars, pipe tobacco, and cigarettes that promise less exposure to toxins; e-cigarettes; and smokeless tobacco products among a cohort of conventional cigarette smokers followed over the past decade. We also evaluated associations between use of such products and cigarette quitting.

METHODS

Participants were 6,110 adult smokers in the United States, who were interviewed as part of the International Tobacco Control Four Country Survey between 2002 and 2011. Respondents reported their concurrent use of other smoked tobacco products (including cigars, pipe tobacco, and cigarillos), smokeless tobacco products (including chewing tobacco, snus, and snuff), unconventional cigarettes (including Omni, Accord, and Eclipse), and electronic cigarettes. Prevalence and correlates of use and associations between use and cigarette quitting were assessed using regression analyses via generalized estimating equations.

RESULTS

Most cigarette smokers did not use unconventional tobacco products, although use of any of these products started to rise at the end of the study period (2011). For each type of tobacco product evaluated, use was most prevalent among those aged 18-24 years. Smokers who did use unconventional tobacco products did not experience a clear cessation advantage.

CONCLUSIONS

During the past decade, relatively few cigarette smokers reported also using other tobacco products. Those that did use such products were no more likely to stop using conventional cigarettes compared with those who did not use such products.

Patient willingness and barriers to receiving a CT scan for lung cancer screening

CT scans are becoming a more common method for detecting lung cancers at an earlier, potentially more curable, stage of disease. There is currently little data on attitudes and beliefs about screening for lung cancer. This paper presents the results of a 2011 survey of adult current and former smokers that queried about past use of CT scanning and reasons for having or not having the screening done. A random-digit dialed telephone survey was administered to a representative sample of 1290 US adults. Logistic regression analyses were used to examine the correlates of having the test while controlling for the covariates. A total of 13.4% (n = 45) of the sample had ever had a CT scan to detect lung cancer. Of current smokers, 14.6% had received a CT scan, as compared with 12.7% of former smokers. The oldest age group (55+) was significantly more likely to have received a CT scan than the younger age groups. 78.5% of current smokers and 81.4% of former smokers indicated willingness to get the test if advised to do so by their doctor. Among those who said they were not willing to get screened, lack of insurance coverage was cited by 33% of current smokers and 25% of former smokers. Additionally, 33% of current smokers were afraid to find out whether they had cancer. The main barrier to CT scanning for lung cancer is likely to be insurance coverage for the test, which would be a burden for those on limited and fixed incomes. Next steps should include further research into the effect of increased public education about the availability, risks, benefits and barriers to lung cancer screening.

The 2014 Surgeon General's report: commemorating the 50th Anniversary of the 1964 Report of the Advisory Committee to the US Surgeon General and updating the evidence on the health consequences of cigarette smoking

The question of whether cigarette smoking was associated with lung cancer was central to the expansion of epidemiology into the study of chronic diseases in the 1950s. The culmination of this era was the 1964 report of the Advisory Committee to the Surgeon General, a landmark document that included an objective synthesis of the evidence of the health consequences of smoking according to causal criteria. The report concluded that cigarette smoking was a cause of lung cancer in men and sufficient in scope that "remedial action" was warranted at the societal level. The 2014 Surgeon General's report commemorates the 50th anniversary of the 1964 report. The evidence on the health consequences of smoking has been updated many times in Surgeon General's reports since 1964. These have summarized our increasingly greater understanding of the broad spectrum of the deleterious health effects of exposure to tobacco smoke across most major organ systems. In turn, this evidence has been translated into tobacco control strategies implemented to protect the public's health. The Surgeon General report process is an enduring example of evidence-based public health in practice. Substantial progress has been made, but cigarette smoking remains one of the most pressing global health issues of our time.

Clinical strategies to enhance the efficacy of nicotine replacement therapy for smoking cessation: a review of the literature

A number of smoking cessation pharmacotherapies have led to increases in quitting and thus to significant benefits to public health. Among existing medications, nicotine replacement therapy (NRT) has been available the longest, has the largest literature base in support, and is the only option for over-the-counter access. While the short-term efficacy of NRT is well documented in clinical trials, long-term abstinence rates associated with using NRT are modest, as most smokers will relapse. This literature review examines emerging clinical strategies to improve NRT efficacy. After an initial overview of NRT and its FDA-approved indications for use, we review randomized trials in which clinical delivery of NRT was manipulated and tested, in an attempt to enhance efficacy, through (1) duration of use (pre-quit and extended use), (2) amount of use (high-dose and combination NRT), (3) tailoring to specific smoker groups (genotype and phenotype), or (4) use of NRT for novel purposes (relapse prevention, temporary abstinence, cessation induction). Outcomes vary within and across topic area, and we highlight areas that offer stronger promise. Combination NRT likely represents the most promising strategy moving forward; other clinical strategies offer conflicting evidence but deserve further testing (pre-quit NRT or tailored treatment) or offer potential utility but are in need of further, direct tests. Some areas, though based on a limited set of studies, do not offer great promise (high-dose and extended treatment NRT). We conclude with a brief discussion of emergent NRT products (e.g., oral nicotine spray, among others), which may ultimately offer greater efficacy than current formulations. In order to further lower the prevalence of smoking, novel strategies designed to optimize NRT efficacy are needed.

The changing public image of smoking in the United States: 1964-2014

Tobacco use behaviors in the U.S. have changed significantly over the past century. After a steep increase in cigarette use rates over the first half of the 20th century, adult smoking prevalence rates started declining from their peak reached in 1964. Improved understanding of the health risks of smoking has been aided by the U.S. Surgeon General's Reports, issued on a nearly annual basis starting in 1964. Among the many forces driving down smoking prevalence were the recognition of tobacco use as an addiction and cause of cancer, along with concerns about the ill effects of breathing secondhand smoke. These factors contributed to the declining social acceptance of smoking, especially with the advent of legal restrictions on smoking in public spaces, mass media counter-marketing campaigns, and higher taxes on cigarettes. This article reviews some of the forces that have helped change the public image of smoking, focusing on the 50 years since the 1964 Surgeon General's Report on smoking and health.

Trends in use of electronic nicotine delivery systems by adolescents

Electronic nicotine delivery systems (ENDS) have been gaining in popularity. The few prevalence studies in adults have found that most ENDS users are current or former smokers. The objectives of this study were to estimate the prevalence of ENDS usage in adolescents, and examine the correlates of use. Self-administered written surveys assessing tobacco use behaviors were conducted in multiple waves as part of a larger intervention study in two large suburban high schools. The prevalence of past-30 day ENDS use increased from 0.9% in February 2010 to 2.3% in June 2011 (p=0.009). Current cigarette smokers had increased odds of past-30 day ENDS use in all study waves. When adjusted for school, grade, sex, race and smoking status, students in October 2010 (Adjusted OR 2.12; 95% confidence interval (CI): 1.12-4.02) and June 2011 (Adjusted OR 2.51; 95% CI: 1.17-4.71) had increased odds past-30 day ENDS use compared to February 2010. The prevalence of ENDS use doubled in this sample of high school students, and current cigarette smoking is the strongest predictor of current use. Continued monitoring of ENDS is needed to determine whether it increases the likelihood of cigarette smoking initiation and maintenance in youth.

Estimating demand for alternatives to cigarettes with online purchase tasks

OBJECTIVES

To explore how advertising affects demand for cigarettes and potential substitutes, including snus, dissolvable tobacco, and medicinal nicotine.

METHODS

A Web-based experiment randomized 1062 smokers to see advertisements for alternative nicotine products or soft drinks, then complete a series of purchase tasks, which were used to estimate demand elasticity, peak consumption, and cross-price elasticity (CPE) for tobacco products.

RESULTS

Lower demand elasticity and greater peak consumption were seen for cigarettes compared to all alternative products (p < .05). CPE did not differ across the alternative products (p ≤ .03). Seeing relevant advertisements was not significantly related to demand.

CONCLUSIONS

These findings suggest significantly lower demand for alternative nicotine sources among smokers than previously revealed.

Abstract C15: Differences in the characteristics of those receiving smoking cessation advice

Clinical practice guidelines recommend that healthcare providers assess the tobacco use status of their patients and advise those that smoke to quit. Studies show that advice to stop smoking delivered by a doctor is associated with a 2-fold increase in smoking cessation. However, not all smokers who are seen by a doctor get advised to stop smoking. This study describes the characteristics of smokers who received advice to stop smoking when they were seen by a health care provider. Based upon previous studies, we hypothesized that older smokers with poorer self-reported health, and greater nicotine addiction would be more likely to report receiving advice to stop smoking when seen by a health provider. Data for this analysis are from the International Tobacco Control (ITC) US adult smoker cohort (N=6,669) survey conducted annually from 2002-2011. Participants who reported having visited a healthcare provider within the past year of survey were eligible for inclusion. Trends in the prevalence of participants reporting cessation advice and quit assistance were assessed. Repeated measures logistic regression using generalized estimating equations (GEE) was used to model receipt of counseling. Predictors of receipt of advice to stop smoking included demographic characteristics (age, gender, race/ethnicity, education, and household income), heaviness of smoking (a measure of nicotine dependence), previous quit attempts, and self-reported health status. Over 60% of respondents reported having been seen by a healthcare provider, with over 60% receiving advice to stop smoking. Those who received advice to stop smoking were more likely to be older, report ‘fair’ or ‘poor’ health, and to have reported a quit attempt since their previous interview. Among those who received advice to quit, less than one third received a referral or quit prescription, and less than one half received a stop smoking pamphlet from their healthcare provider. Results indicate that not all smokers get advice to stop smoking when seen by their doctor and those who do appear to be older and less healthy, and more receptive to a quitting message based upon past quit attempts. These data suggest that health care providers may be profiling their patients in terms of those who are in need of cessation counseling rather than uniformly providing this advice to all patients. Among those who received advice to stop smoking the majority received no other type of assistance suggesting that delivery of cessation services to smokers is inadequate.

Citation Format: Monica E. Cornelius, K Michael Cummings. Differences in the characteristics of those receiving smoking cessation advice. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr C15.