Evaluating Long-term Outcomes of NHS Stop Smoking Services (ELONS): a prospective cohort study

BACKGROUND

NHS Stop Smoking Services (SSSs) provide free at the point of use treatment for smokers who would like to stop. Since their inception in 1999 they have evolved to offer a variety of support options. Given the changes that have happened in the provision of services and the ongoing need for evidence on effectiveness, the Evaluating Long-term Outcomes for NHS Stop Smoking Services (ELONS) study was commissioned.

OBJECTIVES

The main aim of the study was to explore the factors that determine longer-term abstinence from smoking following intervention by SSSs. There were also a number of additional objectives.

DESIGN

The ELONS study was an observational study with two main stages: secondary analysis of routine data collected by SSSs and a prospective cohort study of service clients. The prospective study had additional elements on client satisfaction, well-being and longer-term nicotine replacement therapy (NRT) use.

SETTING

The setting for the study was SSSs in England. For the secondary analysis, routine data from 49 services were obtained. For the prospective study and its added elements, nine services were involved. The target population was clients of these services.

PARTICIPANTS

There were 202,804 cases included in secondary analysis and 3075 in the prospective study.

INTERVENTIONS

A combination of behavioural support and stop smoking medication delivered by SSS practitioners.

MAIN OUTCOME MEASURES

Abstinence from smoking at 4 and 52 weeks after setting a quit date, validated by a carbon monoxide (CO) breath test.

RESULTS

Just over 4 in 10 smokers (41%) recruited to the prospective study were biochemically validated as abstinent from smoking at 4 weeks (which was broadly comparable with findings from the secondary analysis of routine service data, where self-reported 4-week quit rates were 48%, falling to 34% when biochemical validation had occurred). At the 1-year follow-up, 8% of prospective study clients were CO validated as abstinent from smoking. Clients who received specialist one-to-one behavioural support were twice as likely to have remained abstinent than those who were seen by a general practitioner (GP) practice and pharmacy providers [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2 to 4.6]. Clients who received group behavioural support (either closed or rolling groups) were three times more likely to stop smoking than those who were seen by a GP practice or pharmacy providers (OR 3.4, 95% CI 1.7 to 6.7). Satisfaction with services was high and well-being at baseline was found to be a predictor of abstinence from smoking at longer-term follow-up. Continued use of NRT at 1 year was rare, but no evidence of harm from longer-term use was identified from the data collected.

CONCLUSIONS

Stop Smoking Services in England are effective in helping smokers to move away from tobacco use. Using the 52-week CO-validated quit rate of 8% found in this study, we estimate that in the year 2012-13 the services supported 36,249 clients to become non-smokers for the remainder of their lives. This is a substantial figure and provides one indicator of the ongoing value of the treatment that the services provide. The study raises a number of issues for future research including (1) examining the role of electronic cigarettes (e-cigarettes) in smoking cessation for service clients [this study did not look at e-cigarette use (except briefly in the longer-term NRT study) but this is a priority for future studies]; (2) more detailed comparisons of rolling groups with other forms of behavioural support; (3) further exploration of the role of practitioner knowledge, skills and use of effective behaviour change techniques in supporting service clients to stop smoking; (4) surveillance of the impact of structural and funding changes on the future development and sustainability of SSSs; and (5) more detailed analysis of well-being over time between those who successfully stop smoking and those who relapse. Further research on longer-term use of non-combustible nicotine products that measures a wider array of biomarkers of smoking-related harm such as lung function tests or carcinogen metabolites.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The UK Centre for Tobacco and Alcohol Studies provided funding for the longer-term NRT study.

'Opt-out' referrals after identifying pregnant smokers using exhaled air carbon monoxide: impact on engagement with smoking cessation support

Background

In the UK, free smoking cessation support is available to pregnant women; only a minority accesses this. ‘Opt-out’ referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object.

Methods

To assess the impact of ‘opt-out’ referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a ‘before–after’ service development evaluation. In the 6-month ‘before’ period, there was a routine ‘opt-in’ referral system for self-reported smokers at antenatal ‘booking’ appointments. In the 6-month ‘after’ period, additional ‘opt-out’ referrals were introduced at the 12-week ultrasound appointments; women with CO≥4 ppm were referred to, and outcome data were collected from, local SSS.

Results

Approximately 2300 women attended antenatal care in each period. Before the implementation, 536 (23.4%) women reported smoking at ‘booking’ and 290 (12.7%) were referred to SSS. After the implementation, 524 (22.9%) women reported smoking at ‘booking’, an additional 156 smokers (6.8%) were identified via the ‘opt-out’ referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after ‘opt-out’ referrals were implemented (121 (5.3%, 95% CI 4.4% to 6.3%) compared to 57 (2.5%, 95% CI 1.9% to 3.2%) before implementation) and reported being abstinent 4 weeks later (93 (4.1%, 95% CI 3.3% to 4.9%) compared to 46 (2.0%, 1.5% to 2.7%) before implementation).

Conclusions

In a hospital with an ‘opt-in’ referral system, adding CO screening with ‘opt-out’ referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation.

The Lung Screen Uptake Trial (LSUT): protocol for a randomised controlled demonstration lung cancer screening pilot testing a targeted invitation strategy for high risk and 'hard-to-reach' patients

BACKGROUND

Participation in low-dose CT (LDCT) lung cancer screening offered in the trial context has been poor, especially among smokers from socioeconomically deprived backgrounds; a group for whom the risk-benefit ratio is improved due to their high risk of lung cancer. Attracting high risk participants is essential to the success and equity of any future screening programme. This study will investigate whether the observed low and biased uptake of screening can be improved using a targeted invitation strategy.

METHODS/DESIGN

A randomised controlled trial design will be used to test whether targeted invitation materials are effective at improving engagement with an offer of lung cancer screening for high risk candidates. Two thousand patients aged 60-75 and recorded as a smoker within the last five years by their GP, will be identified from primary care records and individually randomised to receive either intervention invitation materials (which take a targeted, stepped and low burden approach to information provision prior to the appointment) or control invitation materials. The primary outcome is uptake of a nurse-led 'lung health check' hospital appointment, during which patients will be offered a spirometry test, an exhaled carbon monoxide (CO) reading, and an LDCT if eligible. Initial data on demographics (i.e. age, sex, ethnicity, deprivation score) and smoking status will be collected in primary care and analysed to explore differences between attenders and non-attenders with respect to invitation group. Those who attend the lung health check will have further data on smoking collected during their appointment (including pack-year history, nicotine dependence and confidence to quit). Secondary outcomes will include willingness to be screened, uptake of LDCT and measures of informed decision-making to ensure the latter is not compromised by either invitation strategy.

DISCUSSION

If effective at improving informed uptake of screening and reducing bias in participation, this invitation strategy could be adopted by local screening pilots or a national programme.

TRIAL REGISTRATION

This study was registered with the ISRCTN (International Standard Registered Clinical/soCial sTudy Number: ISRCTN21774741) on the 23rd September 2015 and the NIH ClinicalTrials.gov database (NCT0255810) on the 22nd September 2015.

Neighbourhood Deprivation and Outcomes of Stop Smoking Support--An Observational Study

Background

Rates of smoking and smoking cessation vary with socio-economic status. The objectives were to assess the association between neighbourhood deprivation, completion of treatment to support quit attempts and success of quit attempts—while taking into account other predictors of outcome.

Methods

555,744 quit attempts supported by English Stop Smoking Services in 2009–2012 were linked to the Index of Multiple Deprivation (IMD) 2010 ranks for the clients’ neighbourhood and split into deciles relative to the national IMD. Logistic regressions tested the association between neighbourhood deprivation and completion (4-week follow-up) of treatment and biochemically validated success (expired-air carbon monoxide <10ppm) while adjusting for demographics and intervention characteristics. Sensitivity analyses assessed subsamples: first supported attempts (n = 364,397), those with recorded cigarette dependence (n = 98,659) and completed treatment (n = 416,436).

Results

Higher neighbourhood deprivation was associated with reduced completion (OR_adj = 0.949, 95% CI: 0.947 to 0.951) and success (OR_adj = 0.957, 95% CI: 0.955 to 0.959). Results of sensitivity analyses were consistent with those of the main analysis.

Conclusions

Neighbourhood deprivation was associated with small but consistent reductions in completion and success of evidence-based interventions. These associations were not explained by intervention characteristics, demographics or dependence and reduced completion did not fully account for reduced success.

Waterpipe Tobacco Use in the United Kingdom: A Cross-Sectional Study among University Students and Stop Smoking Practitioners

INTRODUCTION

Despite cigarette-like adverse health outcomes associated with waterpipe tobacco smoking and increase in its use among youth, it is a much underexplored research area. We aimed to measure the prevalence and patterns of waterpipe tobacco use and evaluate tobacco control policy with respect to waterpipe tobacco, in several universities across the UK. We also aimed to measure stop smoking practitioners' encounter of waterpipe tobacco smoking.

METHODS

We distributed an online survey to six UK universities, asking detailed questions on waterpipe tobacco. Multivariable logistic regression models, adjusted for age, gender, ethnicity, graduate status, university and socioeconomic status (SES) assessed associations between waterpipe tobacco smoking (single use and dual use with cigarettes) and sociodemographic variables. SES was ascertained by average weekly self-spend on non-essentials. We also descriptively analysed data from a 2012 survey of stop smoking practitioners to assess the proportion of clients that used waterpipe regularly.

RESULTS

f 2217 student responses, 66.0% (95% CI 63.9-68.0%) had tried waterpipe tobacco smoking; 14.3% (95% CI 12.8-15.8%) reported past-30 day use, and 8.7% (95% CI 7.6-9.9%) reported at least monthly users. Past-30 day waterpipe-only use was associated with being younger (AOR 0.95, 95% CI 0.91-0.99), male (AOR 1.44, 95% CI 1.08-1.94), higher SES (AOR 1.16, 95% CI 1.06-1.28) and belonging to non-white ethnicities (vs. white, AOR 2.24, 95% CI 1.66-3.04). Compared to less than monthly users, monthly users were significantly more likely to have urges to smoke waterpipe (28.1% vs. 3.1%, p<0.001) report difficulty in quitting (15.5% vs. 0.8%, p<0.001), report feeling guilty, and annoyed when criticised about waterpipe smoking (19.2% vs. 9.2%, p<0.001). Nearly a third (32.5%) of respondents who had tried waterpipe had violated the UK smokefree law and a quarter (24.5%) reporting seeing health warnings on waterpipe tobacco packaging or apparatuses. Of 1,282 smoking cessation practitioners, a quarter (23.4%, 95% CI 21.5-26.1%) reported having some clients who regularly use waterpipes, but 69.5% (95% CI 67.0-72.0%) never ask clients about waterpipe use. Three quarters (74.8%, 95% CI 72.4-77.1%) want more information about waterpipe tobacco smoking.

CONCLUSIONS

While two thirds of university students have ever tried waterpipe tobacco, at least monthly use is less common. Regular users display features of waterpipe tobacco dependence, and a substantial minority of SSS practitioners encounter clients who regularly use waterpipe. The lack of training on waterpipe for SSS practitioners and reported violations of smokefree laws for waterpipe highlight the need for regular surveillance of and a coordinated tobacco control strategy for waterpipe use.

Views from the Coalface: What Do English Stop Smoking Service Personnel Think about E-Cigarettes?

The UK Stop Smoking Services (SSS) are a source of information and advice on e-cigarettes for smokers and thus it is important to understand the knowledge of, and attitudes towards, e-cigarettes held by stop smoking practitioners. The datasets were English SSS quarterly monitoring returns (n = 207,883) and an online survey of English SSS practitioners, managers, and commissioners between 26th November and 15th December 2014 (n = 1801). SSS monitoring data suggested 2% of clients were using e-cigarettes to quit with SSS and that clients using e-cigarettes had similar quit rates to clients using Varenicline. Most SSS personnel are waiting for licenced e-cigarettes to become available before they will recommend them to clients. However, less than a quarter view e-cigarettes as "a good thing". Managers and commissioners were more positive than practitioners. SSS personnel working for the NHS (hospitals and GP surgeries) were less positive about e-cigarettes than those employed elsewhere. E-cigarettes were cited as the most important reason for the recent decline in service footfall. Thus dissemination of information about e-cigarettes needs to be examined and services should address their stance on e-cigarettes with some urgency.

Evaluating an online training module on protecting children from secondhand smoke exposure: impact on knowledge, confidence and self-reported practice of health and social care professionals

Background

Healthcare professionals report that a lack of training is the primary barrier to raising the issue of secondhand smoke (SHS). An open access online training module was therefore developed for those working with smoking families to deliver effective very brief advice on SHS. The current study aimed to evaluate the following: (1) does knowledge increase as a result of participating in the online training module, and (2) does the module impact on participant confidence and self-reported practice relating to SHS.

Methods

Those accessing the module were invited to participate in an evaluation to assess participants’ knowledge about, and confidence in, delivering very brief advice on SHS. Change in knowledge was assessed via ten multiple choice questions and confidence was assessed by Likert scale responses to three statements. Data were collected across three time points: pre-training, post-training and after 3 months. Data were also collected at 3 months post module completion on self-reported changes in practice and key learning points.

Results

Data at all three time points were available for 178 participants (~1 % of those who visited the module homepage over a 2 year period). Knowledge and confidence to deliver effective very brief advice for SHS significantly increased between the pre- and post-training assessments and was maintained at 3 months. Eighty-four percent self-reported that they perceived taking part in the training had led to positive changes in their clinical practice.

Conclusions

There is potential for this module to be embedded within training programmes across health and social care professions, which may help to increase the knowledge and confidence of health and social care professionals to deliver very brief advice for SHS to smoking families. Future research needs to explore whether the smoking families who receive very brief advice for SHS are motivated to make changes to their home smoking behaviours and whether roll-out of this intervention would be cost-effective.

Tobacco Dependence Treatment Training Programs: An International Survey

INTRODUCTION

In line with Article 14 guidelines for the WHO Framework Convention on Tobacco Control, we aimed to assess the progress in training individuals to deliver tobacco cessation treatment.

METHODS

Cross-sectional web-based survey in May-September 2013 among 122 experts in tobacco control and training from 84 countries (73% response rate among 115 countries surveyed). We measured training program prevalence, participants, and challenges faced.

RESULTS

Overall, 21% (n = 18/84) of countries, mostly low and middle-income countries (LMICs; P = .002), reported no training program. Among 66 countries reporting at least one training program, most (84%) trained healthcare professionals but 54% also trained other individuals including community health workers, teachers, and religious leaders. Most programs (54%) cited funding challenges, although stability of funding varied by income level. Government funding was more commonly reported in higher income countries (high 56%, upper middle 50%, lower middle 27%, low 25%; P = .03) while programs in LMICs relied more on nongovernmental organizations (high 11%, upper middle 37%, lower middle 27%, low 38%; P = .02).

CONCLUSIONS

One in five countries reported having no tobacco treatment training program representing little progress in terms of training individuals to deliver tobacco treatment in LMICs. Without more trained tobacco treatment providers, one of the tenets of Article 14 is not yet being met and health inequalities are likely to widen. More effort and resources are needed to ensure that healthcare worker educational programs include training to assess tobacco use and deliver brief advice and that training is available for individuals outside the healthcare system in areas with limited healthcare access.

Treatment manuals, training and successful provision of stop smoking behavioural support

OBJECTIVE

Translating evidence-based behaviour change interventions into practice is aided by use of treatment manuals specifying the recommended content and format of interventions, and evidence-based training. This study examined whether outcomes of stop smoking behavioural support differed with practitioner's use and evaluation of treatment manuals, or practitioner's training.

METHODS

English stop smoking practitioners were invited to complete an online survey including questions on: practitioners' training, availability, use and perceived utility of manuals, and annual biochemically-validated success rates of quit attempts supported (practitioner-reported). Mean success rates were compared between practitioners with/without access to manuals, those using/not using manuals, perceived utility ratings of manuals, and consecutive levels of training completed.

RESULTS

Success rates were higher if practitioners had a manual (Mean (SD) = 54.0 (24.0) versus 48.0 (25.3), t(838) = 2.48, p = 0.013; n = 840), used a manual (F(2,8237) = 4.78, p = 0.009, n = 840), perceived manuals as more useful (F(3,834) = 2.90, p = 0.034, n = 840), and had completed training (F(3,709) = 4.81, p = 0.002, n = 713). Differences were diminished when adjusting for professional and demographic characteristics and no longer reached statistical significance using a conventional alpha for perceived utility of manuals and training status (both p = 0.1).

CONCLUSIONS

Practitioners' performance in supporting smokers to quit varied with availability and use of treatment manuals. Evidence was weaker for perceived utility of manuals and practitioners' evidence-based training. Ensuring practitioners have access to treatment manuals within their service, promoting manual use, and training practitioners to competently apply manuals is likely to contribute to higher success rates in clinical practice.

Smoking is associated with pessimistic and avoidant beliefs about cancer: results from the International Cancer Benchmarking Partnership

Background:

Smoking cessation is the key cancer prevention behaviour for smokers; nonetheless, smokers can still benefit from earlier diagnosis of cancer. However, fewer smokers participate in screening despite their increased risk, which may reflect different beliefs about cancer.

Methods:

A UK population-representative sample of ⩾50 year-olds (n=6965) was surveyed using the Awareness and Beliefs about Cancer measure. These analyses examine six items on cancer beliefs (e.g., ‘cancer can often be cured'), and four on help-seeking barriers (e.g., ‘I would be too embarrassed').

Results:

Smokers were more likely to hold pessimistic cancer beliefs than never-smokers or former-smokers on four of six items. For example, 34% agreed ‘a cancer diagnosis is a death sentence', compared with 24% of non/former-smokers (P<0.001). More smokers (18%) than non/former-smokers (11%) would not want to know if they had cancer (P<0.01). The only barrier to symptomatic help-seeking differing by smoking status was ‘worry about what the doctor might find' (36% vs 28%, P<0.01). Associations were independent of demographics, self-rated health and cancer experience.

Conclusions:

Smokers held more pessimistic and avoidant beliefs about cancer, which could deter early-detection behaviour. A better understanding of these beliefs is needed to increase engagement in early diagnosis by this high-risk group.

Do cravings predict smoking cessation in smokers calling a national quit line: secondary analyses from a randomised trial for the utility of 'urges to smoke' measures

Background

Single-item urges to smoke measures have been contemplated as important measures of nicotine dependence This study aimed to prospectively determine the relationships between measures of craving to smoke and smoking cessation, and compare their ability to predict cessation with the Heaviness of Smoking Index, an established measure of nicotine dependence.

Methods

We conducted a secondary analysis of data from the randomised controlled PORTSSS trial. Measures of nicotine dependence, ascertained before making a quit attempt, were the HSI, frequency of urges to smoke (FUTS) and strength of urges to smoke (SUTS). Self-reported abstinence at six months after quitting was the primary outcome measure. Multivariate logistic regression and Receiver Operating Characteristic (ROC) analysis were used to assess associations and abilities of the nicotine dependence measures to predict smoking cessation.

Results

Of 2,535 participants, 53.5% were female; the median (Interquartile range) age was 38 (28–50) years. Both FUTS and HSI were inversely associated with abstinence six months after quitting; for each point increase in HSI score, participants were 16% less likely to have stopped smoking (OR 0.84, 95% C.I 0.78-0.89, p < 0.0001). Compared to participants with the lowest possible FUTS scores, those with greater scores had generally lower odds of cessation (p across frequency of urges categories=0.0026). SUTS was not associated with smoking cessation. ROC analysis suggested the HSI and FUTS had similar predictive validity for cessation.

Conclusions

Higher FUTS and HSI scores were inversely associated with successful smoking cessation six months after quit attempts began and both had similar validity for predicting cessation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-015-0011-8) contains supplementary material, which is available to authorized users.

Predictors of intentions to quit smoking in Aboriginal tobacco smokers of reproductive age in regional New South Wales (NSW), Australia: quantitative and qualitative findings of a cross-sectional survey

OBJECTIVES

To assess the predictors of intentions to quit smoking in a community sample of Aboriginal smokers of reproductive age, in whom smoking prevalence is slow to decline.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey involved 121 Aboriginal smokers, aged 18-45 years from January to May 2014, interviewed at community events on the Mid-North Coast NSW. Qualitative and quantitative data were collected on smoking and quitting attitudes, behaviours and home smoking rules. Perceived efficacy for quitting, and perceived threat from smoking, were uniquely assessed with a validated Risk Behaviour Diagnosis (RBD) Scale.

MAIN OUTCOME MEASURES

Logistic regression explored the impact of perceived efficacy, perceived threat and consulting previously with a doctor or health professional (HP) on self-reported intentions to quit smoking, controlling for potential confounders, that is, protection responses and fear control responses, home smoking rules, gender and age. Participants' comments regarding smoking and quitting were investigated via inductive analysis, with the assistance of Aboriginal researchers.

RESULTS

Two-thirds of smokers intended to quit within 3 months. Perceived efficacy (OR=4.8; 95% CI 1.78 to 12.93) and consulting previously with a doctor/HP about quitting (OR=3.82; 95% CI 1.43 to 10.2) were significant predictors of intentions to quit. 'Smoking is not doing harm right now' was inversely associated with quit intentions (OR=0.25; 95% CI 0.08 to 0.8). Among those who reported making a quit attempt, after consulting with a doctor/HP, 40% (22/60) rated the professional support received as low (0-2/10). Qualitative themes were: the negatives of smoking (ie, disgust, regret, dependence and stigma), health effects and awareness, quitting, denial, 'smoking helps me cope' and social aspects of smoking.

CONCLUSIONS

Perceived efficacy and consulting with a doctor/HP about quitting may be important predictors of intentions to quit smoking in Aboriginal smokers of reproductive age. Professional support was generally perceived to be low; thus, it could be improved for these Aboriginal smokers. Aboriginal participants expressed strong sentiments about smoking and quitting.

Changes in success rates of smoking cessation treatment associated with take up of a national evidencebased training programme

OBJECTIVE

The English 'stop smoking services' provide behavioural support to some 700,000 smokers annually. Success rates of the services varied considerably before 2010 and had been in slight decline so, to improve performance, a national programme of evidence-based practitioner training was developed to improve knowledge and skills-based competences. This study evaluated whether uptake of the training was associated with improvements in success rates of services.

METHODS

Mean 4-week biochemically verified abstinence rates were compared for 146 (of 151) stop smoking services between 2008-10 (before roll-out of training) and 2011-13 (after roll-out), and the change in success rates for each service was regressed on to the number of practitioners per service trained in a) knowledge (online) and b) skills (face-to-face).

RESULTS

Success rate across all services improved between the two periods (34.1% to 36.5%, p=0.01 1-tailed; 95% CI for difference 0.44-4.48). The magnitude of improvement for each service was associated with the number of practitioners who completed the knowledge and skills training (beta=0.22, p=0.005 1-tailed), and marginally with the number who completed the knowledge training (beta=0.14, p=0.047 1-tailed).

CONCLUSION

English stop smoking services that have greater uptake of a national evidence-based training programme showed greater improvements in success rates.

Smoking cessation education and training in U.K. medical schools: a national survey

INTRODUCTION

Smoking cessation is one of the most cost-effective of all health interventions. Physicians are in a strong position to encourage smokers to make a quit attempt and to help them achieve long-term abstinence. Formal teaching on tobacco-related disease, the evidence base of smoking cessation, and practical skills training regarding cessation advice and counseling are therefore important parts of undergraduate medical education. A survey of U.K. medical schools conducted 11 years ago revealed substantial deficits in the curricular coverage of these topics. This study aimed at establishing whether the situation has improved since then.

METHODS

In 2013, all U.K. medical schools were invited to participate in an online survey of their curricular coverage of tobacco addiction and smoking cessation.

RESULTS

Of the 33 medical schools, 22 (67%) schools responded. Health effects of smoking were addressed in more than 90% of curricula, and factual knowledge on nicotine addiction and withdrawal symptoms was covered in 50% of curricula. Only 1 in 3 medical schools offered practical skills training in artificial (i.e., role play) or clinical settings, and 50% of schools did not address smoking in summative assessments.

CONCLUSIONS

Practical skills training regarding cessation counseling is insufficient at most U.K. medical schools and may have become worse during the last 11 years. Increased curricular coverage-including summative assessments-of these topics would ensure that future physicians are adequately equipped to encourage and support effective evidence-based quit attempts in their patients.

E-cigarettes: online survey of UK smoking cessation practitioners

BACKGROUND

Use of e-cigarettes (inhalable vapour producing battery powered devices that aim to simulate tobacco cigarettes), is rising in a number of countries, but as yet none of these products are regulated as medicinal devices or available as smoking cessation treatments. Smokers seeking support from health professionals to stop smoking are interested in e-cigarettes and may be buying them to aid a quit attempt. Determining what smokers are asking, and what health professionals think about these products may have implications for smoking treatment services in a number of countries.

METHODS

Stop smoking service advisors, managers and commissioners in the United Kingdom were asked to take part in two surveys on e-cigarettes. Data was analysed from 587 practitioners who completed a survey in 2011 and 705 practitioners who completed a repeat survey in 2013. Responses to multiple choice questions and free text comments were analysed.

RESULTS

Responding practitioners reported that interest in, and use of, e-cigarettes is growing among adults seeking help to stop smoking in the UK. In 2013 91% of respondents reported that interest in e-cigarettes had grown in the past year and whilst in 2011, 2% of respondents reported a 'quarter to a half' of their clients saying that they were regularly using e-cigarettes, by 2013 this had increased to 23.5% (p < .001). Responding practitioners' views towards e-cigarettes became more positive between the first and second surveys (15% strongly agreed/agreed in 2011 that 'e-cigarettes are a good thing' rising to 26% in 2013). However, they continued to have concerns about the products. In particular, analysis of free text responses suggested practitioners were unsure about safety or efficacy for smoking cessation, and were worried that smokers may become dependent on the products. Practitioners were also aware of the potential of e-cigarettes to undermine smokers' willingness to use evidence-based methods to stop, and to challenge policies aiming to denormalise tobacco smoking.

CONCLUSIONS

Health professionals are asking for reliable and accurate information on e-cigarettes to convey to smokers who want to quit. Randomized controlled trials and ongoing surveillance of e-cigarette use and its consequences for smoking cessation rates and smoking treatment services are required.

Nicotine patch preloading for smoking cessation (the preloading trial): study protocol for a randomized controlled trial

Background

The use of nicotine replacement therapy before quitting smoking is called nicotine preloading. Standard smoking cessation protocols suggest commencing nicotine replacement therapy only on the first day of quitting smoking (quit day) aiming to reduce withdrawal symptoms and craving. However, other, more successful smoking cessation pharmacotherapies are used prior to the quit day as well as after. Nicotine preloading could improve quit rates by reducing satisfaction from smoking prior to quitting and breaking the association between smoking and reward. A systematic literature review suggests that evidence for the effectiveness of preloading is inconclusive and further trials are needed.

Methods/Design

This is a study protocol for a multicenter, non-blinded, randomized controlled trial based in the United Kingdom, enrolling 1786 smokers who want to quit, funded by the National Institute for Health Research, Health Technology Assessment program, and sponsored by the University of Oxford. Participants will primarily be recruited through general practices and smoking cessation clinics, and randomized (1:1) either to use 21 mg nicotine patches, or not, for four weeks before quitting, whilst smoking as normal. All participants will be referred to receive standard smoking cessation service support.

Follow-ups will take place at one week, four weeks, six months and 12 months after quit day. The primary outcome will be prolonged, biochemically verified six-month abstinence. Additional outcomes will include point prevalence abstinence and abstinence of four-week and 12-month duration, side effects, costs of treatment, and markers of potential mediators and moderators of the preloading effect.

Discussion

This large trial will add substantially to evidence on the effectiveness of nicotine preloading, but also on its cost effectiveness and potential mediators, which have not been investigated in detail previously. A range of recruitment strategies have been considered to try and compensate for any challenges encountered in recruiting the large sample, and the multicentre design means that knowledge can be shared between recruitment teams. The pragmatic study design means that results will give a realistic estimate of the success of the intervention if it were to be rolled out as part of standard smoking cessation service practice.

Trial registration

Current Controlled Trials ISRCTN33031001. Registered 27 April 2012.

Varenicline versus transdermal nicotine patch: a 3-year follow-up in a smoking cessation clinic in Taiwan

RATIONALE

A network meta-analysis of randomized trials and real-world comparative studies strongly suggest that varenicline is more effective in aiding smoking cessation than single form nicotine replacement therapy (NRT). Modeling the health benefits attributable to this difference relies on extrapolation to lifetime cessation, but to date, follow-up has only extended to 12 months. Longer term follow-up data are helpful in checking these assumptions.

OBJECTIVES

This study aimed to compare the sustained abstinence rates of smokers using varenicline versus nicotine patch in their quit attempt up to 36 months.

METHOD

Five hundred eighty-seven smokers were recruited at Kaohsiung Veteran General Hospital between Feb 2006 and Aug 2009. Participants received counseling from a physician and received either varenicline (N=296) or the nicotine patch (N=291) for smoking cessation. Both varenicline and nicotine patch users could receive their medications for a maximum of 8 weeks. Participants were followed up by telephone at 3, 6, 12, and 36 months from the first visit. The primary outcome measure was self-reported sustained abstinence up to 36 months. Measures were also taken of smoking characteristics, cigarette dependence, and sociodemographic characteristics.

RESULTS

Multiple logistic regression of 36-month sustained abstinence on to medication adjusting for other baseline variables showed a significant advantage for varenicline, OR=7.94 (95 % CI 1.87-33.74).

CONCLUSION

An 8-week course of varenicline appears to yield higher abstinence rate up to 3 years than a similar length course of nicotine transdermal patch in routine clinical practice where behavioral support is available.

Validation of risk assessment scales and predictors of intentions to quit smoking in Australian Aboriginal and Torres Strait Islander peoples: a cross-sectional survey protocol

INTRODUCTION

Tobacco smoking is a very significant behavioural risk factor for the health of Australian Aboriginal and Torres Strait Islanders, and is embedded as a social norm. With a focus on women of childbearing age, and men of similar age, this project aims to determine how Aboriginal and Torres Strait Islander smokers assess smoking risks and how these assessments contribute to their intentions to quit. The findings from this pragmatic study should contribute to developing culturally targeted interventions.

METHODS AND ANALYSIS

A cross-sectional study using quantitative and qualitative data. A total of 120 Aboriginal and Torres Strait Islander community members aged 18-45 years will be recruited at community events and through an Aboriginal Community Controlled Health Service (ACCHS). Participants will be interviewed using a tablet computer or paper survey. The survey instrument uses modified risk behaviour scales, that is, the Risk Behaviour Diagnosis (RBD) scale and the Smoking Risk Assessment Target (SRAT) (adapted from the Risk Acceptance Ladder) to determine whether attitudes of Aboriginal and Torres Strait Islander smokers to health risk messages are predictors of intentions to quit smoking. The questionnaire will be assessed for face and content validity with a panel of Indigenous community members. The internal consistency of the RBD subscales and their patterns of correlation will be explored. Multivariate analyses will examine predictors of intentions to quit. This will include demographics such as age, gender, nicotine dependence, household smoking rules and perceived threat from smoking and efficacy for quitting. The two risk-assessment scales will be examined to see whether participant responses are correlated.

ETHICS AND DISSEMINATION

The Aboriginal Health & Medical Research Council Ethics Committee and university ethics committees approved the study. The results will be published in a peer-reviewed journal and a community report will be disseminated by the ACCHS, and at community forums.

NOTE ABOUT TERMINOLOGY

We use the term Aboriginal and Torres Strait Islander peoples, except where previous research has reported findings from only one group for example, Aboriginal people. Indigenous is used here to refer to Indigenous peoples in the international context, and issues, policies or systems, for example, Indigenous health, Indigenous tobacco control.

How stable are stop smoking practitioner success rates over time?

Stop smoking practitioners appear to differ in effectiveness, but the stability of their success rates over time is unknown. The purpose of this study was to assess the degree of stability of success rates of stop smoking practitioners over several years of practice. Using routinely collected practice data, the success rates of 197 practitioners active between April 2009 and April 2012 in the English stop smoking services were correlated across years before and after adjusting for client and intervention characteristics. Changes in client and intervention characteristics were assessed. Success rates for individual practitioners correlated highly in successive years (r = 0.64 to 0.68, p < 0.001, ICC = 0.56) and moderately over non-successive years (r = 0.39 to 0.51, p < 0.001). There was no evidence for increasing effectiveness over time. Practitioners' effectiveness is moderately stable over time. Research is needed to establish what characterises the practice of the more successful practitioners.

Effects of standardised cigarette packaging on craving, motivation to stop and perceptions of cigarettes and packs

OBJECTIVE

To assess whether standardised packs of the form introduced in Australia are associated with a reduction in acute craving and/or an increase in motivation to stop, and to replicate previous findings on perceptions of packaging, perceptions of smokers using it and perceived effects on behaviour.

DESIGN

Following abstinence of at least 12 h, 98 regular and occasional smokers were randomised to exposure to their own cigarette package, another branded package or a standardised package.

MAIN OUTCOME MEASURES

Craving (QSU-brief), motivation to stop, both at baseline and post-exposure. Ratings of 10 attributes concerning package design, perceived smoker characteristics and effects on behaviour, post-exposure only.

RESULTS

For craving, a mixed model ANCOVA showed a significant interaction of packaging and time of measurement (F(2,94) = 8.77, p < .001, partial η(2) = .16). There was no significant main effect or interaction for motivation to stop smoking (p = .9). The standardised pack was perceived to be significantly less appealing and less motivating to buy cigarettes, smokers using them were perceived as less popular and cigarettes from them expected to taste worse.

CONCLUSION

Standardised cigarette packaging may reduce acute (hedonic) craving and is associated with more negative perceptions than branded packaging with less prominent health warnings.

Developing anti-tobacco messages for Australian Aboriginal and Torres Strait Islander peoples: evidence from a national cross-sectional survey

Background

Smoking rates in Australian Aboriginal and Torres Strait Islander peoples remain high, with limited impact of government measures for many subgroups. The aim of this cross-sectional study was to investigate differences in organisational practice for developing anti-tobacco messages for these target populations.

Methods

Telephone interviews were conducted with 47 organisation representatives using a structured questionnaire based on health communication and health promotion frameworks. Responses were coded into phases of message development, message types (educational, threat, positive or advocacy), target groups, message recommendations, and evaluations undertaken. Cultural sensitivity for message development was divided into surface structure (use of images, language, demographics) and deep structure (use of socio-cultural values). A categorical principal component analysis explored the key dimensions of the findings and their component relationships.

Results

Among organisations interviewed, a community-orientated, bottom-up approach for developing anti-tobacco messages was reported by 47% (n = 24); 55% based message development on a theoretical framework; 87% used a positive benefit appeal; 38% used threat messages. More Aboriginal Medical Services (AMSs) targeted youth (p < 0.005) and advised smokers to quit (p < 0.05) than other types of organisations. AMSs were significantly more likely to report using deep structure in tailoring messages compared with non-government (p < 0.05) and government organisations (p < 0.05). Organisations that were oriented to the general population were more likely to evaluate their programs (p < 0.05). A two-dimensional non-linear principal component analysis extracted components interpreted as “cultural understanding” (bottom-up, community-based approaches, deep structures) and “rigour” (theoretical frameworks, and planned/completed evaluations), and accounted for 53% of the variability in the data.

Conclusion

Message features, associated with successful campaigns in other populations, are starting to be used for Aboriginal and Torres Strait Islander peoples. A model is proposed to facilitate the development of targeted anti-tobacco messages for Aboriginal and Torres Strait Islander peoples. Organisations could consider incorporating both components of cultural understanding-rigour to enable the growth of evidence-based practice.

How are the English Stop Smoking Services responding to growth in use of electronic cigarettes?

OBJECTIVE

To assess extent of electronic cigarette use by smokers attending Stop Smoking Services, the advice given about electronic cigarettes and whether this usage is recorded.

METHODS

Fifty-eight managers and 1284 practitioners completed an online survey. Questions covered use of electronic cigarettes, the advice given and whether use was recorded in client databases.

RESULTS

Ninety per cent (n=1150) and 95% (n=1215) of practitioners respectively, reported that their clients were using electronic cigarettes and that they had been asked about them. Seventy-one per cent (n=41) of managers reported that they had a policy on the advice to be given; of whom 85% (n=35) said that practitioners should say that products were unlicensed. Fifty-five per cent (n=707) of practitioners reported giving such advice and 11% (n=138) said they warned smokers about their safety. Only 9% (n=119) reported that they recorded clients' use.

CONCLUSION

Although use of electronic cigarettes by smokers in Stop Smoking Services is common, few provisions are in place to record their use. Practitioners mostly advise that products are not licensed.

PRACTICAL IMPLICATIONS

There is a need to consider additional training for practitioners on use of e-cigarettes and harm reduction generally to ensure that advice is consistent and evidence-based.