Use and effectiveness of lapse prevention strategies among pregnant smokers

Little is known about the use of lapse prevention strategies to help smokers manage situation-triggered urges to smoke. Pregnant smokers (N = 174) participating in an intervention trial reported use of cognitive-behavioural lapse prevention strategies and smoking abstinence (biochemically verified). Participants typically enacted few strategies. Distraction strategies were most commonly used. Total number of strategies used did not predict abstinence. However, using 'self-talk' (odds ratio (OR) = 3.44, 95% confidence interval = 1.14-10.40) or 'avoiding spending time with other smokers' (OR = 4.01, 95% confidence interval = 1.34-11.95) independently increased the odds of abstinence. The promotion of these and other under-utilised evidence-based strategies warrants further attention.

Behavioural therapy for smoking cessation: the effectiveness of different intervention types for disadvantaged and affluent smokers

BACKGROUND

Disadvantaged smokers are less likely to be successful when trying to stop smoking than more affluent smokers. In the UK, NHS Stop Smoking Services (SSS) provide a range of pharmacotherapy and behavioural support, delivered by advisors with a range of backgrounds. Whether the types of support provided and who provides it influence differences in quit rates amongst low SES smokers compared with high SES smokers has not previously been examined.

METHODS

202,084 records of smokers in England who attended a NHS Stop Smoking Service between July 2010 and June 2011 were acquired. Smokers were followed-up by services at four weeks post quit date. Multilevel logistic regression models of CO validated quits were employed. Disadvantage was explored through the National Statistics Socio-Economic Classification (NS-SEC) and by eligibility for free prescriptions, an indicator of low income amongst adults aged between 19 and 59 in England.

RESULTS

Affluent smokers were more likely to quit than disadvantaged smokers (OR 1.38 (1.35 to 1.42) for clients who paid for prescriptions compared to those eligible for free prescriptions). 80% of service clients received one-to-one counselling but open group forms of behavioural therapy were more successful (main effect OR 1.26 (1.12 to 1.41)) except amongst some of the most disadvantaged clients (long-term unemployed and prisoners). Closed groups were little deployed and they were not significantly more successful than one-to-one behavioural therapy after controls. Who delivered treatment did make a difference for some clients, with all but the most affluent less likely to be successful if they had been treated by a nurse compared with other types of advisers, including smoking cessation specialists (main effect OR 0.73 (0.65 to 0.83)).

CONCLUSION

This study provides further evidence that disadvantaged smokers find quitting more difficult even when they have attended a smoking cessation programme. The findings suggest that open groups should be promoted, although they may not be as effective as other forms of behavioural therapy for the long-term unemployed or prisoners. Further research is required to explore why most groups of smokers who attended services staffed by nurses were less likely to quit than those who received treatment from other types of advisors.

To what extent should waterpipe tobacco smoking become a public health priority?

BACKGROUND

Waterpipe tobacco smoking (WTS) popularity is increasing world-wide, and health effects are emerging in the light of evidence that WTS is perceived by users as less harmful than cigarette smoking. However, there remains a paucity of available evidence from which to draw firm conclusions about its public health significance.

AIMS

This narrative review aims to summarize WTS literature to date to inform tobacco control specialists and health-care professionals about this phenomenon and help them to assess whether or not WTS should become a public health priority.

METHODS

Standard electronic databases as well as conference proceedings and personal libraries were searched in English, French and Arabic with inclusive terminology for the variety of names given to WTS.

FINDINGS

Waterpipe smoke contains significant levels of toxins, some of which are known to be carcinogenic to humans. Recent epidemiological trends have established an increasing prevalence of WTS in the Middle East and the United States, particularly among adolescents. It is used commonly across multiple ethnicities and both genders with less of a social gradient than cigarette smoking. Attitudes and beliefs have been researched widely and several reasons for believing it is less harmful than cigarette smoking include water filtration and social acceptability. A wide range of diseases have been associated with WTS, but research in this area is relatively underdeveloped and a better evidence base is needed. Worryingly, the waterpipe industry, including waterpipe cafes, operates in an almost completely unregulated market and employs deceptive marketing techniques to attract new users.

CONCLUSIONS

Waterpipe tobacco smoking (WTS) appears to be on the increase, especially among younger users, and therefore represents a potential public health concern. While legislators should consider enforcing and extending existing tobacco laws to a growing WTS industry, further research is required to fill gaps in the literature and provide evidence-based interventions for tobacco control specialists and health-care professionals.

The importance of practitioner smoking status: a survey of NHS Stop Smoking Service practitioners

OBJECTIVE

To investigate the smoking status of stop smoking practitioners, the impact of this on their practice, and clients' quit rates.

METHODS

Smoking cessation practitioners in the UK NHS Stop Smoking Service were asked about their smoking status, client quit rates and practitioner-client interaction, using an online survey. Associations between responses were investigated using logistic regression.

RESULTS

51% of the sample (N=484) were ex-smokers. Most practitioners had been questioned about their smoking status by clients, with more never than ex-smokers claiming that this reduced their confidence when advising. Never smokers more frequently reported that clients questioned their ability as a practitioner, but no significant difference in quit rates was reported between never and ex-smokers.

CONCLUSION

Although evidence suggests smokers believe many practitioners are never smokers, this survey found that this is not true. Research investigating how many smokers might not be seeking support to quit because of this could be beneficial.

PRACTICE IMPLICATIONS

Raising awareness of the similarity of quit rates achieved by never and former smoker practitioners, and the experience practitioners draw upon when offering advice, might encourage greater use of the NHS SSS. It could also be beneficial to improve training in never smokers to address confidence issues.

Cigarette craving and withdrawal symptoms during temporary abstinence and the effect of nicotine gum

RATIONALE

It is widely believed that nicotine withdrawal symptoms appear within a few hours of stopping smoking, but few data exist documenting their emergence in naturalistic settings. In several countries, nicotine replacement products are licensed for relief of withdrawal symptoms during temporary abstinence, but again, there are no data supporting this from naturalistic settings.

OBJECTIVES

To examine the emergence of cigarette craving and withdrawal symptoms during temporary abstinence in a naturalistic setting while using either nicotine or placebo gum.

METHODS

Double-blind, randomised, placebo-controlled study in which 132 dependent smokers abstained for 6 h with the assistance of either nicotine (2 mg, n = 42 or 4 mg, n = 24) or placebo (n = 66) gum while travelling on a non-smoking train. Outcome measures were ratings of craving and mood withdrawal symptoms prior to treatment and at regular intervals during abstinence.

RESULTS

In a multivariate analysis of all symptoms, there was no interaction between treatment and time [F(21,110) = 1.28, p = 0.20, η²(p)= 0.20] nor an effect of treatment [F(7,124) = 0.45, p = 0.87, η²(p)=  0.03]. There was an effect of time [F(21,110) = 11.59, p < 0.001, η²(p)= 0.69) and univariate analyses revealed that the majority of symptoms increased linearly throughout the period of abstinence with detectable onsets typically between the first 60 and 180 min of abstinence.

CONCLUSIONS

Smokers who temporarily abstain in naturalistic settings experience craving and withdrawal symptoms that emerge linearly over the first 6 h of abstinence. Changes in craving and several mood withdrawal symptoms can be detected within the first 3 h. Nicotine gum may not have an acute effect on the development of these symptoms.

Performance of English stop smoking services in first 10 years: analysis of service monitoring data

OBJECTIVES

To analyse the performance of the English Stop Smoking Services from 2001/02 to 2010/11.

DESIGN

Analysis of national service monitoring data.

SETTING

England.

PARTICIPANTS

Smokers recorded as having been treated by English stop smoking services between April 2001 and March 2011.

MAIN OUTCOME MEASURES

Annual figures for the number of quit dates set (throughput), the percentage of these that led to biochemically verified abstinence after four weeks (four week quit rate), and the "impact" in terms of the number of four week quitters beyond those who it is estimated would have stopped with only a prescription for smoking cessation treatment; characteristics of smokers being treated, medication used, and mode of delivery (for example, one to one, group based); variability across local services in throughput, four week quit rates, and impact for 2010/11.

RESULTS

Throughput rose from 227,335 in 2001/02 to 787,527 (8% of all smokers) in 2010/11. The percentage of four week quitters declined slightly from 35% to 34%. Impact rose from 22,933 four week quitters created in 2001/02 to 72,411 in 2010/11 (corresponding to an estimated 21,723 12 month quitters). The services were successful in reaching disadvantaged smokers; 54% (n = 425,684) were in receipt of free prescriptions in 2010/11. Substantial variation existed across local services in throughput, success rates, and impact.

CONCLUSIONS

The English stop smoking services have had an increasing impact in helping smokers to stop in their first 10 years of operation and have successfully reached disadvantaged groups. However, performance across local services has varied considerably.

Should anti-tobacco media messages be culturally targeted for Indigenous populations? A systematic review and narrative synthesis

OBJECTIVE

To summarise published empirical research on culturally targeted anti-tobacco media messages for Indigenous or First Nations people and examine the evidence for the effectiveness of targeted and non-targeted campaigns.

METHODS

Studies were sought describing mass media and new media interventions for tobacco control or smoking cessation in Indigenous or First Nations populations. Studies of any design were included reporting outcomes of media-based interventions including: cognitions, awareness, recall, intention to quit and quit rates. Then, 2 reviewers independently applied inclusion criteria, which were met by 21 (5.8%) of the studies found. One author extracted data with crosschecking by a second. Both independently assessed papers using Scottish Intercollegiate Guidelines Network (SIGN; quantitative studies) and Daly et al (qualitative studies).

RESULTS

A total of 21 studies were found (4 level 1 randomised controlled trials (RCTs), 11 level 2 studies and 6 qualitative studies) and combined with narrative synthesis. Eight evaluated anti-tobacco TV or radio campaigns; two assessed US websites; three New Zealand studies examined mobile phone interventions; five evaluated print media; three evaluated a CD-ROM, a video and an edutainment intervention.

CONCLUSIONS

Although Indigenous people had good recall of generic anti-tobacco messages, culturally targeted messages were preferred. New Zealand Maori may be less responsive to holistic targeted campaigns, despite their additional benefits, compared to generic fear campaigns. Culturally targeted internet or mobile phone messages appear to be as effective in American Indians and Maori as generic messages in the general population. There is little research comparing the effect of culturally targeted versus generic messages with similar message content in Indigenous people.

How to advise and refer inpatients who smoke

Patients who smoke are more likely to experience postoperative complications than non-smokers and up to one-third of all hospital patients are estimated to be smokers. Inpatients are receptive to an offer of stop-smoking support but are not always referred to stop-smoking services. A pilot of a acute care referral system trained staff to deliver very brief advice on smoking via a short online training module, and provided a streamlined electronic referral system to local NHS stop-smoking services. The three-month pilot resulted in a 600% increase in referrals. Nursing staff felt that the system was simple and effective, and that patients had benefited.

Evaluation of a programme to increase referrals to stop-smoking services using Children's Centres and smoke-free families schemes

AIMS

To assess the feasibility and effectiveness of a new service using referral liaison advisers to increase the number of referrals of parents/carers at selected Children's Centres to National Health Service (NHS) Stop Smoking Services (SSS) and/or smoke-free families schemes (SFS).

DESIGN

This mixed-methods pilot study collected numerical data on indicators of smoking behaviours and carried out face-to-face and telephone interviews.

SETTINGS

Thirteen Children's Centres in Liverpool and Nottingham using local providers of smoking cessation services, from September 2010 to April 2011.

PARTICIPANTS

Parents and carers registered with, and staff working for, Children's Centres.

MEASURES

Number of smokers referred to smoking cessation services and/or smoke-free family schemes and the views of service providers and users on the new service.

FINDINGS

In Liverpool, 181 referrals to NHS SSS were made from 331 identified smokers (54.7%); extrapolated to 12 months, this represents a 182% increase in referrals from baseline and a similar extrapolation indicates a 643% increase from baseline of referrals to smoke-free families schemes. There were no reliable baseline data for Nottingham; 31 referrals were made (30.7% of smokers) to SSS and 44 referrals to SFS from 52 contacts (84.6%). The interviews highlighted the need for sustained personal contact with parents/carers to discuss smoking behaviours and concerns and their willingness to be referred to SFS as part of caring for their child.

CONCLUSIONS

Routine recording of smoking status and appropriate follow-up by trained staff in Children's Centres can lead to significant numbers of clients attending stop-smoking services, although relatively few stop smoking.

Developing the evidence base for addressing inequalities and smoking in the United Kingdom

AIMS

Smoking is an increasing cause of health inequalities in high-income countries. This supplement describes pilot projects set up in England to develop and test pathways to ensure that disadvantaged groups, where smoking is frequently the norm, are reached, encouraged and supported to stop their tobacco use. Target groups were: smokers attending centres set up for highly deprived parents; smokers with serious and enduring mental illness; pregnant smokers; prisoners/other offenders who smoked; South Asian tobacco chewers; and recent quitters from 'routine and manual' occupational groups.

METHODS

Commonalities observed across the six projects are summarized, alongside recommendations for implementation.

RESULTS

A significant barrier to implementation was the lack of mandatory identification of tobacco users across primary, secondary and community health-care settings and routine use of expired air carbon monoxide monitoring, particularly for high-risk groups. Appropriate use of financial incentives and national guidance is probably necessary to achieve both this and the adoption of 'joined-up' tobacco dependence treatment pathways for these target groups. Further research is needed on the impact of 'opt out' pathways: while resulting in increased referral rates, success rates were lower. In general, smoking cessation service targets were a barrier to implementation. Flexibility and tailoring of interventions were required and most projects trained those already working in relevant settings, given their greater understanding of target groups. Mandatory training of all frontline health-care staff was deemed desirable.

CONCLUSIONS

Implementing the findings of these projects will require resources, for training, incentivizing health-care workers and further research. However, continuing with the status quo may result in sustained tobacco use health inequalities for the foreseeable future.

Does it matter who you see to help you stop smoking? Short-term quit rates across specialist stop smoking practitioners in England

AIMS

A network of Stop Smoking Services has been set up within the National Health Service (NHS) in England. The services deliver a combination of behavioural support and medication. It is important to establish the degree of variability in quit rates attributable to differences between individual practitioners, to gauge the scope for improvement by training and professional support. The aim of the present analysis was to examine how far short-term quit rates depend on the practitioner delivering the intervention after adjusting for potential confounding variables.

DESIGN

Observational study using routinely collected data.

SETTING

Thirty-one NHS Stop Smoking Services in England.

PARTICIPANTS

Data from 46,237 one-to-one treatment episodes (supported quit attempts) delivered by specialist practitioners.

MEASUREMENTS

Three-level logistic regression models were fitted for carbon monoxide (CO)-validated short-term (4-week) quit rates. Models adjusted for age, gender, exemption from prescription charges, medication and intervention setting for each treatment episode, number of clients for each practitioner and economic deprivation at the level of the Stop Smoking Service. Secondary analyses included (i) the heaviness-of-smoking index (HSI) as predictor and (ii) 4-week quit rates whether or not confirmed by CO.

FINDINGS

Differences between individual specialist practitioners explained 7.6% of the variance in CO-verified quit rates after adjusting for client demographics, intervention characteristics and practitioner and service variables (P < 0.001). HSI had little impact on this figure; in quits not necessarily validated by CO, practitioners explained less variance.

CONCLUSIONS

Individual stop smoking practitioners appear to differ to a significant degree in effectiveness. It is important to examine what underlies these differences in order to improve selection, training and professional development.

Evaluation of a drop-in rolling-group model of support to stop smoking

AIMS

To assess longer-term outcomes of a drop-in rolling-group model of behavioural support for smoking cessation and the factors that influence cessation outcomes.

DESIGN

Prospective observational cohort study.

SETTING

Fag Ends NHS Stop Smoking Service in Liverpool and Knowsley, UK.

PARTICIPANTS

A total of 2585 clients, aged 16 or over, setting a quit date.

MEASUREMENTS

Routine monitoring data were collected from Fag Ends service users and were supplemented by survey data on socio-economic circumstances, smoking-related behaviour and self-report and carbon monoxide (CO)-validated smoking status at 52-week follow-up.

FINDINGS

The CO-validated prolonged abstinence rate at 52 weeks for smokers attending the groups was 5.6%, compared with 30.7% at 4 weeks (a relapse rate of 78.2%). The sample was particularly disadvantaged: 68% resided in the most deprived decile of the English Index of Multiple Deprivation. Higher socio-economic status within the sample was a predictor of quitting. Other predictors of long-term cessation in multivariate analysis included older age, being female, lower levels of nicotine dependence, having a live-in partner, stronger determination to quit and use of varenicline versus other medication.

CONCLUSIONS

A wholly state-reimbursed clinical stop-smoking service providing behavioural support and medication in a region of high economic and social disadvantage has reached a significant proportion of the smoking population. Long-term success rates are lower than are found typically in clinical trials, but higher than would be expected if the smokers were to try and quit unaided. Research is needed into how to improve on the success rates achieved.

Development of StopAdvisor: A theory-based interactive internet-based smoking cessation intervention

Reviews of internet-based behaviour-change interventions have shown that they can be effective but there is considerable heterogeneity and effect sizes are generally small. In order to advance science and technology in this area, it is essential to be able to build on principles and evidence of behaviour change in an incremental manner. We report the development of an interactive smoking cessation website, StopAdvisor, designed to be attractive and effective across the social spectrum. It was informed by a broad motivational theory (PRIME), empirical evidence, web-design expertise, and user-testing. The intervention was developed using an open-source web-development platform, 'LifeGuide', designed to facilitate optimisation and collaboration. We identified 19 theoretical propositions, 33 evidence- or theory-based behaviour change techniques, 26 web-design principles and nine principles from user-testing. These were synthesised to create the website, 'StopAdvisor' (see http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The systematic and transparent application of theory, evidence, web-design expertise and user-testing within an open-source development platform can provide a basis for multi-phase optimisation contributing to an 'incremental technology' of behaviour change.

Translating evidence-based guidelines into practice: a survey of practices of commissioners and managers of the English stop smoking services

Background

The English National Health Service’s (NHS) Stop Smoking Services (SSSs) constitute one of the most highly developed behavioural support programmes in the world. However, there is significant variation in success rates across the approximately 150 services, some of which may be due to variation in practice. This study aimed to assess these differences in practice.

Methods

Two online surveys were administered. All commissioners (people who purchase services for the NHS) and managers (those who run the services) of NHS SSSs in England were invited to participate. Items included details of current practices and services provided, what informed the commissioning of SSSs, what targets were included within service specifications and whether the types of treatment model to be delivered were specified.

Results

Both surveys had a response rate of 35%, with 50 commissioners and 58 managers participating. There were no significant differences between the characteristics of the Primary Care Trusts (PCTs) from which commissioners and managers responded to this survey and those PCTs from which there was no response. Managers reported that the treatment model most frequently offered by SSSs was one-to-one (98%). A total of 16% of managers reported that some approved medications were not available as first-line treatments. Just over one third (38%) of commissioners reported consulting national guidelines or best evidence to inform local commissioning. Almost one third (30%) of commissioners reported that they specified the types of stop smoking interventions to be delivered by the providers.

Conclusions

A substantial part of commissioning of Stop Smoking Services in England appears to take place without adequate consultation of evidence-based guidelines or specification of the service to be provided. This may account for at least some of the variation in success rates.

Self-reported practices, attitudes and levels of training of practitioners in the English NHS Stop Smoking Services

The primary aim of the current study is to investigate the self-reported practices, attitudes and levels of training of stop smoking practitioners (SSPs) working at the English National Health Service's (NHS) Stop Smoking Services (SSSs). A secondary aim was to investigate differences between 'Specialist' and 'Community' SSPs. An online survey was conducted with 484 SSPs. Most (94%) SSPs offered one-to-one appointments to smokers, only 43% always used the abrupt quit model and 30% reported ever recommending particular medication to clients. SSPs reported an average of 3.7 days training when starting work and 26% reported never observing an experienced practitioner before seeing clients of their own. Over half (56%) never received clinical supervision. SSPs reported having generally positive attitudes towards their jobs, but reported feeling less positive about their prospects for future employment within the field. 'Specialist' SSPs reported receiving more days training (4.1 vs. 3.0, p=0.002), more days observing an experienced practitioner when starting work (12.9 vs. 6.6, p<0.001) and were more likely to receive clinical supervision (48.9% vs. 34.9%, p<0.05) than 'Community' SSPs. Gaps between SSPs' current practices and evidence-based guidelines may be due to inadequate training. Similarly, differences in training between specialist and community SSPs may contribute to the observed difference in these practitioners' success rates. As recommended by the Department of Health for England, standardized training in evidence-based smoking cessation interventions should be implemented for both specialist and community SSPs.

Effect of offering different levels of support and free nicotine replacement therapy via an English national telephone quitline: randomised controlled trial

OBJECTIVE

To compare the effects of free nicotine replacement therapy or proactive telephone counselling in addition to standard smoking cessation support offered through a telephone quitline.

DESIGN

Parallel group, 2 × 2 factorial, randomised controlled trial.

SETTING

National quitline, England.

PARTICIPANTS

2591 non-pregnant smokers aged 16 or more residing in England who called the quitline between February 2009 and February 2010 and agreed to set a quit date: 648 were each randomised to standard support, proactive support, or proactive support with nicotine replacement therapy, and 647 were randomised to standard support with nicotine replacement therapy.

INTERVENTIONS

Two interventions were offered in addition to standard support: six weeks' nicotine replacement therapy, provided free, and proactive counselling sessions (repeat telephone calls from, and interaction with, cessation advisors).

MAIN OUTCOME MEASURES

The primary outcome was self reported smoking cessation for six or more months after the quit date. The secondary outcome was cessation validated by exhaled carbon monoxide measured at six or more months.

RESULTS

At six months, 17.7% (n = 229) of those offered nicotine replacement therapy reported smoking cessation compared with 20.1% (n = 261) not offered such therapy (odds ratio 0.85, 95% confidence interval 0.70 to 1.04), and 18.2% (n = 236) offered proactive counselling reported smoking cessation compared with 19.6% (n = 254) offered standard support (0.91, 0.75 to 1.11). Data validated by carbon monoxide readings changed the findings for nicotine replacement therapy only, with smoking cessation validated in 6.6% (85/1295) of those offered nicotine replacement therapy compared with 9.4% (122/1296) not offered such therapy (0.67, 0.50 to 0.90).

CONCLUSIONS

Offering free nicotine replacement therapy or additional (proactive) counselling to standard helpline support had no additional effect on smoking cessation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00775944.