Oncology Patient Smoking Cessation Treatment Preferences: Perceptions Across Former and Current Cigarette Smokers

Although the benefits of smoking cessation following a cancer diagnosis have been well-established, up to 50% of cancer patients continue to smoke. Continued smoking through oncology treatment leads to increased risk of adverse events including reduced effectiveness of treatment, recurrence of additional malignancies, and reduced survival rates. Upon the cancer diagnosis, oncology healthcare providers become the primary trusted source of information and support, which represents a great opportunity to assist these patients to quit smoking. However, it remains unclear how oncology healthcare providers can best address smoking cessation from a patient-centered perspective. The present study surveyed oncology patients from Birmingham, AL, classified as either former (n = 174) or current smokers (n = 81) to identify their perceptions regarding the role of oncology healthcare providers in their smoking cessation efforts. Current smokers were more likely to be younger, received their cancer diagnosis within the past 3 years, and have a cancer diagnosis with high smoking-related public awareness (i.e., head, neck, or lung) compared to former smokers. Additionally, 81% of current smokers reported experiencing smoking cessation discussions with their oncology healthcare providers with the most prominent recommendations being use of nicotine replacement therapies (46.9%) and medication (35.8%). These smoking cessation experiences align with patient preferences. However, despite the frequency of smoking cessation discussions, current smokers demonstrated an ambivalence in understanding the risks of continued smoking during their medical treatment. Overall, this study highlights the important role of oncology healthcare providers on implementing smoking cessation intervention for their patients who continue to smoke.

Effect of brief nicotine corrective messaging on nicotine beliefs in persons who use opioids

This pilot study tested the effect of a brief nicotine education messaging exposure on beliefs about nicotine, nicotine-replacement therapy (NRT), and e-cigarettes. Participants ages 18 and older were recruited via Amazon Mechanical Turk to complete a 20-min online survey in April/May 2020 to assess relationships between opioid use, smoking, and other behaviors. Participants with past-month extra-medical opioid use completed questions on background characteristics and literacy and then were randomized in a 2:1 ratio of two conditions: nicotine education (n = 362) or no message control (n = 181). Beliefs about nicotine, NRT, and e-cigarettes were asked of all participants; this occurred after message exposure for the nicotine education condition. Bivariate and multivariable analyses examined differences in beliefs by study condition. Brief nicotine messaging increased the probability of a correct response to "Nicotine is a cause of cancer" (false, 63% vs. 36%) and reduced the probability of a don't know response (9% vs. 17%) compared to the no message control condition. Nicotine education also reduced false beliefs about harms of long-term NRT use compared to cigarettes (p < .05). In adjusted models, participants in the nicotine education group had lower mean false beliefs about nicotine (p < .001) and to a lesser extent NRT (p = .053) compared with the control group; there was no difference in mean false beliefs about e-cigarettes (p = .547) between groups. A brief education intervention produced similar changes in nicotine beliefs in adults with past-month extra-medical opioid use as in a general adult sample. Findings support the potential for impact of nicotine public education messaging in vulnerable populations. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Outcomes of a Comprehensive Mobile Smoking Cessation Program With Nicotine Replacement Therapy in Adult Smokers: Pilot Randomized Controlled Trial

BACKGROUND

Cigarette smoking remains the leading cause of preventable illness and death, underscoring ongoing need for evidence-based solutions. Pivot, a US Clinical Practice Guideline-based mobile smoking cessation program, comprises a personal carbon monoxide breath sensor; a smartphone app; in-app, text-based human-provided coaching; nicotine replacement therapy; and a moderated web-based community. Promising Pivot cohort studies have established the foundation for comparative assessment.

OBJECTIVE

This study aimed to compare engagement, retention, attitudes toward quitting smoking, smoking behavior, and participant feedback between Pivot and QuitGuide, a US Clinical Practice Guideline-based smoking cessation smartphone app from the National Cancer Institute.

METHODS

In this remote pilot randomized controlled trial, cigarette smokers in the United States were recruited on the web and randomized to Pivot or QuitGuide. Participants were offered 12 weeks of free nicotine replacement therapy. Data were self-reported via weekly web-based questionnaires for 12 weeks and at 26 weeks. Outcomes included engagement and retention, attitudes toward quitting smoking, smoking behavior, and participant feedback. The primary outcome was self-reported app openings at 12 weeks. Cessation outcomes included self-reported 7- and 30-day point prevalence abstinence (PPA), abstinence from all tobacco products, and continuous abstinence at 12 and 26 weeks. PPA and continuous abstinence were biovalidated via breath carbon monoxide samples.

RESULTS

Participants comprised 188 smokers (94 Pivot and 94 QuitGuide): mean age 46.4 (SD 9.2) years, 104 (55.3%) women, 128 (68.1%) White individuals, and mean cigarettes per day 17.6 (SD 9.0). Engagement via mean "total app openings through 12 weeks" (primary outcome) was Pivot, 157.9 (SD 210.6) versus QuitGuide, 86.5 (SD 66.3; P<.001). Self-reported 7-day PPA at 12 and 26 weeks was Pivot, 35% (33/94) versus QuitGuide, 28% (26/94; intention to treat [ITT]: P=.28) and Pivot, 36% (34/94) versus QuitGuide, 27% (25/94; ITT: P=.12), respectively. Self-reported 30-day PPA at 12 and 26 weeks was Pivot, 29% (27/94) versus QuitGuide, 22% (21/94; ITT: P=.32) and Pivot, 32% (30/94) versus QuitGuide, 22% (21/94; ITT: P=.12), respectively. The biovalidated abstinence rate at 12 weeks was Pivot, 29% (27/94) versus QuitGuide, 13% (12/94; ITT: P=.008). Biovalidated continuous abstinence at 26 weeks was Pivot, 21% (20/94) versus QuitGuide, 10% (9/94; ITT: P=.03). Participant feedback, including ease of setup, impact on smoking, and likelihood of program recommendation were favorable for Pivot.

CONCLUSIONS

In this randomized controlled trial comparing the app-based smoking cessation programs Pivot and QuitGuide, Pivot participants had higher engagement and biovalidated cessation rates and more favorable user feedback at 12 and 26 weeks. These findings support Pivot as an effective, durable mobile smoking cessation program.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04955639; https://clinicaltrials.gov/ct2/show/NCT04955639.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, although some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2022, and reference-checked and contacted study authors.  SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants, or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses.

MAIN RESULTS

We included 78 completed studies, representing 22,052 participants, of which 40 were RCTs. Seventeen of the 78 included studies were new to this review update. Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (RR 1.63, 95% CI 1.30 to 2.04; I2 = 10%; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6). There was moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs was similar between groups (RR 1.02, 95% CI 0.88 to 1.19; I2 = 0%; 4 studies, 1702 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.12, 95% CI 0.82 to 1.52; I2 = 34%; 5 studies, 2411 participants). There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 8 studies, 1272 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; I2 = 0%; 7 studies, 3126 participants). In absolute terms, this represents an additional two quitters per 100 (95% CI 1 to 3). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that (non-serious) AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.03, 95% CI 0.54 to 1.97; I2 = 38%; 9 studies, 1993 participants).  Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Sustained reduction of attentional bias to smoking cues by smartphone-delivered attentional bias modification training for smokers

OBJECTIVE

Cigarette smoking is thought to be at least partially maintained by the attentional bias (AB) toward smoking cues that develops as a consequence of drug dependence. This study evaluated the impact of smartphone-delivered, in-home attentional bias modification (ABM) to reduce AB to smoking cues and to reduce smoking behavior and withdrawal-related symptoms when used as an adjunct to conventional smoking cessation treatment.

METHOD

Participants (N = 246) were treatment-seeking smokers who completed up to 13 days of either ABM designed to train attention away from smoking cues, using a modified dot-probe task, or sham training, followed by 8 weeks of nicotine replacement therapy and counseling. Outcomes measured at baseline, 1-day post-ABM training, and 8 weeks post-ABM training included AB to smoking images and words using the dot-probe and smoking Stroop tasks, respectively, along with cigarettes per day, craving, and smoking abstinence.

RESULTS

We found that ABM training reduced AB to smoking stimuli on both the dot-probe task, ηp² = 0.056, 90% CI [0.024, 0.097], and the smoking Stroop task, ηp² = 0.017, 90% CI [0.002, 0.044], up to 8 weeks after ABM training when covarying for baseline response, but did not concurrently decrease smoking behavior or craving.

CONCLUSIONS

Thirteen days of smartphone-delivered ABM training, as an adjunct to smoking cessation treatment, reduced AB to both modality-specific and cross-modality smoking cues but did not impact smoking-related behavior. While ABM can reduce AB to smoking cues across modalities, it is unclear whether it has therapeutic potential as an adjunct to conventional smoking cessation therapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

[The e-cigarette - means of smoking cessation?]

After several years of declining tobacco consumption, the number of smokers in Germany is currently stagnating or rising again. The reasons seem to be manifold, e. g. stress caused by the pandemic with social isolation, rising cost of living and war in Europe.With tobacco use still widespread in the German population, evidence-based tobacco cessation is rarely implemented.According to recent studies, e-cigarettes are involved in the pathogenesis of lung disease, cardiac and vascular damage. In addition, their ingredients also have carcinogenic effects. However, clinical studies on long-term use are not yet available.E-cigarettes as a consumer product are not superior to nicotine replacement products and addiction-reducing medications recommended in guidelines. In the therapeutic setting, they are slightly more effective than nicotine replacement products. However, they are usually consumed continuously and thus perpetuate nicotine dependence. Their use increases the risk of relapse to tobacco smoking.Despite the various new approaches, such as Internet-based offerings, app, etc., talks and pharmacotherapy are the gold standard and more effective than any therapy on its own.

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults

There is a strong evidence base for the use of existing pharmacotherapies to support tobacco cessation, alone or in combination, ideally with concurrent behavioral interventions. Future pharmacotherapies under development may assist in the most refractory cases. Incorporating current and future therapies into a longitudinal chronic care model for tobacco dependence will help a diverse range of patients achieve independence from nicotine addiction.

Within-person decline in pregnancy smoking is observable prior to pregnancy awareness: Evidence across two independent observational cohorts

Decreased consumption of nicotine and other drugs during pregnancy appears to be a cross-species phenomenon from which mechanism(s) capable of interrupting addictive processes could be elucidated. Whether pregnancy influences smoking behaviour independent of women's knowledge of the pregnancy, however, has not been considered. Using repeated measures analysis of variance (ANOVA), we estimated within-person change in mean cigarettes/day smoked across the estimated date of conception but prior to individually reported dates of pregnancy recognition using longitudinal smoking data from two independent observational cohorts, the Growing Up Healthy (GUH, n = 271) and Midwest Infant Development Studies (MIDS, n = 145). Participants smoked an average of half a pack/day in the month immediately before conception (M (SD) = 12(8.1) and 9.5(6.7) cigarettes/day in GUH and MIDS, respectively). We observed within-person declines in smoking after conception, both before (MGUH  = -0.9; 95% CI -1.6, -0.2; p = 0.01; MMIDS  = -1.1; 95% CI -1.9, -0.3; p = 0.01) and after (MGUH  = -4.8; 95% CI -5.5, -4.1; p < 0.001; MMIDS  = -3.3; 95% CI -4.4, -2.5; p < 0.001) women were aware of having conceived, even when women who had quit and women who were planning to conceive were excluded from analyses. Pregnancy may interrupt smoking-related processes via mechanisms not previously considered. Plausible candidates and directions for future research are discussed.

Availability and content of clinical guidance for tobacco use and dependence treatment - United States, 2000-2019

Evidence-based treatments for tobacco use and dependence can increase cessation success but remain underutilized. Health professional societies and voluntary health organizations (advising organizations) are uniquely positioned to influence the delivery of cessation treatments by providing clinical guidance for healthcare providers. This study aimed to review the guidance produced by these organizations for content and consistency with current evidence. Documents discussing healthcare providers' role in treatment of tobacco use and dependence produced by US-based advising organizations between 2000 and 2019 were identified in both peer-reviewed and grey (i.e., informally or non-commercially published) literature. Extraction of variables, defined in terms of healthcare provider role and endorsement of specific treatment(s), was completed by two independent reviewers. Review of 38 identified documents sponsored by 57 unique advising organizations revealed deficits in the direction of comprehensive care and incorporation of the most recent evidence for treatment of tobacco use and dependence. Documents endorsed: screening (74%), pharmacotherapy (68%), counseling (89%), or follow-up (37%). Few documents endorsed more recent evidence-based treatments including combination nicotine replacement therapy (18%), and text- (11%) and web-based (11%) interventions. Advising organizations have opportunities to address identified gaps and enhance clinical guidance to contribute toward expanding the provision of comprehensive tobacco cessation support.

The Cost-Effectiveness of Nicotine Replacement Therapy Sampling in Primary Care: a Markov Cohort Simulation Model

BACKGROUND

Pharmacotherapies remain a central focus of successful tobacco control, but uptake remains very low.

OBJECTIVE

To estimate the cost effectiveness of a primary care nicotine replacement therapy (NRT) sampling intervention.

DESIGN

A Markov cohort simulation model was constructed to conduct cost-effectiveness analyses. Clinical trial results were used to initialize the Markov model. All other model parameters were derived from the literature. The study was conducted over a lifetime horizon, from the payers' budgetary perspective.

PARTICIPANTS

Smokers with a primary care visit.

INTERVENTION

Medication sampling, which provided short, starter packets of NRT (nicotine patch and lozenge) to smokers in the primary care setting.

MAIN MEASURES

Lifetime healthcare expenditures, quality-adjusted life years, and life years.

KEY RESULTS

Medication sampling was the dominant strategy compared to standard care. Our intervention cost $75, yielding a discounted lifetime savings of $1065 in healthcare expenditures, and increased both discounted quality-adjusted life years and discounted life years by 0.01. One-way sensitivity analyses showed that medication sampling remained dominant in plausible ranges except when it failed to increase cessation relative to standard care. Probabilistic sensitivity analyses confirmed that medication sampling was dominant in 94.1% of the simulated cases, with an implementation cost of $74 (95% CI $73-$76) and discounted lifetime savings in health expenditures of $1061 (- $1106 to - $1,017), increasing quality-adjusted life years by 0.008 (0.0085-0.0093) and life years by 0.008 (0.0081-0.0089).

CONCLUSION

Medication sampling, an easily implementable, scalable and low-cost intervention to encourage smoking cessation, is cost saving and improves quality of life.

Efficacy and safety evaluation of adjuvant auricular acupuncture for smoking cessation: A study protocol of randomized, assessor-blinded, pragmatic pilot trial

BACKGROUND

Smoking negatively impacts public health. There are several treatments to quit smoking, and nicotine replacement treatment (NRT) reportedly doubles the smoking cessation rate, with some limitations. Acupuncture is an alternative option with proven effects on smoking cessation. However, there has been no definite report that indicates the efficacy and safety of auricular acupuncture (AA) combined with NRT on smoking cessation.

METHODS

This is a randomized, assessor-blind, and pragmatic pilot study. We will recruit 40 participants who want to stop smoking and randomly allocate them into an NRT group and an NRT + AA group with a 1:1 ratio. Participants will receive NRT for 4 weeks and the NRT + AA group will receive additional AA treatment with 5 AA points (Shenmen (TF4), lung (CO14), throat (TF3), inner nose (TG4), and endocrine (CO18)) twice a week for 4 weeks. Follow-up will be conducted 1 and 3 months after intervention completion. The primary outcome will be tobacco consumption and abstinence rate determined by calculating the rate of change in cigarette use and a urine test. Secondary outcomes will be the quality of life (EuroQol-5D and visual analogue scale), nicotine dependence (Fagerstrom test for nicotine dependence), nicotine withdrawal (Minnesota nicotine withdrawal scale), physical effects, satisfaction, and safety measurement (adverse events).

RESULTS

We will investigate the efficacy and safety of AA combined with NRT treatment for smoking cessation.

CONCLUSION

Our study will provide additional clinical evidence for AA as an adjuvant treatment for smoking cessation.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service (registration number: KCT0007212).

Antecedents of Self-Efficacy to Achieve Smoking-Behavior-Change Goals among Low-Income Parents Enrolled in an Evidence-Based Tobacco Intervention

Previous studies have shown that greater self-efficacy (SE) to modify smoking behaviors during treatment improves long-term post-treatment outcomes. Little is known about factors that might enhance SE for smoking abstinence and for reducing children's tobacco smoke exposure (TSE). The present study investigated hypothesized predictors of end-of-treatment SE to abstain from smoking and to protect children from TSE by conducting secondary multiple regression analyses of data (N = 327) from the Kids Safe and Smokefree (KiSS) behavioral intervention trial. KiSS aimed to reduce parental smoking and child TSE in urban, low-income, and minority communities. The results showed that partner support and initiating a planned quit attempt during treatment were positively related to SE to abstain from smoking and to reduce children's TSE (all p's < 0.001) at the end of treatment (EOT). Further, lower baseline nicotine dependence and the use of nicotine replacement were related to higher SE to abstain from smoking at EOT (p < 0.01), whereas more restrictive residential smoking rules and lower children's TSE at baseline was associated with higher SE to reduce children's TSE at EOT (all p's < 0.05). These findings inform theory and future intervention design, identifying individual and social-environmental factors that might enhance smoking-behavior-change SE.

Effect of financial voucher incentives provided with UK stop smoking services on the cessation of smoking in pregnant women (CPIT III): pragmatic, multicentre, single blinded, phase 3, randomised controlled trial

OBJECTIVE

To examine effectiveness, cost effectiveness, generalisability, and acceptability of financial incentives for smoking cessation during pregnancy in addition to variously organised UK stop smoking services.

DESIGN

Pragmatic, multicentre, single blinded, phase 3, randomised controlled trial (Cessation in Pregnancy Incentives Trial phase 3 (CPIT III)).

SETTING

Seven UK stop smoking services provided in primary and secondary care facilities in Scotland, Northern Ireland, and England.

PARTICIPANTS

944 pregnant women (age ≥16 years) who self-reported as being smokers (at least one cigarette in the past week) when asked at first maternity visit, less than 24 weeks' gestation, and notified to the trial team by routine stop smoking services.

INTERVENTIONS

Participants in the control group were offered the standard stop smoking services, which includes the offer of counselling by specially trained workers using withdrawal orientated therapy and the offer of free nicotine replacement therapy. The intervention was the offer of usual support from the stop smoking services and the addition of up to £400 ($440; €455) of LoveToShop financial voucher incentives for engaging with current stop smoking services or to stop smoking, or both, during pregnancy.

MAIN OUTCOME MEASURES

Self-reported smoking cessation in late pregnancy (between 34 and 38 weeks' gestation) corroborated by saliva cotinine (and anabasine if using nicotine replacement products). Results were adjusted for age, smoking years, index of multiple deprivation, Fagerström score, before or after covid, and recruitment site. Secondary outcomes included point and continuous abstinence six months after expected date of delivery, engagement with stop smoking services, biochemically validated abstinence from smoking at four weeks after stop smoking date, birth weight of baby, cost effectiveness, generalisability documenting formats of stop smoking services, and acceptability to pregnant women and their carers.

RESULTS

From 9 January 2018 to 4 April 2020, of 4032 women screened by stop smoking services, 944 people were randomly assigned to the intervention group (n=471) or the control group (n=470). Three people asked for their data to be removed. 126 (27%) of 471 participants stopped smoking from the intervention group and 58 (12%) of 470 from the control group (adjusted odds ratio 2.78 (1.94 to 3.97) P<0.001). Serious adverse events were miscarriages and other expected pregnancy events requiring hospital admission; all serious adverse events were unrelated to the intervention. Most people who stopped smoking from both groups relapsed after their baby was born.

CONCLUSIONS

The offer of up to £400 of financial voucher incentives to stop smoking during pregnancy as an addition to current UK stop smoking services is highly effective. This bolt-on intervention supports new guidance from the UK National Institute for Health and Care Excellence, which includes the addition of financial incentives to support pregnant women to stop smoking. Continuing incentives to 12 months after birth is being examined to prevent relapse.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN15236311.

Nicotine Patch Alters Patterns of Cigarette Smoking-Induced Dopamine Release: Patterns Relate to Biomarkers Associated With Treatment Response

INTRODUCTION

Tobacco smoking is a major public health burden. The first-line pharmacological treatment for tobacco smoking is nicotine replacement therapy (eg, the nicotine patch (NIC)). Nicotine acts on nicotinic-acetylcholine receptors on dopamine terminals to release dopamine in the ventral and dorsal striatum encoding reward and habit formation, respectively.

AIMS AND METHODS

To better understand treatment efficacy, a naturalistic experimental design combined with a kinetic model designed to characterize smoking-induced dopamine release in vivo was used. Thirty-five tobacco smokers (16 female) wore a NIC (21 mg, daily) for 1-week and a placebo patch (PBO) for 1-week in a randomized, counter-balanced order. Following 1-week under NIC and then overnight abstinence, smokers participated in a 90-minute [11C]raclopride positron emission tomography scan and smoked a cigarette while in the scanner. Identical procedures were followed for the PBO scan. A time-varying kinetic model was used at the voxel level to model transient dopamine release peaking instantaneously at the start of the stimulus and decaying exponentially. Magnitude and spatial extent of dopamine release were estimated. Smokers were subcategorized by nicotine dependence level and nicotine metabolism rate.

RESULTS

Dopamine release magnitude was enhanced by NIC in ventral striatum and diminished by NIC in dorsal striatum. More-dependent smokers activated more voxels than the less-dependent smokers under both conditions. Under PBO, fast metabolizers activated more voxels in ventral striatum and fewer voxels in dorsal striatum compared to slow metabolizers.

CONCLUSIONS

These findings demonstrate that the model captured a pattern of transient dopamine responses to cigarette smoking which may be different across smoker subgroup categorizations.

IMPLICATIONS

This is the first study to show that NIC alters highly localized patterns of cigarette smoking-induced dopamine release and that levels of nicotine dependence and nicotine clearance rate contribute to these alterations. This current work included a homogeneous subject sample with regards to demographic and smoking variables, as well as a highly sensitive model capable of detecting significant acute dopamine transients. The findings of this study add support to the recent identification of biomarkers for predicting the effect of nicotine replacement therapies on dopamine function which could help refine clinical practice for smoking cessation.

Koori Quit Pack mailout smoking cessation support for Aboriginal and Torres Strait Islander people who smoke: a feasibility study protocol

INTRODUCTION

Smoking remains the leading preventable cause of death for Aboriginal and Torres Strait Islander people in Australia. Aboriginal and Torres Strait Islander people who smoke are more likely to make a quit attempt than their non-Aboriginal counterparts but less likely to sustain the quit attempt. There is little available evidence specifically for and by Indigenous peoples to inform best practice smoking cessation care.The provision of a free Koori Quit Pack with optional nicotine replacement therapy sent by mail may be a feasible, acceptable and effective way to access stop smoking support for Aboriginal and Torres Strait Islander peoples.

METHODS AND ANALYSIS

An Aboriginal-led, multisite non-randomised single-group, pre-post feasibility study across three states in Australia will be conducted. Participants will be recruited via service-targeted social media advertising and during usual care at their Aboriginal Community Controlled Health Services. Through a process of self-referral, Aboriginal and Torres Strait Islander people who smoke daily will complete a survey and receive mailout smoking cessation support. Data will be collected over the phone by an Aboriginal Research Assistant. This pilot study will inform the development of a larger, powered trial.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Aboriginal Health & Medical Research Council Ethics Committee of New South Wales (NSW) (#1894/21) and the University of Newcastle (#H-2022-0174). Findings will be reported through peer-reviewed journals and presentations at relevant local, national and international conferences. The findings will be shared with the NSW and Victoria Quitline, Aboriginal Health and Medical Research Council and Victorian Aboriginal Community Controlled Organisation and the National Heart Foundation.

TRIAL REGISTRATION NUMBER

ACTRN12622000654752.

Optimizing the Implementation of Tobacco Treatment for People with HIV: A Pilot Study

People with HIV (PWH) have higher rates of tobacco use compared to their societal counterparts and are disproportionately affected by tobacco-related morbidity and mortality. A needs assessment was conducted to assess provider beliefs and opinions on tobacco treatment barriers and treatment approaches. The results highlighted a disconnect between the known importance of quitting smoking and barriers in linking patients to treatment, such as lack of patient interest and other patient issues being a higher priority. Using this assessment data, a treatment delivery approach, Proactive Outreach with Medication Opt-out for Tobacco Treatment Engagement (PrOMOTE), was devised and piloted. PrOMOTE consisted of an outpatient clinical pharmacist trained in tobacco treatment proactively contacting patients for counseling and to prescribe smoking cessation pharmacotherapy (varenicline or dual nicotine replacement therapy (NRT)) using an opt-out approach. The pilot was conducted with 10 PWH and patient reach and opt-out rates were evaluated. Of the 10 patients contacted, 7 were reached and none opted out of the pharmacotherapy prescription (varenicline = 6; NRT = 1). Providers know the importance of smoking cessation for PWH but encounter several barriers to implementing treatment. Using PrOMOTE methods to deliver tobacco treatment increased the reach and pharmacotherapy acceptance rate of PWH who smoke.

An EHR-automated and theory-based population health management intervention for smoking cessation in diverse low-income patients of safety-net health centers: a pilot randomized controlled trial

This study tested the preliminary effectiveness of an electronic health record (EHR)-automated population health management (PHM) intervention for smoking cessation among adult patients of a federally qualified health center in Chicago. Participants (N = 190; 64.7% women, 82.1% African American/Black, 8.4% Hispanic/Latino) were self-identified as smokers, as documented in the EHR, who completed the baseline survey of a longitudinal "needs assessment of health behaviors to strengthen health programs and services." Four weeks later, participants were randomly assigned to the PHM intervention (N = 97) or enhanced usual care (EUC; N = 93). PHM participants were mailed a single-page self-determination theory (SDT)-informed letter that encouraged smoking cessation or reduction as an initial step. The letter also addressed low health literacy and low income. PHM participants also received automated text messages on days 1, 5, 8, 11, and 20 after the mailed letter. Two weeks after mailing, participants were called by the Illinois Tobacco Quitline. EUC participants were e-referred following a usual practice. Participants reached by the quitline were offered behavioral counseling and nicotine replacement therapy. Outcome assessments were conducted at weeks 6, 14, and 28 after the mailed letter. Primary outcomes were treatment engagement, utilization, and self-reported smoking cessation. In the PHM arm, 25.8% of participants engaged in treatment, 21.6% used treatment, and 16.3% were abstinent at 28 weeks. This contrasts with no quitline engagement among EUC participants, and a 6.4% abstinence rate. A PHM approach that can reach all patients who smoke and address unique barriers for low-income individuals may be a critical supplement to clinic-based care.

Smoking reduction among homeless smokers in a randomized controlled trial targeting cessation

INTRODUCTION

Homeless populations have high rates of smoking and unique barriers to quitting. General cessation strategies have been unsuccessful in this population. Smoking reduction may be a good intermediate goal. We conducted a secondary analysis to identify predictors of smoking reduction in a cohort of homeless smokers enrolled in a 26-week randomized clinical trial (RCT) targeting smoking cessation.

METHODS

Data are from an RCT comparing motivational interviewing counseling plus nicotine replacement therapy (NRT) to brief advice to quit (standard care) plus NRT among homeless smokers. Using bivariate analyses and multinomial logistic regression, we compared demographics, health and psychosocial variables, tobacco use, substance use, and NRT adherence among those who reported: quitting; reducing smoking by 50-99%; and not reducing smoking by 50%.

RESULTS

Of 324 participants who completed 26-week follow-up, 18.8% and 63.9% self-reported quitting and reducing, respectively. Compared to those who did not reduce smoking, participants reporting reducing indicated higher baseline cigarette use (OR=1.08; CI:1.04-1.12) and menthol use (OR=2.24; CI:1.05-4.77). Compared to participants who reduced, participants reporting quitting were more likely to be male (OR=1.998; CI:1.00-3.98), experience more housing instability (OR=1.97; CI:1.08-3.59), indicate higher importance of quitting (OR=1.27; CI:1.041.55), have higher NRT adherence (OR=1.75; CI:1.00-3.06), and lower odds of reported illicit drug use (OR=0.48; CI:0.24-0.95).

CONCLUSIONS

Over half of participants reduced smoking by at least 50%, indicating reduction is feasible among homeless smokers. Further research is required to understand the impact of reduction on future cessation attempts in homeless smokers. This study shows that reduction is achievable and may be a valid intermediate goal.

Predictors of Cessation Outcomes Among Older Adult Smokers Enrolled in a Proactive Tobacco Quitline Intervention

OBJECTIVES

To identify predictors of older adults' likelihood of quitting following engagement in a proactive tobacco quit line.

METHODS

Older (>60 years) participants (N = 186) enrolled in a four-session quit line with 8-weeks of nicotine replacement therapy reported demographics, beliefs, and information about tobacco use. Point prevalence abstinence was reported at 3 and 12-months.

RESULTS

In final models, endorsement of quitting to take control of one's life and confidence in quitting were positively associated with 3-month cessation (OR = 1.74, 95% CI = 1.16, 2.62; OR = 1.75, 95% CI = 1.21, 2.52, respectively). At 12 months, stronger endorsement of quitting to take control of one's life and decreased nicotine dependence were associated with higher cessation (OR = 1.51, 95% CI = 1.05, 2.17; OR = 0.84, 95% CI = 0.71,0.99, respectively).

DISCUSSION

For tobacco cessation among older adults, programs should provide additional support to those with higher nicotine dependence, promote quitting self-efficacy, and encourage quitting as means to gain control of life and health.

A systematic review of genetic variation within nicotinic acetylcholine receptor genes and cigarette smoking cessation

BACKGROUND

Nicotine produces its effects by binding to nicotinic acetylcholine receptors (nAChRs). Variants of genes encoding properties of nAChRs are candidates for affecting likelihood of smoking cessation.

METHODS

A systematic review was conducted summarizing evidence of associations between single nucleotide polymorphisms (SNPs) of nAChR genes and smoking cessation. From 24 articles meeting inclusion criteria, summary odds ratios (ORs) for associations between nine SNPs and smoking cessation were calculated from 26 studies (N = 233-29,072) stratified by gene, ancestry, study design, and pharmacotherapy; SNPs in linkage disequilibrium were pooled. Results for a tenth SNP from two GWAS were summarized.

RESULTS

People of European ancestry with minor alleles of CHRNA5 rs16969968 and CHRNA3 rs1051730 had longer time to cessation [HR = 0.90, 95 % CI 0.88 - 0.92 (n = 2 studies)] and lower odds of cessation [OR = 0.88, 95 % CI 0.80 - 0.97 (n = 5 cohort studies), OR = 0.64, 95 % CI 0.45 - 0.90 (n = 4 placebo arms)]. Risk of persistent smoking associated with these alleles was attenuated in smokers receiving nicotine replacement therapy (NRT). Recipients of bupropion alone or with NRT with these alleles had higher, though not statistically significant, odds of cessation. Results for CHRNA5 rs588765 and rs680244 were similar to rs16969968/rs1051730 findings. Evidence was limited for other SNPs.

CONCLUSION

Evidence consistently indicates the minor alleles of four SNPs within CHRNA3 or CHRNA5 are risk alleles for cessation failure. Analysis by pharmacotherapy revealed bupropion may be the most efficacious intervention for people with these alleles.

Factors influencing the practice of Smoking Cessation Assessment and Management among Primary Care Doctors (SCAAM-DOC) in three districts of Malaysia

Background

Smoking prevalence remains high in Malaysia. Primary care doctors have a good opportunity to motivate the smokers to quit smoking in view of the accessibility of primary healthcare clinics to the public. The objective of this study was to determine the practice of smoking cessation management among primary care doctors and its associated factors.

Methods

A cross-sectional online survey was carried out among 383 medical officers and interns in all government primary healthcare clinics in the district of Petaling, Klang and Hulu Langat from June to August 2020. All doctors were involved in the care of patients for smoking cessation. The knowledge, attitude and practice of smoking cessation management were assessed using a 17-items validated questionnaire which covered the components of 5As (Ask, advise, assess, assist, arrange) and 5Rs (Relevance, risk, reward, roadblocks, repetition). The management of pre-contemplation phase included the components of ask, advise, assess and 5Rs. The management of the contemplation phase included the components of assist and arrange.

Result

The majority of the respondents had poor score of knowledge (62.4%); attitude (58%) and practice (pre-contemplation management:50.9%; contemplation management:75.7%). Using multivariate logistic regression analysis, the significant factors associated with the poor practice of smoking cessation management in the pre-contemplation phase were poor (OR = 2.14, 95% CI 1.11–4.12, p <0.01) or moderate knowledge (OR = 2.50, 95% CI 1.19–5.26, p<0.01), poor attitude (OR = 2.16, 95% CI 1.39–3.37, p<0.01), lacks smoking cessation banners, brochures and leaflets in the clinic (OR = 2.01, 95%CI 1.26–3.19, p<0.01) and lack of nicotine replacement medications (OR = 2.27. 95%CI 1.27–4.06, p<0.01). No significant factors were shown associated with the practice of the contemplation phase.

Conclusion

The majority of primary care doctors had poor knowledge, attitude and practice of smoking cessation management. Factors that had increased the odds of the poor practice of smoking management at the pre-contemplation phase were poor knowledge, poor attitude, and insufficient organizational support for health promotion materials and nicotine replacement medication.

Assessment of Pharmaceutical Services for Smoking Cessation: An Effectiveness-Implementation Hybrid Study

Smoking is the main preventable cause of illness and early death worldwide. Thus, it is better to promote smoking cessation than to treat tobacco-related diseases. The objective of this study was to assess the implementation and effectiveness of smoking cessation pharmaceutical services offered in primary health care (PHC) in a large Brazilian city through a type 1 effectiveness-implementation hybrid study. The services were offered through individual or group approaches (Jan/2018-Dec/2019). The service indicators were described and the incidence of cessation in the services was evaluated. Factors associated with cessation were assessed by Poisson regression analysis. The services were offered in most PHC centers (61.2%) and by most pharmacists (81.3%). In total, 170 individual (9.7%) and 1591 group (90.3%) approaches occurred, leading to cessation in 39.4% (n = 67) and 44.8% (n = 712) of these, respectively. The use of nicotine plus antidepressants (RR = 1.30; 95%CI = 1.08-1.57; p = 0.006) and the number of sessions with pharmacists (RR = 1.21; 95%CI = 1.19-1.23; p < 0.001) were positively associated with cessation; a very high level of dependence was negatively associated (RR = 0.77; 95%CI = 0.67-0.89; p = 0.001). The smoking cessation services were effective and should be encouraged.

The impact of COVID-19 on smoking cessation in pregnancy

OBJECTIVES

A greater proportion of non-pregnant smokers attempted to stop smoking during compared to before the COVID-19 pandemic. The objective of this study was to determine if a greater proportion of pregnant women also attempted to stop smoking during the pandemic rather than before.

METHODS

The use of antenatal smoking cessation services and nicotine replacement therapies (NRT) in pregnant women was audited before (2019-2020) and during the COVID pandemic (2020-2021). Anonymised data from January 2019 to March 2021 were analysed from the Lambeth and Southwark smoking cessation service.

RESULTS

A total of 252 pregnant women who smoked were referred to their local antenatal smoking cessation service, of which 90 (35.7%) (median age: 31 years [19-52 years]) chose to attend smoking cessation clinics. The COVID-19 pandemic was not associated with an increase in the number of women attending smoking cessation clinics, (2020-2021 n=46 [40.8%] of 110); compared to (2019-2020 n=44 [30.9%] of 142 referred pregnant women pre-pandemic) p=0.061. Eighty-two women utilised NRT to help them stop smoking and the frequency of NRT use did not change during the pandemic (2019-2020 n=39, 2020-2021 n=43; p=0.420). No significant difference in smoking cessation rates between the two periods was observed at either the four-week (p=0.285) or twelve-week follow-up (p=0.829).

CONCLUSIONS

Smoking cessation rates in pregnant women and the demand for antenatal smoking cessation services was unchanged during compared to before the COVID-19 pandemic.

The effect of a real-world intervention for smoking cessation in Adults with and without comorbid psychiatric and substance use disorders: A one-year follow-up study

This study evaluated short-term abstinence and prolonged abstinence following a real-world intervention for smoking cessation in a sample of 1,213 adults with nicotine dependence only (ND), nicotine dependence and past history of another substance use disorder (ND-SUD), nicotine dependence and a non-substance use mental health disorder (ND-MD), or nicotine dependence and comorbid substance use disorder and mental health disorder (ND-SUMD). Participants received six sessions of group Cognitive Behavioral Therapy (CBT) and pharmacotherapy. Abstinence was assessed following completion of treatment and at 12-month follow-up. Logistic regression and survival analyses were performed. Participants who were lost to follow-up were included as censored and baseline differences were used as covariates in multivariate analyses. Rates of short-term abstinence and prolonged abstinence were significantly different between ND and ND-SUMD (20.9% versus 36.5%; 14.9% versus 22.4%, respectively). Among participants with follow-up, 37.7% were abstinent at 12-month. Diagnostic group was not associated with abstinence at 12-month follow-up after adjusting for nicotine dependence severity, which was associated with lower likelihood of abstinence (HR=1.11;95%CI:1.03-1.19). CBT plus pharmacotherapy had a positive effect on smoking cessation among the participants in this study. Special attention should be given to adults with more severe nicotine dependence and comorbid psychiatric and substance use disorders.

Approach bias retraining to augment smoking cessation: A pilot randomized controlled trial

BACKGROUND

Approach tendency to smoking-related cues has been associated with greater cravings, nicotine dependence, and the likelihood of relapse. In this pilot randomized clinical trial, we examined the efficacy of approach bias retraining (ABR; i.e., increasing avoidance tendency) for enhancing standard smoking cessation treatment (ST).

METHODS

Adult smokers (N = 96) motivated to quit were randomly assigned to 7 weekly in-person treatment sessions consisting of either (1) cognitive-behavioral therapy for smoking cessation (ST) and ABR (ST+ABR) or ST and sham retraining (ST+Sham). All participants also received optional nicotine replacement therapy for up to 8 weeks following the scheduled quit date (week 6). We measured avoidance tendency from weeks 1-7. Point prevalence abstinence (PPA) and prolonged abstinence (PA) were measured up to 3 months following the quit attempt (week 18 follow-up).

RESULTS

Consistent with our hypothesis, participants in ST+ABR evidenced higher abstinence rates than those in ST+Sham at the final follow-up (b=0.71, 95 % CI: [0.14, 1.27], t[1721]=2.46, p = 0.014, OR=2.03, 95 % CI: [1.15, 3.57]). Specifically, PPA and PA rates were 50 % and 66 % in ST+ABR compared to 31 % and 47 % in ST+Sham. As expected, participants assigned to the ST+ABR condition also showed a greater training-compatible increase in avoidance tendency scores relative to those assigned to the ST+Sham condition (b=248.06, 95 % CI: [148.51, 347,62], t[84]=4.96, p < .001).

CONCLUSIONS

The current pilot randomized clinical trial provides initial evidence for the efficacy of integrating standard smoking cessation with ABR. These findings encourage the testing of the long-term efficacy and mechanisms of action of this integrated intervention.

Novel rapid-acting sublingual nicotine tablet as a cigarette substitution strategy

RATIONALE

Current nicotine replacement products provide a much slower onset of nicotine delivery than cigarettes, and hence are only marginally effective at supplanting cigarette smoking. Therefore, more effective forms of nicotine replacement are needed.

OBJECTIVES

This initial investigation characterized the pharmacokinetic (PK) and subjective effects of a novel sublingual (SL) nicotine tablet designed to deliver nicotine more rapidly to the bloodstream of smokers.

METHODS

Study 1 (N = 6) characterized the pharmacokinetics of a 2 mg nicotine SL tablet in comparison to an FDA-approved, marketed 2 mg nicotine lozenge. Study 2 (N = 24) assessed subjective responses of smokers to a single use of a 1 mg and 2 mg SL tablet.

RESULTS

Study 1 found that the time to maximum blood nicotine concentrations was significantly shorter for the SL tablet (14 min) than for the lozenge (82 min), and the initial rate of nicotine absorption was higher (0.4 ng/mL*min vs. 0.0 ng/mL*min), supporting the hypothesis that the SL tablet delivered nicotine more rapidly. Study 2 found that participants reported immediate relief of nicotine withdrawal symptoms after tablet administration, and craving reduction after the 2 mg tablet approached the degree reported for their usual brands of cigarettes (4.2 vs. 4.6 on a 7-point scale). Other subjective responses showed the tablet to be an appealing alternative to smoking.

CONCLUSIONS

The novel SL tablet studied shows promise as a nicotine substitution strategy for tobacco harm reduction and smoking cessation treatment. Additional studies are warranted to further investigate the potential of this new approach.

Update and recommendations: Pharmacists' prescriptive authority for tobacco cessation medications in the United States

To characterize state laws in the United States regarding the expansion of pharmacists' prescriptive authority for tobacco cessation medications, compare key components across different models, and discuss important considerations for states that are considering similar legislation or policies. Legislative language was reviewed and summarized for all states with pharmacist prescriptive authority for tobacco cessation medications, and state boards of pharmacy were contacted to determine the number of registered complaints or safety concerns received as a result of pharmacists' prescribing under these authorities. As of June 2022, 17 states have enacted laws for pharmacists' prescriptive authority for tobacco cessation medications; most (N = 16) have implemented procedures, and 1 is in the process of adopting a similar prescribing model. Of 16 states with fully delineated protocols, 8 (Colorado, Idaho, Indiana, New Mexico, North Dakota, Oregon, Utah, Vermont) include all medications approved by the U.S. Food and Drug Administration for smoking cessation, and 8 (Arizona, Arkansas, California, Iowa, Maine, Minnesota, Missouri, North Carolina) include nicotine replacement therapy medications only. Most protocols specify minimum cessation education requirements for pharmacists and define required intervention elements (e.g., screening, cessation intervention components, follow-up, and documentation requirements). Personal communications with state boards of pharmacy revealed no complaints or safety concerns regarding pharmacists' prescribing for cessation medications since these authorities were first implemented, in New Mexico, in 2004. The number of states with pharmacists' prescriptive authority for tobacco cessation medications has increased substantially in recent years. There have been no registered complaints or safety concerns since the inception of this expanded scope of practice. Although the profession has made meaningful progress, there are inconsistencies across states with respect to medications that are included and requirements for implementing tobacco cessation services, which may impede broader adoption.

Economic evaluations of tobacco control interventions in low- and middle-income countries: a systematic review

BACKGROUND AND AIMS

Tobacco consumption and its associated adverse outcomes remain major public health issues, particularly in low- and middle-income countries. This systematic review aimed to identify and critically assess full economic evaluations for tobacco control interventions in low- and middle-income countries.

METHODS

Electronic databases, including EMBASE, MEDLINE and PsycINFO and the grey literature, were searched using terms such as 'tobacco', 'economic evaluation' and 'smoking' from 1994 to 2020. Study quality was assessed using the Consensus Health Economic Criteria and the Philips checklist. Studies were included which were full economic evaluations of tobacco control interventions in low- and middle-income settings. Reviews, commentaries, conference proceedings and abstracts were excluded. Study selection and quality assessment were conducted by two reviewers independently. A narrative synthesis was conducted to synthesize the findings of the studies.

RESULTS

This review identified 20 studies for inclusion. The studies evaluated a wide range of interventions, including tax increase, nicotine replacement therapy (nicotine patch/gum) and financial incentives. Overall, 12 interventions were reported to be cost-effective, especially tax increases for tobacco consumption and cessation counselling. There were considerable limitations regarding data sources (e.g. using cost data from other countries or assumptions due to the lack of local data) and the model structure; sensitivity analyses were inadequately described in many studies; and there were issues around the transferability of results to other settings. Additionally, the affordability of the interventions was only discussed in two studies.

CONCLUSIONS

There are few high-quality studies of the cost-effectiveness of tobacco use control interventions in low- and middle-income countries. The methodological limitations of the existing literatures could affect the generalizability of the findings.

Integrating Financial Coaching and Referrals into a Smoking Cessation Program for Low-income Smokers: a Randomized Waitlist Control Trial

BACKGROUND

Financial distress is a barrier to cessation among low-income smokers.

OBJECTIVE

To evaluate an intervention that integrated financial coaching and benefits referrals into a smoking cessation program for low-income smokers.

DESIGN

Randomized waitlist control trial conducted from 2017 to 2019.

PARTICIPANTS

Adult New York City residents were eligible if they reported past 30-day cigarette smoking, had income below 200% of the federal poverty level, spoke English or Spanish, and managed their own funds. Pregnant or breastfeeding people were excluded. Participants were recruited from two medical centers and from the community.

INTERVENTION

The intervention (n = 208) offered smoking cessation coaching, nicotine replacement therapy, money management coaching, and referral to financial benefits and empowerment services. The waitlist control (n=202) was usual care during a 6-month waiting period.

MAIN MEASURES

Treatment engagement, self-reported 7-day abstinence, and financial stress at 6 months.

KEY RESULTS

At 6 months, intervention participants reported higher abstinence (17% vs. 9%, P=0.03), lower stress about finances (β, -0.8 [SE, 0.4], P=0.02), and reduced frequency of being unable to afford activities (β, -0.8 [SE, 0.4], P=0.04). Outcomes were stronger among participants recruited from the medical centers (versus from the community). Among medical center participants, the intervention was associated with higher abstinence (20% vs. 8%, P=0.01), higher satisfaction with present financial situation (β, 1.0 [SE, 0.4], P=0.01), reduced frequency of being unable to afford activities (β, -1.0 [SE, 0.5], P=0.04), reduced frequency in getting by paycheck-to-paycheck (β, -1.0 [SE, 0.4], P=0.03), and lower stress about finances in general (β, -1.0 [SE, 0.4], P = 0.02). There were no group differences in outcomes among people recruited from the community (P>0.05).

CONCLUSIONS

Among low-income smokers recruited from medical centers, the intervention produced higher abstinence rates and reductions in some markers of financial distress than usual care. The intervention was not efficacious with people recruited from the community.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03187730.

Tobacco Use and Treatment of Tobacco Dependence Among People With Human Immunodeficiency Virus: A Practical Guide for Clinicians

More than 40% of people with human immunodeficiency virus (PWH) in the United States smoke tobacco cigarettes. Among those on antiretroviral therapy, smoking decreases life expectancy more than human immunodeficiency virus (HIV) itself. Most PWH who smoke want to quit, but tobacco dependence treatment has not been widely integrated into HIV care. This article summarizes the epidemiology of tobacco use among PWH, health consequences of tobacco use and benefits of cessation in PWH, and studies of treatment for tobacco dependence among the general population and among PWH. We provide practical guidance for providers to treat tobacco dependence among PWH. A 3-step Ask-Advise-Connect framework includes asking about tobacco use routinely during clinical encounters, advising about tobacco cessation with emphasis on the benefits of cessation, and actively connecting patients to cessation treatments, including prescription of pharmacotherapy (preferably varenicline) and direct connection to behavioral interventions via telephone quitline or other means to increase the likelihood of a successful quit attempt.

Integration of smoking cessation into standard treatment for patients receiving opioid agonist therapy who are smoking tobacco: protocol for a randomised controlled trial (ATLAS4LAR)

BACKGROUND

About 85% of patients receiving opioid agonist therapy (OAT) for opioid dependence are smoking tobacco. Although smoke-related pulmonary diseases are significant contributors to morbidity and mortality, few smoking cessation interventions are evaluated within this group, and few OAT patients are offered smoking cessation as an integrated part of their addiction treatment. This study protocol describes an integrated smoking cessation intervention aimed at patients receiving OAT and smoking tobacco.

METHODS

This is a multicentre, randomised controlled clinical trial that will recruit 266 daily tobacco smoking patients receiving OAT in OAT outpatient clinics in Bergen and Stavanger, Norway. The patients randomised for the intervention arm will be offered smoking cessation therapy consisting of weekly brief behavioural interventions and prescription-free nicotine replacement products. In the control arm, patients will receive standard care without any added interventions related to smoking cessation. The smoking cessation intervention includes psychoeducational techniques with components from motivational interviewing, and nicotine replacement products such as nicotine lozenges, patches, and chewing gum. The duration of the intervention is 16 weeks, with the option of extending it by a further 8 weeks. The main outcomes are measured at 16 weeks after initiation of the intervention, and sustained effects are evaluated 1 year after intervention initiation. The primary outcome is smoking cessation verified by carbon monoxide (CO) levels or at least a 50% reduction in the number of cigarettes smoked. Secondary outcomes are changes in psychological well-being, biochemical inflammation markers, changes in physical health, quality of life, and fatigue.

DISCUSSION

Integration of other treatments to standard OAT care improves adherence and completion rates providing another rationale for integrated smoking cessation treatment. Thus, if integrated smoking cessation treatment is superior to standard care, this trial provides important information on further scale-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05290025. Registered on 22 March 2022.

Medium- and longer-term cardiovascular effects of e-cigarettes in adults making a stop-smoking attempt: a randomized controlled trial

BACKGROUND

Smoking is a major risk factor for cardiovascular disease and smoking cessation reduces excess risk. E-cigarettes are popular for smoking cessation but there is little evidence on their cardiovascular health effect. Our objective was to compare the medium- and longer-term cardiovascular effects in smokers attempting to quit smoking using e-cigarettes with or without nicotine or prescription nicotine replacement therapy (NRT).

METHODS

This was a single-center, pragmatic three-arm randomized (1:1:1) controlled trial, which recruited adult smokers (≥ 10 cigarettes/day), who were willing to attempt to stop smoking with support (n = 248). Participants were randomized to receive behavioral support with either (a) e-cigarettes with 18 mg/ml nicotine, (b) e-cigarettes without nicotine, and (c) NRT. Flow-mediated dilation (%FMD) and peak cutaneous vascular conductance (CVCmax) responses to acetylcholine (ACh) and sodium nitroprusside (SNP), mean arterial pressure (MAP), and other outcomes were recorded at baseline, 3, and 6 months after stopping smoking. Data were analyzed using generalized estimating equations (GEE).

RESULTS

At 3- and 6-month follow-up, %FMD showed an improvement over baseline in all three groups (e.g., p < 0.0001 at 6 months). Similarly, ACh, SNP, and MAP improved significantly over baseline in all groups both at 3 and 6 months (e.g., ACh: p = 0.004, at 6 months).

CONCLUSIONS

Smokers attempting to quit experienced positive cardiovascular impact after both a 3- and 6-month period. None of the groups (i.e., nicotine-containing and nicotine-free e-cigarettes or NRT) offered superior cardiovascular benefits to the others.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03061253 . Registered on 17 February 2017.

Changes in Smoking Cessation-Related Behaviors Among US Adults During the COVID-19 Pandemic

IMPORTANCE

Smoking cessation is an urgent public health priority given that smoking is associated with increased risk of severe COVID-19 outcomes and other diseases. It is unknown how smoking cessation changed nationally during the COVID-19 pandemic.

OBJECTIVE

To investigate changes in smoking cessation-related behaviors in the US during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted using 2011 to 2020 data on 788 008 individuals who had smoked in the past year from the nationally representative Behavioral Risk Factor Surveillance System (BRFSS) survey. Representative retail scanner sales data between January 2017 and July 2021 for 1004 unique nicotine replacement therapy (NRT) universal product codes in 31 US states from NielsenIQ were also used.

EXPOSURES

Calendar year and 4-week sales periods.

MAIN OUTCOMES AND MEASURES

Changes in annual self-reported prevalence of past-year quit attempts and recent successful cessation before (ie, 2011-2019) and during (ie, 2020) the COVID-19 pandemic and changes in sales volumes in millions of pieces of nicotine gum, lozenge, and patch brands before (1271 four-week sales periods between January 2017 and February 2020) and during (558 four-week sales periods between March 2020 and July 2021) the COVID-19 pandemic were calculated.

RESULTS

The 2011 to 2020 pooled BRFSS sample (response rate range, 45.2%-49.9%) included 788 008 respondents (243 061 individuals ages 25-44 years [weighted percentage, 42.5%]; 374 519 men [weighted percentage, 55.7%]). For the first time since 2011, annual past-year quit attempt prevalence decreased between 2019 and 2020, from 65.2% (95% CI, 64.5% to 65.9%) to 63.2% (95% CI, 62.3% to 64.0%), with the largest relative decreases among individuals ages 45 to 64 years (61.4% [95% CI, 60.3% to 62.5%] vs 57.7% [95% CI, 56.3% to 59.2%]), those with 2 or more comorbidities (67.1% [95% CI, 66.0% to 68.2%] to 63.0% [95% CI, 61.6% to 64.4%]), and Black individuals (72.5% [95% CI, 70.3 to 74.6] vs 68.4% [95% CI, 65.3% to 71.3%]). Recent successful cessation remained unchanged during 2019 to 2020. Observed mean (SD) 4-week NRT sales volume in the prepandemic period was 105.6 (66.2) million gum pieces, 51.9 (31.6) million lozenges, and 2.0 (1.1) million patches. Compared with expected sales, observed sales during the COVID-19 pandemic were lower by 13.0% (95% CI, -13.7% to -12.3%) for lozenges, 6.4% (95% CI, -7.3% to -5.5%) for patches, and 1.2% (95% CI, -1.7% to -0.7%) for gum.

CONCLUSIONS AND RELEVANCE

This study found that serious smoking cessation activity among US adults decreased immediately and remained depressed for more than a year during the COVID-19 pandemic. These findings suggest that smokers experiencing disproportionately negative outcomes during the pandemic should be reengaged and assisted in quit attempts.

The effect of Varenicline and Bupropion on smoking cessation: A network meta-analysis of 20 randomized controlled trials

OBJECTIVE

A network meta-analysis (NMA) was conducted to investigate the effect of varenicline (VAR), bupropion (BUP), and nicotine replacement therapy (NRT) on smoking cessation.

METHODS

Eight databases were searched in May 2021, and only randomized controlled trials (RCTs) using varenicline, bupropion, or NRT (single or combined) for smoking cessation were included. The risk of bias in the included RCTs was assessed using the Cochrane Handbook tool. Stata 15.1 software was used to perform NMA, and the quality of the evidence was evaluated using Confidence in Network Meta-analysis (CINeMA).

FINDINGS

Twenty RCTs involving 16,702 smokers were included. The risk of bias results showed that 10 RCTs were rated as high, three were low, and seven were unclear. A total of 21 pairs were compared based on seven interventions. The NMA showed that, compared to the placebo (PLA), the other six interventions had significant efficacy in smoking cessation, where VAR + BUP showed the best effect of all treatments (odds ratio (OR) = 6.08, 95% confidence interval (CI) [3.47, 10.66]). Moreover, VAR + BUP was superior to VAR + NRT (OR = 1.66, 95% CI [1.07, 2.59]) and the three monotherapies (VAR, BUP, and NRT). In the monotherapies, the results of pairwise comparisons of VAR, BUP, and NRT did not show significant differences. Finally, the surface under the cumulative ranking curve (SUCRA) value indicated that VAR + BUP had the greatest probability of becoming the best intervention.

CONCLUSIONS

The efficacy of VAR, BUP, and NRT alone increased the odds of smoking abstinence better than the placebo, combined interventions were superior to monotherapy, and VAR combined with other interventions had a better smoking cessation effect.

Effectiveness of Varenicline and Cytisine for Alcohol Use Reduction Among People With HIV and Substance Use: A Randomized Clinical Trial

IMPORTANCE

Cigarette smoking and risky alcohol consumption co-occur and are undertreated. Nicotine receptor partial agonists and nicotine replacement therapy (NRT) treat smoking but are unproven for alcohol, and clinical trials rarely include individuals with HIV, substance use, and mental health conditions.

OBJECTIVE

To compare the effects on drinking and smoking of nicotinic acetylcholine receptor partial agonists varenicline and cytisine with those of NRT.

DESIGN, SETTING, AND PARTICIPANTS

This 4-group randomized, double-blinded, placebo-controlled clinical trial was conducted from July 2017 to December 2020 in St Petersburg, Russia. Included participants were 400 individuals with HIV who engaged in risky drinking (≥5 prior-month heavy-drinking days [HDDs]) and daily smoking; they were followed up for 12 months after enrollment. Data were analyzed from May 2021 through June 2022.

INTERVENTIONS

Participants received alcohol and tobacco counseling, 1 active medication, and 1 placebo in 1 of 4 groups: active varenicline and placebo NRT (group 1), placebo varenicline and active NRT (group 2), active cytisine and placebo NRT (group 3), or placebo cytisine and active NRT (group 4).

MAIN OUTCOMES AND MEASURES

The primary outcome was number of prior-month HDDs at 3 months. Secondary outcomes included biochemically validated abstinence from alcohol at 3 months and smoking at 6 months.

RESULTS

Among 400 participants (263 [65.8%] men; mean [SD] age, 39 [6] years), 97 individuals (24.3%) used opioids and 156 individuals (39.1%) had depressive symptoms. These individuals had a mean (SD) CD4 count of 391 (257) cells/mm3, smoked a mean (SD) of 21 [8] cigarettes/d, and reported a mean (SD) of 9.3 (5.8) HDDs in the prior 30 days. At 3 months, the mean (SD) number of HDDs was decreased vs baseline across all groups (group 1: 2.0 [3.8] HDDs vs. 9.5 [6.1] HDDs; group 2: 2.1 [4.3] HDDs vs 9.3 [5.7] HDDs; group 3: 1.5 [3.3] HDDs vs 8.9 [5.0] HDDs; group 4: 2.4 [5.2] HDDs vs 9.6 [6.3] HDDs). There were no significant differences at 3 months between groups in mean (SD) HDDs, including group 1 vs 2 (incident rate ratio [IRR], 0.94; 95% CI, 0.49-1.79), 3 vs 4 (IRR, 0.60; 95% CI, 0.30-1.18), and 1 vs 3 (IRR, 1.29; 95% CI, 0.65-2.55). There were no significant differences at 6 months between groups in smoking abstinence, including group 1 vs 2 (15 of 100 individuals [15.0%] vs 17 of 99 individuals [17.2%]; odds ratio [OR],0.89; 95% CI, 0.38-2.08), 3 vs 4 (19 of 100 individuals [19.0%] vs 19 of 101 individuals [18.8%]; OR, 1.00; 95% CI, 0.46-2.17), and 1 vs 3 (OR, 0.79; 95% CI, 0.35-1.78). Post hoc analyses suggested lower mean (SD) HDDs (eg, at 3 months: 0.7 [1.8] HDDs vs 2.3 [4.6] HDDs) and higher alcohol abstinence (eg, at 3 months: 30 of 85 individuals [35.3%] vs 54 of 315 individuals [17.1%]) among those who quit vs continued smoking.

CONCLUSIONS AND RELEVANCE

This study found that among individuals with HIV who engaged in risky drinking and smoking, varenicline and cytisine were not more efficacious than NRT to treat risky drinking and smoking but that behavior change rates were high in all groups.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02797587.

Longitudinal Assessments of Neurocognitive Performance and Brain Structure Associated With Initiation of Tobacco Use in Children, 2016 to 2021

IMPORTANCE

The landscape of tobacco use is changing. However, information about the association between early-age tobacco use and cognitive performances is limited, especially for emerging tobacco products such as electronic cigarettes (e-cigarettes).

OBJECTIVE

To assess the association between early-age initiation of tobacco use and cognitive performances measured by the National Institutes of Health (NIH) Toolbox Cognitive Battery and to examine whether initiation is associated with differences in brain morphometry.

DESIGN, SETTING, AND PARTICIPANTS

This observational cohort study examined the longitudinal associations of initiation of tobacco use with neurocognition using multivariate linear mixed models. Children aged 9 to 10 years from 21 US sites were enrolled in wave 1 (October 1, 2016, to October 31, 2018 [n = 11 729]) and the 2-year follow-up (August 1, 2018, to January 31, 2021 [n = 10 081]) of the Adolescent Brain Cognitive Development (ABCD) Study.

EXPOSURES

Ever use (vs none) of any tobacco products at wave 1, including e-cigarettes, cigarettes, cigars, smokeless tobacco, hookah, pipes, and nicotine replacement.

MAIN OUTCOMES AND MEASURES

Neurocognition measured by the NIH Toolbox Cognition Battery and morphometric measures of brain structure and region of interest analysis for the cortex from structural magnetic resonance imaging.

RESULTS

Among 11 729 participants at wave 1 (mean [SE] age, 9.9 [0.6] years; 47.9% girls and 52.1% boys; 20.3% Hispanic; 14.9% non-Hispanic Black; and 52.1% non-Hispanic White), 116 children reported ever use of tobacco products. Controlling for confounders, tobacco ever users vs nonusers exhibited lower scores in the Picture Vocabulary Tests at wave 1 (b [SE] = -2.9 [0.6]; P < .001) and 2-year follow-up (b [SE] = -3.0 [0.7]; P < .001). The crystalized cognition composite score was lower among tobacco ever users than nonusers both at wave 1 (b [SE] = -2.4 [0.5]; P < .001) and 2-year follow-up (b [SE] = -2.7 [0.8]; P = .005). In structural magnetic resonance imaging, the whole-brain measures in cortical area and volume were significantly lower among tobacco users than nonusers, including cortical area (b [SE] = -5014.8 [1739.8] mm2; P = .004) at wave 1 and cortical volume at wave 1 (b [SE] = -174 621.0 [5857.7] mm3; P = .003) and follow-up (b [SE] = -21 790.8 [7043.9] mm3; P = .002). Further region of interest analysis revealed smaller cortical area and volume in multiple regions across frontal, parietal, and temporal lobes at both waves.

CONCLUSIONS AND RELEVANCE

In this cohort study, initiating tobacco use in late childhood was associated with inferior cognitive performance and reduced brain structure with sustained effects at 2-year follow-up. These findings suggest that youths vulnerable to e-cigarettes and tobacco products should be treated as a priority population in tobacco prevention.

Smoking and quitting characteristics of Aboriginal and Torres Strait Islander women of reproductive age: findings from the Which Way? study

OBJECTIVE

To describe smoking characteristics, quitting behaviour and other factors associated with longest quit attempt and the use of nicotine replacement therapy (NRT) and stop-smoking medication (SSM) in a population of Indigenous Australian women of reproductive age.

DESIGN, SETTING AND PARTICIPANTS

A national cross-sectional survey of Aboriginal and Torres Strait Islander women aged 16-49 years who were smokers or ex-smokers was conducted online during the period July to October 2020.

MAIN OUTCOME MEASURES

Quitting experience: attempt to cut down, time since last quit attempt, longest period without smoking, attempt to cut down during last quit attempt, any use of NRT and/or SSM.

RESULTS

Most of the 428 participating women (302 [70.6%]) reported using an Aboriginal health service. Younger women (16-20-year-olds) smoked fewer cigarettes daily (24/42 [57.1%], 0-5 cigarettes per day), waited longer to smoke after waking (20/42 [47.6%], > 60 minutes after waking), and were categorised as low smoking dependency compared with those aged 35 years and over. One-third of women (153 [35.7%]) had ever used NRT and/or SSM. A greater proportion of older women (35-49-year-olds) had sustained a quit attempt for years (62/149 [45.6%]) and reported trying NRT and/or SSM (78/149 [52.4%]) than women in younger age groups. Quitting suddenly rather than gradually was significantly associated with sustained abstinence (prevalence ratio, 1.27 [95% CI, 1.10-1.48]). Among women who had never used NRT or SSM, most (219/275 [79.6%]) reported reasons for this in the category of attitudes and beliefs. NRT and SSM use was also more likely among women who were confident talking to their doctor about quitting (odds ratio, 2.50 [95% CI, 1.23-5.10]) and those who received most of their information from a health professional (odds ratio, 1.71 [95% CI, 1.11-2.63]).

CONCLUSION

Aboriginal and Torres Strait Islander women want to quit smoking and are making attempts to quit. Quitting suddenly, rather than reducing cigarette consumption, is associated with increased sustained abstinence. Health providers can enable access and uptake of NRT and/or SSM and should recognise that NRT and/or SSM use may change over time. Consistent messaging, frequent offers of smoking cessation support, and access to a range of smoking cessation supports should be provided to Aboriginal and Torres Strait Islander women to enable them to be smoke-free.

Revised Guidelines for smoking cessation in New Zealand, 2021

AIMS

To summarise the literature underpinning key recommendations made in the 2021 revision of the Ministry of Health's New Zealand Guidelines for Helping People to Stop Smoking.

METHODS

A comprehensive literature review of smoking cessation interventions was undertaken in July 2021. Recommendations were formulated from the findings of the literature review and expert advice.

RESULTS

Healthcare professionals should ask and briefly advise all people who smoke to stop smoking, regardless of whether they say they are ready to stop smoking or not. They should offer smoking cessation support, which includes both behavioural and pharmacological (e.g., nicotine replacement therapy, nortriptyline, bupropion or varenicline) interventions. The Guidelines also include advice around the use of vaping in smoking cessation. Recommendations are also formulated for priority populations of smokers: Māori, Pacific, pregnant women, and people with mental illness and other addictions.

CONCLUSIONS

The guidelines will assist healthcare professionals in providing evidence-based smoking cessation support to people who smoke. To be effective and equitable, the ABC model requires organisational commitment, integration into routine practice, and increased attention to the upstream determinants of smoking and quitting.

Smartphone Application for Smoking Cessation (Quit with US): A Randomized Controlled Trial among Young Adult Light Smokers in Thailand

This study aimed to determine the efficacy of a smartphone application named Quit with US among young adult smokers. An open-label, parallel, 2-group, randomized controlled trial with a 12-week follow-up was conducted between March and November 2020 among undergraduate students (18 to 24 years) in Chiang Mai Province, Thailand. A total of 273 participants were assigned by simple randomization procedure to the Quit with US intervention group (n = 137) or the control group (n = 136). All participants received pharmacists’ smoking cessation counseling at baseline and follow-ups. In addition, the intervention group’s participants were advised to use Quit with US. The baseline and 12-week follow-up assessments were conducted at a study unit, whereas other follow-ups were completed over the telephone. The primary abstinence outcome was the exhaled CO concentration level (≤6 ppm) verified 7-day point prevalence abstinence. At baseline, the participants’ mean (standard deviation) age was 21.06 (1.62) years. Most identified as daily smokers (57.9%, n = 158), consumed ≤10 cigarettes daily (89.4%, n = 244), and expressed low level of nicotine dependence as measured by Heaviness of Smoking Index score (86.1%, n = 235). Regarding intention-to-treat analyses, participants in the Quit with US intervention group achieved significantly greater smoking abstinence rate than those in the control group (58.4% (80/137) vs. 30.9% (42/136), risk ratio = 1.89, 95% confidence intervals = 1.42 to 2.52, p < 0.001). In conclusion, Quit with US integrated with pharmacists’ smoking cessation counseling significantly enhanced smoking abstinence rates among young adult light smokers consuming ≤ 10 cigarettes daily.

SISTAQUIT: training health care providers to help pregnant Aboriginal and Torres Strait Islander women quit smoking. A cluster randomised controlled trial

BACKGROUND

About 44% of Indigenous Australian women smoke during pregnancy, compared with 12% of pregnant non-Indigenous women. Health care providers can assist smoking cessation, but they are not typically trained in culturally appropriate methods.

OBJECTIVES

To determine whether a health care worker training intervention increases smoking cessation rates among Indigenous pregnant smokers compared with usual care.

METHODS AND ANALYSIS

Supporting Indigenous Smokers to Assist Quitting (SISTAQUIT) study is a multicentre, hybrid type 1, pragmatic, cluster randomised controlled trial that compares the effects of an intervention for improving smoking cessation by pregnant Indigenous women (16 years or older, 32 weeks' gestation or less) with usual care. Twenty-one health services caring for Indigenous people in five Australian jurisdictions were randomised to the intervention (ten sites) or control groups (eleven sites). Health care providers at intervention sites received smoking cessation care training based on the ABCD (ask/assess; brief advice; cessation; discuss psychosocial context) approach to smoking cessation for Indigenous women, an educational resource package, free oral nicotine replacement therapy for participating women, implementation support, and trial implementation training. Health care providers in control group services provided usual care.

PRIMARY OUTCOME

abstinence from smoking (self-reported abstinence via survey, validated by carbon monoxide breath testing when possible) four weeks after enrolment in the study.

SECONDARY OUTCOMES

health service process evaluations; knowledge, attitudes, and practices of health care providers; and longer term abstinence, perinatal outcomes, and respiratory outcomes for babies (to six months). Ethics approval: The human research ethics committees of the University of Newcastle (H-2015-0438) and the Aboriginal Health and Medical Research Council of NSW (1140/15) provided the primary ethics approval. Dissemination of results: Findings will be disseminated in peer-reviewed publications, at local and overseas conferences, and via public and social media, and to participating health services in art-based formats and reports. Policy briefs will be communicated to relevant government organisations.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry, ACTRN12618000972224 (prospective).

Treatment use patterns in a large extended-treatment tobacco cessation program: predictors and cost implications

BACKGROUND

Tobacco dependence follows a chronic and relapsing course, but most treatment programmes are short. Extended care has been shown to improve outcomes. Examining use patterns for longer term programmes can quantify resource requirements and identify opportunities for improving retention.

METHODS

We analyse 38 094 primary care treatment episodes from a multisite smoking cessation programme in Ontario, Canada that provides free nicotine replacement therapy (NRT) and counselling. We calculate distributional measures of weeks of NRT used, clinical visits attended and total length of care. We then divide treatment courses into four exclusive categories and fit a multinomial logistic regression model to measure associations with participant characteristics, using multiple imputation to address missing data.

RESULTS

Time in treatment (median=50 days), visits (median=3) and weeks NRT used (median=8) were well below the maximum available. Of all programme enrolments, 28.8% (95% CI=28.3% to 29.3%) were single contacts, 31.3% (30.8% to 31.8%) lasted <12 weeks, 19.2% (18.8% to 19.6%) were ≥12 weeks with an 8-week interruption and 20.7% (20.3%-21.1%) were ≥12 weeks without interruptions. Care use was most strongly associated with participant age and whether the nicotine patch was dispensed at the first visit.

CONCLUSION

Treatment use results imply that the marginal costs of extending treatment programmes are relatively low. The prevalence of single contacts supports additional engagement efforts at the initial visit, while interruptions in care highlight the ability of longer term care to address relapse. Results show that use of the nicotine patch is associated with retention in care, and that improving engagement of younger patients should be a priority.

Cost-Effectiveness of a Telephone-Based Smoking Cessation Randomized Trial in the Lung Cancer Screening Setting

BACKGROUND

There are limited data on the cost-effectiveness of smoking cessation interventions in lung cancer screening settings. We conducted an economic analysis embedded in a national randomized trial of 2 telephone counseling cessation interventions.

METHODS

We used a societal perspective to compare the short-term cost per 6-month bio-verified quit and long-term cost-effectiveness of the interventions. Trial data were used to micro-cost intervention delivery, and the data were extended to a lifetime horizon using an established Cancer Intervention Surveillance and Modeling Network lung cancer model. We modeled the impact of screening accompanied by 8 weeks vs 3 weeks of telephone counseling (plus nicotine replacement) vs screening alone based on 2021 screening eligibility. Lifetime downstream costs (2021 dollars) and effects (life-years gained, quality-adjusted life-years [QALYs]) saved were discounted at 3%. Sensitivity analyses tested the effects of varying quit rates and costs; all analyses assumed nonrelapse after quitting.

RESULTS

The costs for delivery of the 8-week vs 3-week protocol were $380.23 vs $144.93 per person, and quit rates were 7.14% vs 5.96%, respectively. The least costly strategy was a 3-week counseling approach. An 8-week (vs 3-week) counseling approach increased costs but gained QALYs for an incremental cost-effectiveness ratio of $4029 per QALY. Screening alone cost more and saved fewer QALYs than either counseling strategy. Conclusions were robust in sensitivity analyses.

CONCLUSIONS

Telephone-based cessation interventions with nicotine replacement are considered cost-effective in the lung screening setting. Integrating smoking cessation interventions with lung screening programs has the potential to maximize long-term health benefits at reasonable costs.

[Tobacco cessation treatment for people with schizophrenia]

Among patients suffering from schizophrenia, tobacco smoking prevalence is extremely high and represents a major burden in terms of morbidity and mortality. Tobacco smoking is under-diagnosed and under-treated by mental health professionals, mostly due to an overestimated risk of jeopardizing the patient's mental condition, but also due to a lack of expertise on tobacco cessation treatment. Despite the extent of this problem, pharmacological approaches haven't been studied enough. However, treatments such as varenicline, bupropion and nicotine replacement are effective and well tolerated and their prescription should be recommended for tobacco withdrawal among these patients.

Longitudinal Electronic Cigarette Use Among Patients Recently Diagnosed With Cancer Enrolled in a Smoking Cessation Trial

INTRODUCTION

Many cancer patients who smoke report concurrent e-cigarette use. Using a mixed-methods approach, we aimed to (1) describe longitudinal e-cigarette use over 6 months after a cancer diagnosis and (2) assess the association between e-cigarette use and smoking cessation, among cancer patients in a smoking cessation trial.

AIMS AND METHODS

Data were from a 2-site randomized controlled trial of Standard (brief counseling) versus Intensive treatment (sustained counseling plus smoking cessation medication) in individuals who smoke recently diagnosed with cancer. Participants (n = 303) reported e-cigarette use at baseline, 3 months, and 6 months. Biochemically-verified past 7-day cigarette abstinence was collected at 6 months. Qualitative interviews at 6 months explored factors related to e-cigarette use.

RESULTS

E-cigarette use prevalence was highest between baseline and 3 months (16%) and declined over time. Participants using e-cigarettes at follow-up had higher baseline cigarette dependence and smoked more heavily. Multivariable analyses found no significant association between follow-up e-cigarette use and 6-month cigarette abstinence. E-cigarette use at follow-up was higher in the Standard versus Intensive treatment group (p = .003 and .001 at 3 and 6 mo, respectively). Smoking cessation and health concerns were primary reasons for using e-cigarettes.

CONCLUSIONS

Among individuals who smoke recently diagnosed with cancer and enrolled in a smoking cessation intervention trial, e-cigarette use during trial participation was not associated with smoking abstinence. Individuals who chose to use e-cigarettes were less likely to be receiving intensive cessation support as part of the trial. Further studies are needed to evaluate the association between e-cigarette use and smoking cessation in cancer patients.

IMPLICATIONS

E-cigarette use was not associated with cigarette abstinence at 6 months among adults who smoke recently diagnosed with cancer enrolled in a smoking cessation trial. Individuals with easier access to evidence-based smoking cessation treatment may be less likely to use e-cigarettes.

Comparable Impairment of Vascular Endothelial Function by a Wide Range of Electronic Nicotine Delivery Devices

INTRODUCTION

Electronic nicotine delivery systems (ENDS; ie, vaping devices) such as e-cigarettes, heated tobacco products, and newer coil-less ultrasonic vaping devices are promoted as less harmful alternatives to combustible cigarettes. However, their cardiovascular effects are understudied. We investigated whether exposure to aerosol from a wide range of ENDS devices, including a new ultrasonic vaping device, impairs endothelial function.

AIMS AND METHODS

We measured arterial flow-mediated dilation (FMD) in rats (n = 8/group) exposed to single session of 10 cycles of pulsatile 5-second exposure over 5 minutes to aerosol from e-liquids with and without nicotine generated from a USONICIG ultrasonic vaping device, previous generation e-cigarettes, 5% nicotine JUUL pods (Virginia Tobacco, Mango, Menthol), and an IQOS heated tobacco product; with Marlboro Red cigarette smoke and clean air as controls. We evaluated nicotine absorption and serum nitric oxide levels after exposure, and effects of different nicotine acidifiers on platelet aggregation.

RESULTS

Aerosol/smoke from all conditions except air significantly impaired FMD. Serum nicotine varied widely from highest in the IQOS group to lowest in USONICIG and previous generation e-cig groups. Nitric oxide levels were not affected by exposure. Exposure to JUUL and similarly acidified nicotine salt e-liquids did not affect platelet aggregation rate. Despite lack of heating coil, the USONICIG under airflow conditions heated e-liquid to ~77°C.

CONCLUSIONS

A wide range of ENDS, including multiple types of e-cigarettes with and without nicotine, a heated tobacco product, and an ultrasonic vaping device devoid of heating coil, all impair FMD after a single vaping session comparably to combusted cigarettes.

IMPLICATIONS

The need to understand the cardiovascular effects of various ENDS is of timely importance, as we have seen a dramatic increase in the use of these products in recent years, along with the growing assumption among its users that these devices are relatively benign. Our conclusion that a single exposure to aerosol from a wide range of ENDS impairs endothelial function comparably to cigarettes indicates that vaping can cause similar acute vascular functional impairment to smoking and is not a harmless activity.

Interest in Electronic Cigarettes for Smoking Cessation Among Adults With Opioid Use Disorder in Buprenorphine Treatment: A Mixed-Methods Investigation

INTRODUCTION

Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with Food and Drug Administration (FDA)-approved cessation aids, suggesting need for novel approaches. Electronic cigarettes (e-cigarettes) might benefit this population, but e-cigarettes' acceptability for tobacco reduction or cessation among smokers in OUD treatment is not known.

METHODS

A cross-sectional mixed-methods study of 222 adults in OUD treatment with buprenorphine in the Boston, Massachusetts metropolitan area was conducted in 2020. We used quantitative and qualitative data to investigate individuals' experience with and interest in e-cigarettes and other methods for smoking cessation and assessed factors associated with interest in e-cigarette use.

RESULTS

One hundred sixty (72%) of the 222 participants were past 30-day cigarette smokers. They most frequently reported having ever used nicotine replacement therapy (NRT; 83%) and e-cigarettes (71%) for smoking cessation and most often indicated interest in using NRT (71%) and e-cigarettes (44%) for future smoking cessation. In multiple logistic regression analysis, interest in using e-cigarettes for future smoking cessation was independently associated with having ever used e-cigarettes for smoking cessation, current e-cigarette use, and perceiving e-cigarettes to be less harmful than cigarettes (ps < .05). In qualitative data, many current vapers/former smokers reported that e-cigarettes had been helpful for quitting cigarettes. For current smokers who currently or formerly vaped, frequently reported challenges in switching to e-cigarettes were concerns about replacing one addiction with another and e-cigarettes not adequately substituting for cigarettes.

CONCLUSIONS

E-cigarettes had a moderate level of acceptability for smoking cessation among cigarette smokers in OUD treatment. More research is warranted to test the efficacy of this approach.

IMPLICATIONS

Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with existing smoking cessation tools, suggesting a need for novel cessation treatment approaches. In this mixed-methods study of individuals receiving medication treatment for OUD with buprenorphine in Massachusetts in 2020, we found a moderate level of acceptability of e-cigarettes for smoking cessation.

Characterizing Participant Perceptions about Smoking-Cessation Pharmacotherapy and E-Cigarettes from Facebook Smoking-Cessation Support Groups

The prevalence of smoking among young adults aged 19-28 years old in the United States persists at rates of 14.3%. Young adults underutilize pharmacotherapy for smoking cessation, and the use of e-cigarettes has increased. We analyzed comments from online smoking-cessation support groups to understand young-adult smokers' views of pharmacotherapy and e-cigarettes, to provide a more in-depth insight into the underutilization of pharmacotherapy. A qualitative analysis was performed on comments about pharmacotherapy and e-cigarettes from participants enrolled in online smoking-cessation support groups in 2016-2020. A codebook was developed with a deductive approach to code the comments, followed by thematic analysis. Eighteen themes were identified, with four dominant themes: interest, benefit, knowledge, and flavor. Participants expressed less interest in both nicotine-replacement therapy and e-cigarettes; moreover, they expressed unfamiliarity with and misconceptions about pharmacotherapy, and recognized the enticing flavors of e-cigarettes. Participants often felt e-cigarettes were not useful for smoking cessation, but the flavors of e-cigarettes were appealing for use. Participants had mixed opinions about the use of e-cigarettes for smoking cessation, but predominantly felt e-cigarettes were not useful for smoking cessation. The use of social media may be an effective way to address misconceptions about pharmacotherapy for smoking cessation and increase willingness to accept assistance.

Can inpatient pharmacists move the needle on smoking cessation? Evaluating reach and representativeness of a pharmacist-led opt-out smoking cessation intervention protocol for hospital settings

PURPOSE

Hospitalization affords an opportunity to reduce smoking, but fewer than half of patients who smoke receive evidence-based cessation treatment during inpatient stays. This study evaluated a pharmacist-led, electronic health record (EHR)-facilitated opt-out smoking cessation intervention designed to address this need.

METHODS

Analyses of EHR records for adult patients who smoked in the past 30 days admitted to an academic medical center in the upper Midwest were conducted using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. The reach of a pharmacist-led, EHR-facilitated protocol for smoking cessation treatment was assessed by comparing patients' receipt of nicotine replacement therapy (NRT) and tobacco quitline referral before and after implementation. χ2 tests, t tests, and multiple logistic regression models were used to compare reach across patient demographic groups to assess treatment disparities and the representativeness of reach. Adoption of the program by hospital services was also assessed.

RESULTS

Of the 70 hospital services invited to implement the program, 88.6% adopted it and 78.6% had eligible admissions. Treatment reach increased as rates of delivering NRT rose from 43.6% of eligible patients before implementation to 50.4% after implementation (P < 0.0001) and quitline referral rates rose from 0.9% to 11.9% (P < 0.0001). Representativeness of reach by sex and ethnicity improved after implementation, although disparities by race and age persisted after adjustment for demographics, insurance, and primary diagnosis. Pharmacists addressed tobacco use for eligible patients in 62.5% of cases after protocol implementation.

CONCLUSION

Smoking cessation treatment reach and representativeness of reach improved after implementation of a proactive, pharmacist-led, EHR-facilitated opt-out smoking cessation treatment protocol in adult inpatient services.

Institutional Tobacco Policy and Tobacco Use Among Kansas Sheriffs' Staff and Individuals Incarcerated in Jail

This article describes the factors that contribute to Kansas county jails' tobacco culture to identify reasons for high tobacco use and intervention opportunities. Kansas sheriffs' offices were asked to complete a novel 26-item survey from August through November 2019, and 40% responded. A few reported that tobacco cessation counseling was available to staff (31%) or incarcerated individuals (12%). Seventy-nine percent reported that staff were permitted to use tobacco in designated places outside, whereas 24% reported that tobacco use by incarcerated individuals was permitted in designated places outside. In the jails' commissaries, 5% reported selling nicotine gum or nicotine lozenges and 26% reported selling e-cigarettes. The lack of tobacco cessation counseling and nicotine replacement therapy, weak policies, and availability of tobacco all contribute to Kansas county jails' prevalent tobacco culture.