Telephone counselling for smoking cessation

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines

BACKGROUND

The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient's perspective in order to inform strategies for improving QL engagement.

METHODS

We conducted interviews with 55 patients who agreed to an eReferral at a primary care visit to 1 of 8 safety-net community health centers in Cuyahoga County, Ohio (September 2017-August 2018). Interviews were designed to explore the experiences of three subgroups of patients who subsequently: 1) declined participation in the QL; 2) were unreachable by the QL; or 3) were enrolled in or had completed the QL program. Analysis was guided by a phenomenological approach designed to identify emergent themes.

RESULTS

Reasons for QL program non-completion included changing life circumstances and events making cessation unviable; misunderstandings about the QL; discomfort with telephonic counseling; perceived lack of time for counseling; cell phone barriers; and having already quit smoking. We found that some individuals who were no longer engaged with the QL still desired continued support from the QL.

CONCLUSIONS

Participants intentionally and unintentionally disengage from the QL for a wide variety of reasons, several of which are mediated by low socioeconomic status. Integrating QL care with community-based resources that address these mediators could be a promising strategy.

Coronavirus Disease 2019 and Smoking: How and Why We Implemented a Tobacco Treatment Campaign

Smoking is associated with one of five deaths in the United States. Multimodality tobacco treatment increases rates of successful cessation by at least 20%. The coronavirus disease 2019 pandemic has put a halt to many inpatient and outpatient medical visits that have been deemed nonessential, including tobacco treatment. The transition to telehealth has been wrought with challenges. Although data on the association between coronavirus disease 2019 and tobacco products are mixed, the overall health consequences of tobacco point towards increased risk of morbidity and death that is associated with the virus. This leaves smoking as one of the few readily modifiable risk factors in an environment understandably not set up to prioritize cessation. A military health facility on Fort Eustis in Virginia runs a successful tobacco treatment program and adapted it to pandemic times. This article describes the process and lessons learned from this initiative. The model is applicable and scalable to government and civilian health centers as health care adapts to a new normal.

An Experimental Feasibility Study of a Hybrid Telephone Counseling/Text Messaging Intervention for Post-Discharge Cessation Support Among Hospitalized Smokers in Brazil

OBJECTIVE

Text messaging interventions are effective. Despite high utilization of smartphones, few studies evaluate text messaging for cessation in middle-/lower-income countries. Initiating tobacco treatment in hospitals is an effective but underutilized approach for reaching smokers. We evaluated a hybrid phone counseling/text messaging intervention for supporting cessation among hospitalized smokers in Brazil.

METHODS

We used an experimental design to assess the feasibility and potential effect size of the intervention. Participants (N = 66) were recruited from a university hospital and randomized in a 2:1 ratio into TXT (one session of telephone counseling plus 2 weeks of text messaging; N = 44) or Standard Care control group (N = 22). Participants lost to follow-up were counted as smokers.

RESULTS

Counselors sent 1186 texts, of which 924 (77.9%) were received by study participants. Participants rated the TXT content as "helpful" (80.4%) and the phone counseling length to be "just right" (95.1%). Although the study was not powered to evaluate abstinence rates, we did observe a higher prevalence of abstinence in the TXT compared to control group at both 1-month follow-up (25.0% vs. 9.1%) and 3-month follow-up (31.8% vs. 9.1%). Carbon monoxide-verified abstinence at month 3 was also higher in TXT (20.5% vs. 4.5%).

CONCLUSIONS

This hybrid telephone/text intervention should progress to full-scale effectiveness testing as it achieved favorable outcomes, was acceptable to participants, and was readily implemented. This type of intervention has strong potential for expanding the reach of hospital-initiated tobacco treatment in middle-/lower-income countries.

IMPLICATIONS

This study extends research on hospital-initiated smoking cessation by establishing the feasibility of a novel text-messaging approach for post-discharge follow-up. Text messaging is a low-cost alternative to proactive telephone counseling that could help overcome resource barriers in middle- and lower-income countries. This hybrid texting/counseling intervention identified smokers in hospitals, established rapport through a single telephone follow-up, and expanded acceptability and reach of later support by using text-messaging, which is free of charge in this and other low-income countries. The favorable cessation outcomes achieved by the hybrid intervention provide support for a fully powered effectiveness trial.

Achieving Smoking Cessation Among Persons with Opioid Use Disorder

While prevalence of tobacco use in the US general population is declining, prevalence among those with opioid use disorder (OUD) remains high and results in excessive tobacco-related disease and premature mortality. Among smokers with OUD, tobacco cessation rates are negligible without treatment. However, both low-intensity behavioral interventions and more intensive motivational interventions yield negligible cessation rates. While contingency management has potent short-term cessation effects, effects are not maintained at post-intervention follow-up. Evidence-based smoking cessation pharmacotherapies, such as nicotine replacement therapy, bupropion, and varenicline, result in very modest cessation rates among smokers with OUD. Intensification of pharmacotherapy, such as high-dose and combination nicotine replacement therapy or extended medication treatment, has failed to improve cessation outcomes compared with standard treatment regimens. Targeting the unique challenges faced by smokers with OUD, including nicotine-opioid interactions and poor medication adherence, has potential to improve cessation outcomes, but further research is needed to optimize intervention efficacy among smokers with OUD.

Pharmacological interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy causes serious health problems for the developing fetus and mother. When used by non-pregnant smokers, pharmacotherapies (nicotine replacement therapy (NRT), bupropion, and varenicline) are effective for increasing smoking cessation, however their efficacy and safety in pregnancy remains unknown. Electronic cigarettes (ECs) are becoming widely used, but their efficacy and safety when used for smoking cessation in pregnancy are also unknown.

OBJECTIVES

To determine the efficacy and safety of smoking cessation pharmacotherapies and ECs used during pregnancy for smoking cessation in later pregnancy and after childbirth, and to determine adherence to smoking cessation pharmacotherapies and ECs for smoking cessation during pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2019), trial registers, and grey literature, and checked references of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) conducted in pregnant women, comparing smoking cessation pharmacotherapy or EC use with either placebo or no pharmacotherapy/EC control. We excluded quasi-randomised, cross-over, and within-participant designs, and RCTs with additional intervention components not matched between trial arms.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. The primary efficacy outcome was smoking cessation in later pregnancy; safety was assessed by 11 outcomes (principally birth outcomes) that indicated neonatal and infant well-being. We also collated data on adherence to trial treatments. We calculated the risk ratio (RR) or mean difference (MD) and the 95% confidence intervals (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate.

MAIN RESULTS

We included 11 trials that enrolled a total of 2412 pregnant women who smoked at enrolment, nine trials of NRT and two trials of bupropion as adjuncts to behavioural support, with comparable behavioural support provided in the control arms. No trials investigated varenicline or ECs. We assessed four trials as at low risk of bias overall. The overall certainty of the evidence was low across outcomes and comparisons as assessed using GRADE, with reductions in confidence due to risk of bias, imprecision, and inconsistency. Compared to placebo and non-placebo (behavioural support only) controls, there was low-certainty evidence that NRT increased the likelihood of smoking abstinence in later pregnancy (RR 1.37, 95% CI 1.08 to 1.74; I² = 34%, 9 studies, 2336 women). However, in subgroup analysis by comparator type, there was a subgroup difference between placebo-controlled and non-placebo controlled RCTs (test for subgroup differences P = 0.008). There was unclear evidence of an effect in placebo-controlled RCTs (RR 1.21, 95% CI 0.95 to 1.55; I² = 0%, 6 studies, 2063 women), whereas non-placebo-controlled trials showed clearer evidence of a benefit (RR 8.55, 95% CI 2.05 to 35.71; I² = 0%, 3 studies, 273 women). An additional subgroup analysis in which studies were grouped by the type of NRT used found no difference in the effectiveness of NRT in those using patches or fast-acting NRT (test for subgroup differences P = 0.08). There was no evidence of a difference between NRT and control groups in rates of miscarriage, stillbirth, premature birth, birthweight, low birthweight, admissions to neonatal intensive care, caesarean section, congenital abnormalities, or neonatal death. In one study infants born to women who had been randomised to NRT had higher rates of 'survival without developmental impairment' at two years of age compared to the placebo group. Non-serious adverse effects observed with NRT included headache, nausea, and local reactions (e.g. skin irritation from patches or foul taste from gum), but data could not be pooled. Adherence to NRT treatment regimens was generally low. We identified low-certainty evidence that there was no difference in smoking abstinence rates observed in later pregnancy in women using bupropion when compared to placebo control (RR 0.74, 95% CI 0.21 to 2.64; I² = 0%, 2 studies, 76 women). Evidence investigating the safety outcomes of bupropion use was sparse, but the existing evidence showed no difference between the bupropion and control group.

AUTHORS' CONCLUSIONS

NRT used for smoking cessation in pregnancy may increase smoking cessation rates in late pregnancy. However, this evidence is of low certainty, as the effect was not evident when potentially biased, non-placebo-controlled RCTs were excluded from the analysis. Future studies may therefore change this conclusion. We found no evidence that NRT has either positive or negative impacts on birth outcomes; however, the evidence for some of these outcomes was also judged to be of low certainty due to imprecision and inconsistency. We found no evidence that bupropion may be an effective aid for smoking cessation during pregnancy, and there was little evidence evaluating its safety in this population. Further research evidence on the efficacy and safety of pharmacotherapy and EC use for smoking cessation in pregnancy is needed, ideally from placebo-controlled RCTs that achieve higher adherence rates and that monitor infants' outcomes into childhood. Future RCTs of NRT should investigate higher doses than those tested in the studies included in this review.

A Smartphone App Designed to Help Cancer Patients Stop Smoking: Results From a Pilot Randomized Trial on Feasibility, Acceptability, and Effectiveness

Background

Persistent smoking after a cancer diagnosis predicts worse treatment outcomes and mortality, but access to effective smoking cessation interventions is limited. Smartphone apps can address this problem by providing a highly accessible, low-cost smoking cessation intervention designed for patients with a recent cancer diagnosis.

Objective

This study aimed to summarize our development process and report the trial design, feasibility, participant acceptability, preliminary effectiveness, and impact on processes of change (eg, cancer stigma) of the first-known smoking cessation smartphone app targeted for cancer patients.

Methods

We used an agile, user-centered design framework to develop a fully automated smartphone app called Quit2Heal that provided skills training and stories from cancer survivors focusing on coping with internalized shame, cancer stigma, depression, and anxiety as core triggers of smoking. Quit2Heal was compared with the National Cancer Institute’s QuitGuide, a widely used stop smoking app for the general population, in a pilot double-blinded randomized trial with a 2-month follow-up period. Participants were 59 adult smokers diagnosed with cancer within the past 12 months and recruited through 2 cancer center care networks and social media over a 12-month period. The most common types of cancer diagnosed were lung (21/59, 36%) and breast (10/59, 17%) cancers. The 2-month follow-up survey retention rate was 92% (54/59) and did not differ by study arm (P=.15).

Results

Compared with QuitGuide participants, Quit2Heal participants were more satisfied with their assigned app (90% [19/21] for Quit2Heal vs 65% [17/26] for QuitGuide; P=.047) and were more likely to report that the app assigned to them was made for someone like them (86% [18/21] for Quit2Heal vs 62% [16/26] for QuitGuide; P=.04). Quit2Heal participants opened their app a greater number of times during the 2-month trial period, although this difference was not statistically significant (mean 10.0, SD 14.40 for Quit2Heal vs mean 6.1, SD 5.3 for QuitGuide; P=.33). Self-reported 30-day point prevalence quit rates at the 2-month follow-up were 20% (5/25) for Quit2Heal versus 7% (2/29) for QuitGuide (odds ratio 5.16, 95% CI 0.71-37.29; P=.10). Quit2Heal participants also showed greater improvement in internalized shame, cancer stigma, depression, and anxiety, although these were not statistically significant (all P>.05).

Conclusions

In a pilot randomized trial with a high short-term retention rate, Quit2Heal showed promising acceptability and effectiveness for helping cancer patients stop smoking. Testing in a full-scale randomized controlled trial with a longer follow-up period and a larger sample size is required to test the effectiveness, mediators, and moderators of this promising digital cessation intervention.

Trial Registration

ClinicalTrials.gov NCT03600038; https://clinicaltrials.gov/ct2/show/NCT03600038

Chat-based hotlines for health promotion: a systematic review

BACKGROUND

Chat-based hotlines use online messaging services or popular chat applications such as WhatsApp, Facebook Messenger, and WeChat, to connect users to trained health providers or staff. Chat-based hotlines can provide real-time communication between health providers and patients.

METHODS

The evidence for chat-based hotlines for health promotion has not been reviewed systematically. Electronic databases (PubMed, Cochrane Database, Google Scholar) were searched to identify English-language studies describing original research published from 2009 to 2020. This review was registered with Prospero Register of Systematic Reviews (ID: CRD42020156670).

RESULTS

Twelve publications met our criteria. Ten studies reported on user characteristics, eight on comparing use of chat-based hotlines with different modes of support, six on health outcomes and six on user satisfaction. Included studies report that chat-based hotlines have been used primarily for crisis and emotional support in high-income countries. Chat-based hotlines using instant messenger applications were preferred over other modes of services such as email, text messaging, voice calls, and face-to-face counselling. Evaluations of health outcomes, although limited in rigor due to mostly observational study designs, indicate mostly positive and statistically significant effects on mental health outcomes such as anxiety, depression, well-being and suicidality. User satisfaction with chat-based hotlines were moderately high.

CONCLUSIONS

Chat-based hotlines may be effective ways to deliver crisis support services in high income settings. They may have the potential to be effective in low- and middle-income countries to expand the reach of mental health and crisis support services although such services have not yet been publicly evaluated.

The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard

The Tobacco Control Scorecard, published in 2004, presented estimates of the effectiveness of different policies on smoking rates. Since its publication, new evidence has emerged. We update the Scorecard to include recent studies of demand-reducing tobacco policies for high-income countries. We include cigarette taxes, smoke-free air laws, media campaigns, comprehensive tobacco control programs, marketing bans, health warnings, and cessation treatment policies. To update the 2004 Scorecard, a narrative review was conducted on reviews and studies published after 2000, with additional focus on 3 policies in which previous evidence was limited: tobacco control programs, graphic health warnings, and marketing bans. We consider evaluation studies that measured the effects of policies on smoking behaviors. Based on these findings, we derive estimates of short-term and long-term policy effect sizes. Cigarette taxes, smoke-free air laws, marketing restrictions, and comprehensive tobacco control programs are each found to play important roles in reducing smoking prevalence. Cessation treatment policies and graphic health warnings also reduce smoking and, when combined with policies that increase quit attempts, can improve quit success. The effect sizes are broadly consistent with those previously reported for the 2004 Scorecard but now reflect the larger evidence base evaluating the impact of health warnings and advertising restrictions.

Predictors of Tobacco Cessation Among American Indian/Alaska Native Adults Enrolled in a State Quitline

Background: High rates of smoking are documented among some American Indian and Alaska Native (AI/AN) communities, with potential variability by region and urban/rural settings. Quitlines are a cost-effective strategy for providing evidence-based cessation treatment, but little is known about the effectiveness of quitline services for the AI/AN population. Objectives: This study compared demographic characteristics, tobacco use, and cessation and program utilization behaviors between AI/AN (n = 297) and Non-Hispanic White (NHW; n = 13,497) quitline callers. The study also identified predictors of 30-day cessation at 7-month follow-up among AI/AN callers and determined if predictors were different between AI/AN and NHW callers. Methods: Data from callers to the Arizona Smokers' Helpline between January 2011 and June 2016 were analyzed. Results: At enrollment, AI/AN callers were less likely to use tobacco daily and were less dependent on nicotine compared to NHW callers. Both groups reported similar rates of 30-day cessation at 7-month follow-up (37.3% and 39.7% for AI/AN and NHW callers, respectively). For AI/AN callers, 30-day cessation was significantly associated with tobacco cessation medication use (OR = 2.24, 95% CI: 1.02-4.93), number of coaching sessions (OR = 1.14, 95% CI: 1.04-1.26), and other smokers in the home (OR = 0.41, 95% CI: 0.19-0.91). The effect of other smokers in the home was significantly different between AI/AN and NHW callers (p = .007). Conclusions: Different individual characteristics and predictors of cessation among AI/AN callers compared to NHW callers were documented. Findings may be used to inform the development of culturally-tailored strategies and protocols for AI/AN quitline callers.

A Randomized Controlled Trial of an Optimized Smoking Treatment Delivered in Primary Care

Background

The effectiveness of smoking cessation treatment is limited in real-world use, perhaps because we have not selected the components of such treatments optimally nor have treatments typically been developed for and evaluated in real-world clinical settings.

Purpose

To validate an optimized smoking cessation treatment package that comprises intervention components identified as effective in factorial screening experiments conducted as per the Multiphase Optimization Strategy (MOST).

Methods

Adult smokers motivated to quit were recruited from primary care clinics (N = 623). Participants were randomized to receive either recommended usual care (R-UC; 10 min of in-person counseling, 8 weeks of nicotine patch, and referral to quitline services) or abstinence-optimized treatment (A-OT; 3 weeks of prequit mini-lozenges, 26 weeks of nicotine patch + mini-lozenges, three in-person and eight phone counseling sessions, and 7-11 automated calls to prompt medication use). The key outcomes were self-reported and biochemically confirmed (carbon monoxide, CO <6 ppm) 7-day point-prevalence abstinence.

Results

A-OT participants had significantly higher self-reported abstinence rates than R-UC participants at 4, 8, 16, and 26 weeks (ORs: 1.91-3.05; p <. 001). The biochemically confirmed 26-week abstinence rates were lower than the self-reported 26-week rates, but revealed a similar treatment effect size (OR = 2.94, p < .001). There was no moderation of treatment effects on 26-week abstinence by demographic, psychiatric, or nicotine dependence variables. A-OT had an incremental cost-effectiveness ratio for 26-week CO-confirmed abstinence of $7,800.

Conclusions

A smoking cessation treatment that is optimized via MOST development meaningfully enhances cessation rates beyond R-UC smoking treatment in smokers seen in primary care.

Clinical Trial Registration

NCT02301403.

Testing the feasibility of a guided imagery tobacco cessation intervention delivered by a telephone quitline: Study protocol for a randomized controlled feasibility trial

Background

Guided imagery (GI) is an evidence-based method that uses the imagination to practice and achieve a desired outcome. Little research has focused on how GI can be delivered to smokers using remote or virtual methods, such as a telephone-based intervention. Telephone-based services for tobacco cessation (quitlines) have emerged as standard of care for tobacco cessation. However, quitlines reach only a small fraction of smokers, and men and racial/ethnic minorities are less likely to use quitlines than majority women. GI has the potential to attract under-served minority groups as well as smokers who are looking for an alternative approach to cessation. The present study is designed to test the feasibility and potential impact of a GI tobacco cessation intervention delivered by telephone. This study compares the GI intervention with a standard behavioral (SB) intervention.

Methods

Participants (N = 100) are randomized to either the GI (intervention) or SB (control) condition. Each condition features a 6-week intervention in which participants work with coaches to quit tobacco. Primary outcomes are feasibility related (recruitment, retention, adherence), and secondary outcomes include cessation at 6 months post-intervention (7-day and 30-day abstinence).

Discussion

A GI intervention delivered via quitline would allow for scalability and dissemination, potentially reaching a more representative group of smokers. Results from this study will determine the feasibility of delivering the GI intervention, and describe the reach of the intervention to under-represented tobacco users. If successful, our study results will guide the design and conduct of a future efficacy trial.

A structured telephone-delivered intervention to reduce problem alcohol use (Ready2Change): study protocol for a parallel group randomised controlled trial

Background

Current population surveys suggest around 20% of Australians meet diagnostic criteria for an alcohol use disorder. However, only a minority seek professional help due to individual and structural barriers, such as low health literacy, stigma, geography, service operating hours and wait lists. Telephone-delivered interventions are readily accessible and ideally placed to overcome these barriers. We will conduct a randomised controlled trial (RCT) to examine the efficacy of a standalone, structured telephone-delivered intervention to reduce alcohol consumption, problem severity and related psychological distress among individuals with problem alcohol use.

Methods/design

This is a single site, parallel group, two-arm superiority RCT. We will recruit 344 participants from across Australia with problem alcohol use. After completing a baseline assessment, participants will be randomly allocated to receive either the Ready2Change (R2C) intervention (n = 172, four to six sessions of structured telephone-delivered intervention, R2C self-help resource, guidelines for alcohol consumption and stress management pamphlets) or the control condition (n = 172, four phone check-ins < 5 min, guidelines for alcohol consumption and stress management pamphlets). Telephone follow-up assessments will occur at 4–6 weeks, 3 months, 6 months and 12 months post-baseline. The primary outcome is the Alcohol Use Disorders Identification Test (AUDIT) score administered at 3 months post-baseline. Secondary outcomes include change in AUDIT score (6 and 12 months post-baseline), change in number of past-month heavy drinking days, psychological distress, health and wellbeing, quality of life, client treatment evaluation and cost effectiveness.

Discussion

This study will be one of the first RCTs conducted internationally to examine the impact of a standalone, structured telephone-delivered intervention to address problem alcohol use and associated psychological morbidity. The proposed intervention is expected to contribute to the health and wellbeing of individuals who are otherwise unlikely to seek treatment through mainstream service models, to reduce the burden on specialist services and primary care providers and to provide an accessible and proportionate response, with resulting cost savings for the health system and broader community.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12618000828224. Pre-registered on 16 May 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3462-9) contains supplementary material, which is available to authorized users.

Health System Implementation of a Tobacco Quitline eReferral

BACKGROUND

Proactive referrals through electronic orders (eReferrals) can increase patient connection with tobacco quitlines. More information is needed on "real-world" implementation of electronic health record tools to promote tobacco cessation while minimizing provider burden.

OBJECTIVES

This paper examines the health system implementation of an eReferral to a tobacco quitline without best practice alerts in primary care, specialty, and hospital settings in an academic health system.

METHODS

This is a prospective implementation study of a health system tobacco eReferral to a state quitline that was completed with an approach to minimize provider cognitive burden. Data are drawn from electronic health record data at University of California, Davis Health Systems (March 2013-February 2016).

RESULTS

Over 3 years, 16,083 encounters with smokers resulted in 1,137 eReferral orders (7.1%). Treatment reach was 1.6% for quitline services and 2.3% for outpatient group classes. While the group classes were offered to outpatient smokers, the eReferral order was included in an outpatient order set and eventually an automated inpatient discharge order set; no provider alerts were implemented. Referrals were sustained and doubled after inpatient order set implementation. Among all first time eReferral patients, 12.2% had a 6 to 12 month follow-up visit at which they were documented as nonsmoking.

CONCLUSION

This study demonstrates a quitline eReferral order can be successfully implemented and sustained with minimal promotion, without provider alerts and in conjunction with group classes. Reach and effectiveness were similar to previously described literature.

Smoking prevalence and attributable deaths in Thailand: predicting outcomes of different tobacco control interventions

Background

Despite substantial positive impacts of Thailand’s tobacco control policies on reducing the prevalence of smoking, current trends suggest that further reductions are needed to ensure that WHO’s 2025 voluntary global target of a 30% relative reduction in tobacco use is met. In order to confirm this hypothesis, we aim to estimate the effect of tobacco control policies in Thailand on the prevalence of smoking and attributed deaths and assess the possibilities of achieving WHO’s 2025 global target. This paper addresses this knowledge gap which will contribute to policy control measures on tobacco control. Results of this study can help guide policy makers in implementing further interventions to reduce the prevalence of smoking in Thailand.

Method

A Markov chain model was developed to examine the effect of tobacco control policies, such as accessibility restrictions for youths, increased tobacco taxes and promotion of smoking cessation programs, from 2015 to 2025. Outcomes included smoking prevalence and the number of smoking-attributable deaths. Due to the very low prevalence of female smokers in 2014, this study applied the model to estimate the smoking prevalence and attributable mortality among males only.

Results

Given that the baseline prevalence of smoking in 2010 was 41.7% in males, the target of a 30% relative reduction requires that the prevalence be reduced to 29.2% by 2025. Under a baseline scenario where smoking initiation and cessation rates among males are attained by 2015, smoking prevalence rates will reduce to 37.8% in 2025. The combined tobacco control policies would further reduce the prevalence to 33.7% in 2025 and 89,600 deaths would be averted.

Conclusion

Current tobacco control policies will substantially reduce the smoking prevalence and smoking-attributable deaths. The combined interventions can reduce the smoking prevalence by 19% relative to the 2010 level. These projected reductions are insufficient to achieve the committed target of a 30% relative reduction in smoking by 2025. Increased efforts to control tobacco use will be essential for reducing the burden of non-communicable diseases in Thailand.

A pragmatic randomised trial of two counselling models at the Swedish national alcohol helpline

BACKGROUND

Alcohol telephone helplines targeting alcohol consumers in the general population can extend the reach of brief interventions while preserving in-person counselling. So far, studies of client outcomes in the setting of alcohol helplines are scarce. This study aims to compare the 6-months alcohol-related outcomes of two counselling models delivered at the Swedish National Alcohol Helpline.

METHODS

A pragmatic randomised trial was set up at the Swedish National Alcohol Helpline. First-time callers with current hazardous or harmful alcohol use who contacted the helpline, from May 2015 to December 2017, were invited to participate. Clients were allocated with 1:1 ratio to two groups: (1) brief, structured intervention (n = 128), including self-help material and one counsellor-initiated call, and (2) usual care (n = 133), i.e. multiple-session counselling using Motivational Interviewing (MI). The primary outcome was a downward change in AUDIT risk-zone between baseline and 6-months follow-up. The analysis followed an intention-to-treat approach.

RESULTS

Recruitment ended in December 2017. At 6-months follow-up, 70% of the enrolled participants had data on the outcome. In the brief, structured intervention (n = 107) 68% changed to a lower risk-level, compared to 61% in the usual care group (n = 117), yielding a risk ratio (RR) of 1.12 (95% CI 0.93 to 1.37) and risk difference of 0.08 (95% CI -0.05 to 0.20). The total AUDIT score and the scores from the AUDIT consumption questions (AUDIT-C) did not reveal any between-group differences in the mean change at follow-up.

CONCLUSIONS

The counselling at the Swedish National Alcohol Helpline was followed by a significant decrease in alcohol use among clients, without clear superiority for either counselling model.

TRIAL REGISTRATION

This trial was retrospectively registered with ISRCNT.com (ID: ISRCTN13160878 ) 18/01/2016.

Smoking cessation interventions for potential use in the lung cancer screening setting: A systematic review and meta-analysis

OBJECTIVES

Current guidelines recommend delivery of smoking cessation interventions with lung cancer screening (LCS). Unfortunately, there are limited data to guide clinicians and policy-makers in choosing cessation interventions in this setting. Several trials are underway to fill this evidence gap, but results are not expected for several years.

METHODS AND MATERIALS

We conducted a systematic review and meta-analysis of current literature on the efficacy of smoking cessation interventions among populations eligible for LCS. We searched PubMed, Medline, and PsycINFO for randomized controlled trials of smoking cessation interventions published from 2010-2017. Trials were eligible for inclusion if they sampled individuals likely to be eligible for LCS based on age and smoking history, had sample sizes >100, follow-up of 6- or 12-months, and were based in North America, Western Europe, Australia, or New Zealand.

RESULTS

Three investigators independently screened 3,813 abstracts and identified 332 for full-text review. Of these, 85 trials were included and grouped into categories based on the primary intervention: electronic/web-based, in-person counseling, pharmacotherapy, and telephone counseling. At 6-month follow-up, electronic/web-based (odds ratio [OR] 1.14, 95% CI 1.03-1.25), in-person counseling (OR 1.46, 95% CI 1.25-1.70), and pharmacotherapy (OR 1.53, 95% CI 1.33-1.77) interventions significantly increased the odds of abstinence. Telephone counseling increased the odds but did not reach statistical significance (OR 1.21, 95% CI 0.98-1.50). At 12-months, in-person counseling (OR 1.28 95% CI 1.10-1.50) and pharmacotherapy (OR 1.46, 95% CI 1.17-1.84) remained efficacious, although the decrement in efficacy was of similar magnitude across all intervention categories.

CONCLUSIONS

Several categories of cessation interventions are promising for implementation in the LCS setting.

Parent eReferral to Tobacco Quitline: A Pragmatic Randomized Trial in Pediatric Primary Care

INTRODUCTION

Quitlines are effective in helping smokers quit, but pediatrician quitline referral rates are low, and few parents who smoke use the service. This study compared enrollment of parents who smoke in the quitline using electronic referral with that using manual referral.

STUDY DESIGN

The study was designed as a pragmatic RCT.

SETTING/PARTICIPANTS

Participants were recruited from one large, urban pediatric primary care site in Philadelphia, Pennsylvania with a high percentage of low-income families. Participants included adult parents who smoked and were present at their child's healthcare visit.

INTERVENTION

Pediatricians screened for tobacco use; smokers were given brief advice to quit and, if interested in quitting, were referred to the quitline. The eReferral ("warm handoff") involved electronically sending parent information to the quitline (parent received a call within 24-48 hours). Control group procedures were identical to eReferral, except the quitline number was provided to the parent. Data were collected between March 2017 and February 2018 and analyzed in 2018.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of parents enrolled in quitline treatment. Secondary outcomes included parent factors (e.g., demographics, nicotine dependence, and quitting motivation) associated with successful enrollment. Number of quitline contacts was also explored.

RESULTS

During the study period, in the eReferral group, 10.3% (24 of 233) of parents who smoked and were interested in quitting enrolled in the quitline, whereas only 2.0% (5 of 251) of them in the control group enrolled in the quitline-a difference of 8.3% (95% CI=4.0, 12.6). Parents aged ≥50 years enrolled in the quitline more frequently. Although more parents in the eReferral group connected to the quitline, among parents who had at least one quitline contact, there was no significant difference in the mean number of quitline contacts between eReferral and control groups (mean, 2.04 vs 2.40 calls; difference, 0.36 [95% CI=0.35, 1.06]).

CONCLUSIONS

Smoking parent eReferral from pediatric primary care may increase quitline enrollment and could be adopted by practices interested in increasing rates of parent treatment.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02997735.

Effects of post-discharge counseling and medication utilization on short and long-term smoking cessation among hospitalized patients

Numerous studies have tested the effect of multicomponent post-discharge smoking cessation interventions on post-discharge smoking cessation, and many are effective. However, little is known regarding the relative efficacy of the different intervention components on short or long-term cessation. The present study is a secondary analysis (n = 984) of a randomized controlled trial for hospitalized smokers that took place at two large hospitals in Kansas from 2011 to 2014. All study participants were offered post-discharge quitline services. Pharmacotherapy was recommended during bedside tobacco treatment. The study outcomes were self-reported cessation at 1-month and biochemically verified cessation at 6-months post-randomization. During the post-discharge period, 69% of participants completed at least one quitline call and 28% of participants reported using cessation pharmacotherapy. After controlling for known predictors of cessation among hospitalized smokers, both the number of total quitline calls completed post-discharge and use of cessation pharmacotherapy post-discharge were predictive of cessation at 1-month. After accounting for predictors of cessation and quitting at 1-month, total post-discharge quitline calls was associated with cessation at 6-months (OR [95% CI] = 1.23 [1.12, 1.35], p < 0.001) while post-discharge cessation pharmacotherapy use was not. The results suggest that both engagement in quitline services and use pharmacotherapy independently facilitate cessation beyond the influence of known clinical characteristics associated with cessation. Over the longer term, the effect of engaging in quitline services persists while the effect of pharmacotherapy diminishes. To optimize outcomes, future research should investigate methods to increase utilization of medications and promote sustained counseling engagement in order to sustain the effects of treatment during the post-discharge period.

•

Counseling and pharmacotherapy are effective interventions for helping hospitalized smokers quit smoking, but the relative contribution of each intervention component to short or long-term abstinence is not well understood

•

This secondary analysis of a large clinical trial found that quitline counseling and pharmacotherapy – when used after hospital discharge - were associated with increased odds of quitting smoking at 1-month follow up

•

Controlling for early abstinence at 1 month, only post-discharge quitline counseling remained predictive of cessation at 6-months follow-up

•

Pharmacotherapy and quitline counseling independently facilitate short-term abstinence, while long-term abstinence is facilitated by engagement in quitline counseling services

•

Hospitals could work directly with state quitlines to integrate counseling into post-discharge care

Development of a Discrete Choice Experiment (DCE) Questionnaire to Understand Veterans' Preferences for Tobacco Treatment in Primary Care

BACKGROUND

Providers often prescribe counseling and/or medications for tobacco cessation without considering patients' treatment preferences.

OBJECTIVE

The primary aims of this study are to describe (1) the development of a discrete choice experiment (DCE) questionnaire designed to identify the attributes and levels of tobacco treatment that are most important to veterans; and (2) the decision-making process in choosing between hypothetical tobacco treatments.

METHODS

We recruited current smokers who were already scheduled for a primary care appointment within a single Veterans Affairs (VA) healthcare system. Subjects were asked to rate the importance of selected treatment attributes and were interviewed during two rounds of pilot testing of initial DCE instruments. Key attributes and levels of the initial instruments were identified by targeted literature review; the instruments were iteratively revised after each round of pilot testing. Using a 'think aloud' approach, subjects were interviewed while completing DCE choice tasks. Constant comparison techniques were used to characterize the issues raised by subjects. Findings from the cognitive interviews were used to revise the initial DCE instruments.

RESULTS

Most subjects completed the DCE questionnaire without difficulty and considered two or more attributes in choosing between treatments. Two common patterns of decision-making emerged during the cognitive interviews: (1) counting 'pros' and 'cons' of each treatment alternative; and (2) using a 'rule-out' strategy to eliminate a given treatment choice if it included an undesirable attribute. Subjects routinely discounted the importance of certain attributes and, in a few cases, focused primarily on a single 'must-have' attribute.

CONCLUSION

Cognitive interviews provide valuable insights into the comprehension and interpretation of DCE attributes, the decision processes used by veterans during completion of choice tasks, and underlying reasons for non'-compensatory decision-making.

Interventions for smoking cessation in people diagnosed with lung cancer

BACKGROUND

Lung cancer is one of the most common causes of death from cancer worldwide. Smoking induces and aggravates many health problems, including vascular diseases, respiratory illnesses and cancers. Tobacco smoking constitutes the most important risk factor for lung cancer. Most people with lung cancer are still active smokers at diagnosis or frequently relapse after smoking cessation. Quitting smoking is the most effective way for smokers to reduce the risk of premature death and disability. People with lung cancer may benefit from stopping smoking. Whether smoking cessation interventions are effective for people with lung cancer and whether one method of quitting is more effective than any other has not been systematically reviewed.

OBJECTIVES

To determine the effectiveness of smoking cessation programmes for people with lung cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (accessed via PubMed) and Embase up to 22 December 2018. We also searched the American Society of Clinical Oncology (ASCO) Annual Meeting proceedings, the lung cancer sections of the proceedings of the ESMO Congress, the lung cancer sections of the proceedings of the European Conference of Clinical Oncology (ECCO) Congress, the World Conference on Lung Cancer proceedings, the Society for Research on Nicotine and Tobacco Annual Meeting from 2013, the Food and Drug Administration website, the European Medicine Agency for drug registration website, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal, ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) to 30 December 2018. We applied no restriction on language of publication.

SELECTION CRITERIA

We planned to include any randomised controlled trial (RCT) of any psychosocial or pharmacological smoking cessation intervention or combinations of both, compared with no intervention, a different psychosocial or pharmacological (or both) intervention or placebo for pharmacological interventions in people with lung cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the studies from the initial search for potential trials for inclusion. We planned to use standard methodological procedures expected by Cochrane. We found no trials that met the inclusion criteria.

MAIN RESULTS

We identified no RCTs that met our inclusion criteria. Among the 1817 records retrieved using our search strategy, we retrieved 19 studies for further investigation. We excluded 15 trials: ten trials because we could not distinguish people with lung cancer from the other participants, or the participants were not people with lung cancer, four because they were not randomised, or RCTs. We excluded one trial because, though it was completed in 2004, no results are available. We assessed four ongoing trials for inclusion when data become available.

AUTHORS' CONCLUSIONS

There were no RCTs that determined the effectiveness of any type of smoking cessation programme for people with lung cancer. There was insufficient evidence to determine whether smoking cessation interventions are effective for people with lung cancer and whether one programme is more effective than any other. People with lung cancer should be encouraged to quit smoking and offered smoking cessation interventions. However, due to the lack of RCTs, the efficacy of smoking cessation interventions for people with lung cancer cannot be evaluated and concluded. This systematic review identified a need for RCTs to explore these.

Higher quality quit-date goal setting enhances quit attempts among quitline callers

INTRODUCTION

At tobacco quitlines, coaching and cessation medications are commonly structured around setting a date for making a quit attempt. However, limited literature evaluating this practice suggests that callers do not routinely set quit-date goals. High quality goal setting may increase the frequency of caller quit attempts. In this study, we examine the quality of quit-date goal setting and its association with in-program quit attempts and the timing of callers’ first quit attempt.

METHODS

Using call recordings, we scored the quality of quit-date goal setting among 90 callers enrolled at Arizona Smokers’ Helpline between August and December 2017. The primary exposure was quality of quit-date goal setting assessed using the Lorencatto et al. rating scale. Coding reliability was assessed using Cohen’s kappa. Multivariable logistic regression was used to examine the association between quality of goal setting and in-program quit attempts (>24 h tobacco free).

RESULTS

The mean quality goal setting score was 3.1 (range: -3 to 7). Sixty-nine callers (77%) set a quit date and 39 (43%) made a quit attempt. Compared to callers who experienced low-quality goal setting, the adjusted odds of in-program quitting for high quality goal setting was AOR=3.98 (95% CI: 1.55–10.20) and for making a quit attempt within two weeks OR=6.23 (95% CI: 1.52–25.49).

CONCLUSIONS

Quit-date goal setting is an important element of quitline services and callers benefit from high quality quit-date goal setting. Quitlines should establish quality improvement measures to ensure that coaches are trained to provide high quality quit-date goal setting opportunities to all callers.

Staying Quit After Release (SQuARe) trial protocol: a randomised controlled trial of a multicomponent intervention to maintain smoking abstinence after release from smoke-free prisons in Victoria, Australia

INTRODUCTION

Smoke-free policies have been introduced in prisons internationally. However, high rates of relapse to smoking after release from prison indicate that these policies typically result in short-term smoking cessation only. These high rates of relapse, combined with a lack of investment in relapse prevention, highlight a missed opportunity to improve the health of a population who smoke tobacco at two to six times the rate of the general population. This paper describes the rationale and design of a randomised controlled trial, testing the effectiveness of a caseworker-delivered intervention promoting smoking cessation among former smokers released from smoke-free prisons in Victoria, Australia.

METHODS AND ANALYSIS

The multicomponent, brief intervention consists of behavioural counselling, provision of nicotine spray and referral to Quitline and primary care to promote use of government-subsidised smoking cessation pharmacotherapy. The intervention is embedded in routine service delivery and is administered at three time points: one prerelease and two postrelease from prison. Control group participants will receive usual care. Smoking abstinence will be assessed at 1 and 3 months postrelease, and confirmed with carbon monoxide breath testing. Linkage of participant records to survey and routinely collected administrative data will provide further information on postrelease use of health services and prescribed medication.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Corrections Victoria Research Committee, the Victorian Department of Justice Human Research Ethics Committee, the Department of Human Services External Request Evaluation Committee and the University of Melbourne Human Research Ethics Committee. Results will be submitted to major international health-focused journals. In case of success, findings will assist policymakers to implement urgently needed interventions promoting the maintenance of prison-initiated smoking abstinence after release, to reduce the health disparities experienced by this marginalised population.

TRIAL REGISTRATION NUMBER

ACTRN12618000072213; Pre-results.

Study protocol for a telephone-based smoking cessation randomized controlled trial in the lung cancer screening setting: The lung screening, tobacco, and health trial

Lung cancer mortality can be reduced by 20% via low dose CT lung cancer screening (LCS) and treatment of early-stage disease. Providing tobacco use treatment to high risk cigarette smokers in the LCS setting may result in health benefits beyond the impact of LCS. As one of the nine trials in the National Cancer Institute's Smoking Cessation at Lung Examination (SCALE) collaboration, the goal of the Lung Screening, Tobacco, and Health (LSTH) trial is to develop a scalable and cost-effective cessation intervention for subsequent implementation by LCS programs. Guided by the RE-AIM Framework, the LSTH trial is a two-arm RCT (N = 1330) enrolling English- and Spanish-speaking smokers registered for LCS at one of seven collaborating sites. Participants are randomly assigned to Usual Care (UC; three proactive telephone counseling sessions/two weeks of nicotine patches) vs. Intensive Telephone Counseling (ITC; eight proactive sessions/eight weeks of nicotine patches, plus discussion of the LCS results to increase motivation to quit). Telephone counseling is provided by tobacco treatment specialists. To increase continuity of care, referring physicians are notified of participant enrollment and smoking status following the intervention. Outcomes include: 1) self-reported 7-day, 30-day, and sustained abstinence, and biochemically-verified at 3-, 6-, and 12-months post-randomization, 2) reach and engagement of the interventions, and 3) cost-effectiveness of the interventions. The Cancer Intervention and Surveillance Modeling Network (CISNET) will model long-term impacts of six SCALE trials on the cost per life year saved, quality-adjusted life years saved, lung cancer mortality reduction, and population mortality. CLINICAL TRIALS REGISTRATION: The trial is registered at clinical trials.gov: NCT03200236.

Evaluating NHS Stop Smoking Service engagement in community pharmacies using simulated smokers: fidelity assessment of a theory-based intervention

OBJECTIVES

Smokers are more likely to quit if they use the National Health Service (NHS) Stop Smoking Service (SSS). However, community pharmacies experience low service uptake. The Smoking Treatment Optimisation in Pharmacies (STOP) programme aims to address this problem by enhancing staff training using a theory-based intervention. In this study, we evaluated intervention fidelity using simulated smokers (actors) to assess smoker engagement and enactment of key intervention components by STOP trained staff.

DESIGN

An observational pilot study.

SETTINGS

Five community pharmacies in North East London with an NHS SSS.

METHODS

Six actors, representative of East London's population, were recruited and trained to complete intervention fidelity assessments. Consenting pharmacy staff from five participating pharmacies received STOP Intervention training. Four weeks after the staff training, the actors visited the participating pharmacies posing as smokers eligible for smoking cessation support. Engagement behaviour by pharmacy staff and enactment of intervention components was assessed using a scoring tool derived from the STOP logic model (scoring range of 0-36), and contemporaneous field notes taken by actors.

RESULTS

18 of 30 completed assessments were with STOP trained staff (10/18 were counter assistants). Mean score for smoker engagement was 24.4 (SD 9.0) points for trained and 16.9 (SD 7.8) for untrained staff, respectively. NHS SSS leaflets (27/30) were the most common smoking cessation materials seen on pharmacy visits. Most trained counter staff engaged with smokers using leaflets and a few proactively offered appointments with their cessation advisors. Appropriate use of body language was reported on 26/30 occasions alongside the use of key phrases from the STOP training session (n=8). Very few pharmacy staff wore STOP promotional badges (4/30).

CONCLUSIONS

STOP training may change client engagement behaviour in pharmacy staff and could improve the uptake of the NHS SSS. A cluster randomised controlled trial is currently in progress to evaluate its effectiveness and cost-effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN16351033.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I² = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I² = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I² = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

WhatsApp embedded in routine service delivery for smoking cessation: effects on abstinence rates in a randomized controlled study

Background

The demand for smoking cessation services has risen in Turkey, as smokers planning to quit reached 35% in 2012. Communication technologies are used globally to support quitters, yet their integration to health services is rare. This study aims to evaluate the effect of support messages through WhatsApp application added to the usual care of a university hospital cessation unit, as compared to usual care alone, on abstinence rates at first month.

Methods

A randomized controlled intervention study was conducted with 132 patients applying to Ege University Hospital’s Department of Public Health Smoking Cessation Clinic, between March and July 2017. Intervention content was prepared and 60 WhatsApp messages about having a plan of action and preventing relapse were developed through expert panels. These messages lasted for 3 months and follow-ups continued for 6 months. The primary outcome was abstinence rate at 1st month post target quit day. As secondary outcomes; the continuous abstinence rates at 3rd and 6th months, number of follow-ups, change in weight and continuity of medication were evaluated. Intention-to-treat analysis was used.

Results

Abstinence rate at 1st month was 65.9% in the intervention group and 40.9% in the control group (p = 0.007); 50.0 and 30.7% at 3rd month and 40.9 and 22.7% at 6th month, consecutively (both p < 0.05). Being in the intervention group increased abstinence rate by 3.50 (OR, 95% CI = 1.30–9.44) times in the 1st month. When controlled for all other factors in the multivariate logistic regression, the intervention was the only variable significantly associated with abstinence. For secondary outcomes, the intervention increased abstinence rate by 2.50 (OR, 95% CI = 1.08–6.40) times in the 3rd and 2.31 (OR, 95% CI = 1.03–5.16) times in the 6th month. In the intervention group, the number of follow-ups and face-to-face follow-ups were higher at 1st and 3rd months and continuity of medication was longer at 3rd month.

Conclusions

WhatsApp support embedded in cessation service delivery increases the abstinence rate and has favorable effects on follow-up.

Trial registration

This trial is retrospectively registered online at ClinicalTrials.gov with the identifier NCT03714971.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6727-z) contains supplementary material, which is available to authorized users.

Mobile Phone-Based Smoking-Cessation Intervention for Patients Undergoing Elective Surgery: Protocol for a Randomized Controlled Trial

Background

Several large studies have shown that the risk of cardiovascular, respiratory, and wound-healing complications (including death) within 30 days of surgery is greater for smokers than for nonsmokers. However, there is evidence that even short-term perioperative smoking cessation may reduce postoperative morbidity. Over the past few years, it has become more evident that short message service (SMS)–based interventions can help individuals quit smoking.

Objective

The overall aim of this project is to fill the knowledge gap on whether an SMS-based smoking-cessation intervention can be effective in helping patients stop smoking perioperatively. The aim of this trial is to evaluate the effectiveness of an SMS-based intervention on smoking behavior of patients undergoing elective surgery.

Methods

A two-arm parallel-group randomized controlled trial will be conducted at 20 surgical departments in southeast Sweden. Smokers undergoing elective surgery who own a mobile phone will be included. Power calculations indicate that it will be necessary to randomize 434 participants. One group will be given access to a novel 12-week SMS program, which includes daily SMS messages with behavior change–enforcing text content and hyperlinks to interactive modules, while the other group will not be given access to the intervention. Both groups will have access to the surgical departments’ current routine for smoking cessation prior to surgery. Primary outcome measures, prolonged abstinence, and point prevalence of smoking cessation will be measured through questionnaires at 3, 6, and 12 months after randomization. Logistic regression models adjusted using baseline characteristics will be explored to identify potential effects of the intervention.

Results

Recruitment started in late October 2018 and is expected to last for a maximum of 30 months. The first results are expected to be available approximately 3 months after the final date of recruitment.

Conclusions

Owing to the structural problems and scarcity of time and resources, patients at most Swedish surgical departments are simply instructed to quit smoking, and perhaps, referred to a primary health care clinic. An SMS-based smoking-cessation aid can be effective in helping individuals quit smoking and is a very simple and time-efficient tool for surgical departments to use.

Trial Registration

ISRCTN Registry ISRCTN33869008; http://www.isrctn.com/ISRCTN33869008

International Registered Report Identifier (IRRID)

PRR1-10.2196/12511

Digital Education for Health Professions on Smoking Cessation Management: Systematic Review by the Digital Health Education Collaboration

BACKGROUND

Tobacco smoking, one of the leading causes of preventable death and disease, is associated with 7 million deaths every year. This is estimated to rise to more than 8 million deaths per year by 2030, with 80% occurring in low- and middle-income countries. Digital education, teaching, and learning using digital technologies have the potential to increase educational opportunities, supplement teaching activities, and decrease distance barriers in health professions education.

OBJECTIVE

The primary objective of this systematic review was to evaluate the effectiveness of digital education compared with various controls in improving learners' knowledge, skills, attitudes, and satisfaction to deliver smoking cessation therapy. The secondary objectives were to assess patient-related outcomes, change in health professionals' practice or behavior, self-efficacy or self-rated competence of health professionals in delivering smoking cessation therapy, and cost-effectiveness of the interventions.

METHODS

We searched 7 electronic databases and 2 trial registers for randomized controlled trials published between January 1990 and August 2017. We used gold standard Cochrane methods to select and extract data and appraise eligible studies.

RESULTS

A total of 11 studies (number of participants, n=2684) were included in the review. All studies found that digital education was at least as effective as traditional or usual learning. There was some suggestion that blended education results in similar or greater improvements in knowledge (standardized mean difference, SMD=0.19, 95% CI -0.35 to 0.72), skill (SMD=0.58, 95% CI 0.08-1.08), and satisfaction (SMD=0.62, 95% CI 0.12-1.12) compared with digital education or usual learning alone. There was also some evidence for improved attitude (SMD=0.45, 95% CI 0.18-0.72) following digital education compared with usual learning. Only 1 study reported patient outcomes and the setup cost of blended education but did not compare outcomes among groups. There were insufficient data to investigate what components of the digital education interventions were associated with the greatest improvements in learning outcomes.

CONCLUSIONS

The evidence suggests that digital education is at least as effective as usual learning in improving health professionals' knowledge and skill for delivering smoking cessation therapy. However, limitations in the evidence base mean that these conclusions should be interpreted with some caution.

TRIAL REGISTRATION

PROSPERO CRD42016046815; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=46815.

Efficacy of Mobile Phone-Delivered Smoking Cessation Interventions for Socioeconomically Disadvantaged Individuals: A Randomized Clinical Trial

IMPORTANCE

Limited evidence supports mobile phone-delivered cessation interventions for socioeconomically disadvantaged individuals.

OBJECTIVE

To assess the efficacy of mobile phone-delivered cessation interventions targeted to smokers at neighborhood sites serving racial/ethnic minority and socioeconomically disadvantaged individuals.

DESIGN, SETTING, AND PARTICIPANTS

This group-randomized clinical trial with neighborhood site serving as the sampling unit compared smoking cessation interventions that included (1) nicotine replacement therapy (NRT), (2) NRT plus text messaging, and (3) NRT plus text messaging plus proactive counseling via mobile phone. Recruitment took place at churches, public housing complexes, and community centers located throughout the Houston, Texas, area. A total of 624 current cigarette smokers 18 years or older were enrolled at neighborhood sites from August 13, 2011, through December 12, 2014. Final follow-up was completed on June 12, 2015, and data were analyzed from August 17, 2017, through May 10, 2018, based on intention to treat.

INTERVENTIONS

Nicotine replacement therapy consisted of transdermal nicotine patches; NRT plus text messages, transdermal nicotine patches and individually tailored mobile phone text messages; and NRT plus text plus call, transdermal patches, individually tailored mobile phone text messages, and proactive counseling via mobile phone.

MAIN OUTCOMES AND MEASURES

The primary outcome was smoking abstinence at 6 months, defined as (1) biochemically verified smoking abstinence (calculated among a subgroup of 377 participants) as determined by saliva cotinine level; and (2) self-reported 30-day abstinence (calculated among all 624 participants).

RESULTS

The study sample included 624 current cigarette smokers (50.6% female; mean [SD] age, 45.8 [12.8] years). Among the 377 participants eligible for biochemical verification, 127 self-reported 30-day abstinence and were asked to provide saliva samples. Of these, 98 samples were returned (participants who did not return samples were coded as smoking). Biochemically verified abstinence rates were 12.0% for NRT, 12.0% for NRT plus text, and 25.5% for NRT plus text plus call. Participants in the NRT plus text plus call group were 2.11 (95% CI, 1.00-4.48) times more likely to be biochemically verified as abstinent compared with the NRT group. No differences in biochemically verified abstinence between the NRT plus text group and the NRT group were observed. Similar associations were observed with the self-report cessation outcomes.

CONCLUSIONS AND RELEVANCE

Findings indicate that assignment to an intervention consisting of text messaging alone may not increase cessation rates for socioeconomically disadvantaged smokers. However, text messaging plus proactive counseling may be an efficacious option.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00948129.

Quitline treatment dose predicts cessation outcomes among safety net patients linked with treatment via Ask-Advise-Connect

The efficacy of tobacco treatment delivered by state quitlines in diverse populations is well-supported, yet little is known about associations between treatment dose and cessation outcomes following the implementation of Ask-Advise-Connect (AAC), an electronic health record-based systematic referral process that generates a high volume of proactive calls from the state quitline to smokers. The current study is a secondary analysis of a 34-month implementation trial evaluating ACC in 13 safety-net clinics in Houston, TX. Treatment was delivered by a quitline and comprised up to five proactive, telephone-delivered multi-component cognitive-behavioral treatment sessions. Associations between treatment dose and abstinence were examined. Abstinence was assessed by phone six months after treatment enrollment, and biochemically confirmed via mailed saliva cotinine. Among smokers who enrolled in treatment and agreed to follow-up (n = 3704), 29.2% completed no treatment sessions, 35.5% completed one session, 16.4% completed two sessions, and 19.0% completed ≥three sessions. Those who completed one (vs. no) sessions were no more likely to report abstinence (OR: 0.98). Those who completed two (vs. no) sessions were nearly twice as likely to report abstinence (OR: 1.83). Those who completed ≥three (vs. no) sessions were nearly four times as likely to report abstinence (OR: 3.70). Biochemically-confirmed cessation outcomes were similar. Most smokers received minimal or no treatment, and treatment dose had a large impact on abstinence. Results highlight the importance of improving engagement in evidence-based treatment protocols following enrollment. Given that motivation to quit fluctuates, systematically offering enrollment to all smokers at all visits is important.

•

The majority of smokers received minimal or no evidence-based tobacco treatment.

•

Smokers who completed 0 or 1 treatment sessions were unlikely to achieve abstinence.

•

Completion of 2 calls doubled the likelihood of abstinence at 6 months.

•

Completion of ≥3 calls was associated with a near quadrupling of abstinence rates.

•

Improving engagement in evidence-based treatment protocols is a research priority.

Effectiveness of a telephone-based intervention for smoking cessation in patients with severe mental disorders: study protocol for a randomized controlled trial

Background

Up to 75% of inpatients with mental disorders smoke, and their life expectancy is decreased by up to 25 years compared to the general population. Hospitalized patients without monitoring after discharge quickly return to prehospitalization levels of tobacco use. The aim of the 061 QuitMental study is to assess the effectiveness of a multicomponent and motivational telephone-based intervention to stop smoking through a quitline addressed to smokers discharged from mental health hospital wards.

Methods

A pragmatic randomized controlled trial, single blinded, will include 2:1 allocation to the intervention group (IG) and the control group (CG). The IG will receive telephone assistance to quit smoking (including psychological and psychoeducational support, and pharmacological treatment advice if required) proactively for 12 months, and the CG will receive only brief advice after discharge. The sample size, calculated with an expected difference of 15 points on smoking abstinence between groups (IG, 20% and CG, 5%), α = 0.05, β = 0.10, and 20% loss, will be 334 participants (IG) and 176 participants (CG). Participants are adult smokers discharged from psychiatric units of five acute hospitals.

Measurements include dependent variables (self-reported 7-day point prevalence smoking abstinence (carbon monoxide verified), duration of abstinence, number of quit attempts, motivation, and self-efficacy to quit) and independent variables (age, sex, and psychiatric diagnoses). In data analysis, IG and CG data will be compared at 48 h and 1, 6, and 12 months post discharge. Multivariate logistic regression (odds ratio; 95% confidence interval) of dependent variables adjusted for potential confounding variables will be performed. The number needed to treat to achieve one abstinence outcome will be calculated. We will compare the abstinence rate of enrolled patients between groups.

Discussion

This trial evaluates an innovative format of a quitline for smokers with severe mental disorders regardless of their motivation to quit. If effective, the pragmatic nature of the study will permit transfer to routine clinical practice in the National Health System.

Trial registration

ClinicalTrials.gov, NCT03230955. Registered on 24 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3106-5) contains supplementary material, which is available to authorized users.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials that provide a structured programme for smokers to follow may increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of print-based self-help materials that provide a structured programme for smokers to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print-based self-help, such as computer-generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The date of the most recent search was March 2018.

SELECTION CRITERIA

We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested print-based materials providing self-help compared with minimal print-based self-help (such as a short leaflet) or a lower-intensity control. We defined 'self-help' as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in accordance with standard methodological procedures set out by Cochrane. The main outcome measure was abstinence from smoking after at least six months' follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each study and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

We identified 75 studies that met our inclusion criteria. Many study reports did not include sufficient detail to allow judgement of risk of bias for some domains. We judged 30 studies (40%) to be at high risk of bias for one or more domains.Thirty-five studies evaluated the effects of standard, non-tailored self-help materials. Eleven studies compared self-help materials alone with no intervention and found a small effect in favour of the intervention (n = 13,241; risk ratio (RR) 1.19, 95% confidence interval (CI) 1.03 to 1.37; I² = 0%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for indirect relevance to populations in low- and middle-income countries because evidence for this comparison came from studies conducted solely in high-income countries and there is reason to believe the intervention might work differently in low- and middle-income countries. This analysis excluded two studies by the same author team with strongly positive outcomes that were clear outliers and introduced significant heterogeneity. Six further studies of structured self-help compared with brief leaflets did not show evidence of an effect of self-help materials on smoking cessation (n = 7023; RR 0.87, 95% CI 0.71 to 1.07; I² = 21%). We found evidence of benefit from standard self-help materials when there was brief contact that did not include smoking cessation advice (4 studies; n = 2822; RR 1.39, 95% CI 1.03 to 1.88; I² = 0%), but not when self-help was provided as an adjunct to face-to-face smoking cessation advice for all participants (11 studies; n = 5365; RR 0.99, 95% CI 0.76 to 1.28; I² = 32%).Thirty-two studies tested materials tailored for the characteristics of individual smokers, with controls receiving no materials, or stage-matched or non-tailored materials. Most of these studies used more than one mailing. Pooling studies that compared tailored self-help with no self-help, either on its own or compared with advice, or as an adjunct to advice, showed a benefit of providing tailored self-help interventions (12 studies; n = 19,190; RR 1.34, 95% CI 1.20 to 1.49; I² = 0%) with little evidence of difference between subgroups (10 studies compared tailored with no materials, n = 14,359; RR 1.34, 95% CI 1.19 to 1.51; I² = 0%; two studies compared tailored materials with brief advice, n = 2992; RR 1.13, 95% CI 0.86 to 1.49; I² = 0%; and two studies evaluated tailored materials as an adjunct to brief advice, n = 1839; RR 1.72, 95% CI 1.17 to 2.53; I² = 10%). When studies compared tailored self-help with non-tailored self-help, results favoured tailored interventions when the tailored interventions involved more mailings than the non-tailored interventions (9 studies; n = 14,166; RR 1.42, 95% CI 1.20 to 1.68; I² = 0%), but not when the two conditions were contact-matched (10 studies; n = 11,024; RR 1.07, 95% CI 0.89 to 1.30; I² = 50%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for risk of bias.Five studies evaluated self-help materials as an adjunct to nicotine replacement therapy; pooling three of these provided no evidence of additional benefit (n = 1769; RR 1.05, 95% CI 0.86 to 1.30; I² = 0%). Four studies evaluating additional written materials favoured the intervention, but the lower confidence interval crossed the line of no effect (RR 1.20, 95% CI 0.91 to 1.58; I² = 73%). A small number of other studies did not detect benefit from using targeted materials, or find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that when no other support is available, written self-help materials help more people to stop smoking than no intervention. When people receive advice from a health professional or are using nicotine replacement therapy, there is no evidence that self-help materials add to their effect. However, small benefits cannot be excluded. Moderate-certainty evidence shows that self-help materials that use data from participants to tailor the nature of the advice or support given are more effective than no intervention. However, when tailored self-help materials, which typically involve repeated assessment and mailing, were compared with untailored materials delivered similarly, there was no evidence of benefit.Available evidence tested self-help interventions in high-income countries, where more intensive support is often available. Further research is needed to investigate effects of these interventions in low- and middle-income countries, where more intensive support may not be available.

Associations Between Comorbid Health Conditions and Quit Outcomes Among Smokers Enrolled in a State Quitline, Arizona, 2011-2016

OBJECTIVE

Smokers with comorbid health conditions have a disproportionate burden of tobacco-related death and disease. A better understanding of differences in quit rates among smokers with comorbid health conditions can guide tailoring of quitline services for subgroups. The objective of this study was to examine self-reported tobacco cessation rates among Arizona Smokers' Helpline callers with chronic health conditions (CHCs) and/or a mental health condition (MHC).

METHODS

We analyzed data from quitline telephone callers (n = 39 779) who enrolled in and completed at least 1 behavioral counseling session (ie, coaching call). We categorized callers as CHC only (cardiovascular disease/respiratory-related/cancer; 32%), MHC only (eg, mood/anxiety/substance dependence; 13%), CHC + MHC (25%), or no comorbid condition (30%). We assessed 30-day abstinence at 7-month follow-up for 16 683 clients (41.9%). We used logistic regression analysis to test associations between comorbidity and quit outcomes after controlling for relevant variables (eg, nicotine dependence).

RESULTS

Overall quit rates were 45.4% for those with no comorbid condition, 43.3% for those with a CHC only, 37.0% for those with an MHC only, and 33.3% for those with CHC + MHC. Compared with other groups, the CHC + MHC group had the lowest odds of quitting (adjusted odds ratio = 0.60; 95% confidence interval, 0.52-0.69).

CONCLUSION

Having a comorbid condition was associated with lower quit rates, and smokers with co-occurring CHCs and MHCs had the lowest quit rates. Quitlines should evaluate more intensive, evidence-driven, tailored services for smoking cessation among callers with comorbid conditions.

"Quitlink"-A Randomized Controlled Trial of Peer Worker Facilitated Quitline Support for Smokers Receiving Mental Health Services: Study Protocol

Introduction: Although smokers with severe mental illnesses (SSMI) make quit attempts at comparable levels to other smokers, fewer are successful in achieving smoking cessation. Specialized smoking cessation treatments targeting their needs can be effective but have not been widely disseminated. Telephone delivered interventions, including by quitlines, show promise. However, few SSMI contact quitlines and few are referred to them by health professionals. Mental health peer workers can potentially play an important role in supporting smoking cessation. This study will apply a pragmatic model using peer workers to engage SSMI with a customized quitline service, forming the "Quitlink" intervention. Methods: A multi-center prospective, cluster-randomized, open, blinded endpoint (PROBE) trial. Over 3 years, 382 smokers will be recruited from mental health services in Victoria, Australia. Following completion of baseline assessment, a brief intervention will be delivered by a peer worker. Participants will then be randomly allocated either to no further intervention, or to be referred and contacted by the Victorian Quitline and offered a targeted 8-week cognitive behavioral intervention along with nicotine replacement therapy (NRT). Follow-up measures will be administered at 2-, 5-, and 8-months post-baseline. The primary outcome is 6 months continuous abstinence from end of treatment with biochemical verification. Secondary outcomes include 7-day point prevalence abstinence from smoking, increased quit attempts, and reductions in cigarettes per day, cravings and withdrawal, mental health symptoms, and other substance use, and improvements in quality of life. We will use a generalized linear mixed model (linear regression for continuous outcomes and logistic regression for dichotomous outcomes) to handle clustering and the repeated measures at baseline, 2-, 5-, and 8-months; individuals will be modeled as random effects, cluster as a random effect, and group assignment as a fixed effect. Discussion: This is the first rigorously designed RCT to evaluate a specialized quitline intervention accompanied by NRT among SSMI. The study will apply a pragmatic model to link SSMI to the Quitline, using peer workers, with the potential for wide dissemination. Clinical Trial Registration: Trial Registry: The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines. Trial Sponsor: University of Newcastle, NSW, Australia.

Addressing Tobacco Cessation at Federally Qualified Health Centers: Current Practices & Resources

This study assesses the current practices of Federally Qualified Health Centers (FQHCs) to address tobacco cessation with patients. A national sample of 112 FQHC medical directors completed the web-based survey. Frequently endorsed barriers to providing tobacco cessation services were: patients lacking insurance coverage (35%), limited transportation (27%), and variance in coverage of cessation services by insurance type (26%). Nearly 50% indicated that two or more tobacco cessation resources met the needs of their patients; 25% had one resource, and the remaining 25% had no resources. There were no differences among resource groups in the use of electronic health record (EHR) best-practice-alerts for tobacco use or in the perceived barriers to providing tobacco cessation assistance. Systems changes to harmonize coverage of tobacco assistance, such as broader accessibility to evidence-based cessation services could have a positive impact on the efforts of FQHCs to provide tobacco cessation assistance to their patients.

Kick.it: The development of an evidence-based smoking cessation smartphone app

Currently, the evidence for mobile health (mHealth) smoking cessation interventions is limited and heterogeneous, warranting the need for innovative rigorously developed solutions. The aim of this study was to describe the development of a smoking cessation smartphone application (app) developed using evidence-based principles. The app (Kick.it) was designed using the Intervention Mapping framework, incorporating an extensive literature review and qualitative study, in combination with the Behavioural Change Taxonomy v1, the Theoretical Domains Framework, and the Persuasive System Design framework. Kick.it provides quit smoking education, skills training, motivational content and self-regulation functionality for smokers, as well as their social support network. By logging cravings and cigarettes smoked, users will create their own smoking profile, which will be used to provide tailored interventions. It hosts a social network to allow 24/7 social support and provides in-app tools to help with urges to smoke. The app aims to motivate smokers to retry if they slip-up or relapse, allowing them to learn from previous smoking cessation attempts. Rather than basing the app on a singular behavioral change approach, Kick.it will use elements stemming from a variety of behavioral approaches by combining methods of multiple psychological theories. The use of best-practice intervention development frameworks in conjunction with evidence-based behavioral change techniques is expected to result in a smartphone app that has an optimal chance of helping people to quit smoking.

Evaluating an insurer-based health coaching program: Impact of program engagement on healthcare utilization and weight loss

Insurers and employers are increasingly offering lifestyle and weight-loss coaching programs; however, few evaluations have examined their effectiveness. Our objectives were to determine whether level of program engagement was associated with differences in healthcare utilization and weight pre/post coaching. We conducted a retrospective evaluation of enrollees in an insurer-based telephonic health coaching program in Maryland (2013-2014). Our independent variables were program engagement benchmarks (≥3 and ≥6 sessions). Our dependent variables included change in outpatient and emergency department (ED) visits (more visits post program, fewer visits post, or no change pre-post) and associated costs (difference pre-post) using claims data. We calculated mean percent weight change from baseline. We used multivariate-adjusted linear and multinomial logistic regression, as appropriate, to examine the association between outcomes and engagement benchmarks. We included 225 enrollees with mean age 50.7 years, 81.3% women, and mean body mass index of 35.0 kg/m2. Most participants focused on weight management (75.6%) and improving general health (57.8%). Few individuals had outpatient or ED visits, and no significant changes in healthcare utilization were associated with program engagement. Among the weight management subgroup (n = 170), mean weight change was -2.1% (SD 5.1). Participants achieved significantly greater weight loss if they met the 6-session engagement benchmark (β -3.5%, p < 0.01). Weight management is a popular focus for health coaching participants, and these programs can achieve modest weight loss. Programs should consider designing and testing strategies that promote engagement, given that weight-loss success was improved if participants completed at least 6 coaching sessions.

Cost-effectiveness of enhancing a Quit-and-Win smoking cessation program for college students

OBJECTIVES

We conducted a cost-effectiveness analysis and model-based cost-utility and cost-benefit analysis of increased dosage (3 vs. 1 consecutive contests) and enhanced content (supplemental smoking-cessation counseling) of the Quit-and-Win contest using data from a randomized control trial enrolling college students in the US.

METHODS

For the cost-utility and cost-benefit analyses, we used a microsimulation model of the life course of current and former smokers to translate the distribution of the duration of continuous abstinence among each treatment arm's participants observed at the end of the trial (N = 1217) into expected quality-adjusted life-years (QALYs) and costs and an incremental net monetary benefit (INMB). Missing observations in the trial were classified as smoking. For our reference case, we took a societal perspective and used a 3% discount rate for costs and benefits. A probabilistic sensitivity analysis (PSA) was performed to account for model and trial-estimated parameter uncertainty. We also conducted a cost-effectiveness analysis (cost per additional intermediate cessation) using direct costs of the intervention and two trial-based estimates of intermediate cessation: (a) biochemically verified (BV) 6-month continuous abstinence and (b) BV 30-day point prevalence abstinence at 6 months.

RESULTS

Multiple contests resulted in a significantly higher BV 6-month continuous abstinence rate (RD 0.04), at a cost of $1275 per additional quit, and increased the duration of continuous abstinence among quitters. In the long run, multiple contests lead to an average gain of 0.03 QALYs and were cost saving. Incorporating parameter uncertainty into the analyses, the expected INMB was greater than $1000 for any realistic willingness to pay (WTP) for a QALY.

CONCLUSIONS

Assuming missing values were smoking, multiple contests appear to dominate a single contest from a societal perspective. Funding agencies seeking to promote population health by funding a Quit-and-Win contest in a university setting should strongly consider offering multiple consecutive contests. Further research is needed to evaluate multiple contests compared to no contest.

Allen Carr's Easyway to Stop Smoking - A randomised clinical trial

OBJECTIVE

To determine if Allen Carr's Easyway to Stop Smoking (AC) was superior to Quit.ie in a randomised clinical trial (RCT).

SETTING

Single centre, open RCT, general population based.

PARTICIPANTS

300 adult smokers, 18 years plus, minimum 5 cigarettes daily, and English speaking. AC, 151 (females 44.4%) and Quit.ie, 149 (females 45.6%), mean age 44 years. outcomes for all 300 were analysed (intention-to-treat). Recruited through advertisement from July 2015 to February 2016.

INTERVENTION

Randomly assigned to AC (n=151) and Quit.ie (n=149), matched for age, sex and education. Block randomisation, enrolment and follow-up at 1, 3, 6 and 12 months. Primary aim was to determine if AC had higher quit rates than Quit.ie service at 3 months. Secondary aims: quit rates at 1, 6 and 12 months and analysis of associated factors including weight. AC consisted of a 5-hour seminar, in a group setting. Quit.ie is an online portal for smoking cessation.

RESULTS

AC had higher quit rates at 1, 3, 6 and 12 months. AC: 38%, (n=57), 27% (n=40), 23% (n=35), 22% (n=33) vs Quit.ie: 20% (n=30), 15% (n=22), 15% (n=23), 11% (n=17), respectively (all p values <0.05). Logistic regression AC vs Quit.ie, OR 2.26 (95% CI 1.22 to 4.21) p value=0.01. Weight gain 3.8 kg in AC vs 1.8 kg in Quit.ie (p value <0.05).

CONCLUSIONS

All AC quit rates were superior to Quit.ie, outcomes were comparable with established interventions.

TRIAL REGISTRATION NUMBER

ISRCTN12951013. Recruitment July 2015-February 2016.

Factors Predicting Client Re-Enrollment in Tobacco Cessation Services in a State Quitline

Introduction

Quitlines are an integral part of tobacco treatment programs and reach groups of smokers who have a wide range of barriers to cessation. Although tobacco dependence is chronic and relapsing, little research exists on factors that predict the likelihood of clients re-engaging and reconnecting with quitlines for treatment. The objective of this study was to describe factors that predict the re-enrollment of clients in Arizona’s state quitline.

Methods

This was a retrospective analysis of data collected from clients (N = 49,284) enrolled in the Arizona Smokers’ Helpline from January 2011 through June 2016. We used logistic regression to analyze predictors of re-enrollment in services after controlling for theoretically relevant baseline variables (eg, nicotine dependence, smokers in the home) and follow-up variables (eg, program use, quit outcome).

Results

Compared with clients who reported being quit after their first enrollment, clients who reported not being quit were almost 3 times as likely to re-enroll (odds ratio = 2.89; 95% confidence interval, 2.54–3.30). Other predictors were having a chronic condition or a mental health condition, greater nicotine dependence, and lower levels of social support. Women and clients not having other smokers in the home were more likely to re-enroll than were men and clients not living with other smokers.

Conclusion

Understanding baseline and in-program factors that predict client-initiated re-enrollment can help quitlines tailor strategies to proactively re-engage clients who may have difficulty maintaining long-term abstinence.

Prevention and Treatment of Tobacco Use: JACC Health Promotion Series

Tobacco use is the leading preventable cause of death worldwide and is a major risk factor for cardiovascular disease (CVD). Both prevention of smoking initiation among youth and smoking cessation among established smokers are key for reducing smoking prevalence and the associated negative health consequences. Proven tobacco cessation treatment includes pharmacotherapy and behavioral support, which are most effective when provided together. First-line medications (varenicline, bupropion, and nicotine replacement) are effective and safe for patients with CVD. Clinicians who care for patients with CVD should give as high a priority to treating tobacco use as to managing other CVD risk factors. Broader tobacco control efforts to raise tobacco taxes, adopt smoke-free laws, conduct mass media campaigns, and restrict tobacco marketing enhance clinicians' actions working with individual smokers.

Electronic nicotine devices to aid smoking cessation by alcohol- and drug-dependent clients: protocol for a pilot randomised controlled trial

Background

Up to 95% of people entering treatment for use of alcohol or other drugs (AOD) smoke tobacco. Smokers receiving treatment for AOD use are interested in quitting and make quit attempts, but relapse is more common and rapid compared with the general population of smokers. New ways to address smoking in this population are needed. Electronic nicotine devices (ENDs) or electronic cigarettes hold significant potential as both cessation aids and harm reduction support. This study focuses on the potential of ENDs to facilitate smoking cessation and to sustain it in the medium term among people in treatment for AOD use. The aim of this trial is to explore the effectiveness, feasibility and acceptability of ENDs for smoking cessation compared with combination nicotine replacement therapy (NRT) for clients after discharge from a smoke-free AOD residential withdrawal service.

Methods/design

The study is a pragmatic randomised controlled trial. In total, 100 participants will be recruited following admission to a smoke-free residential withdrawal service in Melbourne, Australia. Participants will complete a baseline survey and be randomised to either the END group (n = 50) or the NRT group (n = 50) prior to discharge. Both groups will receive telephone counselling support from quitline. Follow-up measures will be assessed at 6 and 12 weeks following discharge. The primary outcome is continuous abstinence from smoking at 12 weeks post discharge. Secondary outcomes include: 7-day point prevalence from smoking, point prevalence abstinence from all nicotine (including NRT and ENDs), cravings and withdrawal, time to relapse, and treatment adherence (use of NRT, ENDs and quitline).

Discussion

This is the first randomised controlled trial to assess the effectiveness and acceptability of ENDs within a population dependent on AOD, a priority group with very high levels of smoking. The research will test a model of how to incorporate novel smoking cessation support into a period of high treatment receptiveness.

Trial registration

Australian New Zealand Clinical Trial Registry, ACTRN12617000849392. Registered on 8 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2786-1) contains supplementary material, which is available to authorized users.

Predicting Smoking Events with a Time-Varying Semi-Parametric Hawkes Process Model

Health risks from cigarette smoking - the leading cause of preventable death in the United States - can be substantially reduced by quitting. Although most smokers are motivated to quit, the majority of quit attempts fail. A number of studies have explored the role of self-reported symptoms, physiologic measurements, and environmental context on smoking risk, but less work has focused on the temporal dynamics of smoking events, including daily patterns and related nicotine effects. In this work, we examine these dynamics and improve risk prediction by modeling smoking as a self-triggering process, in which previous smoking events modify current risk. Specifically, we fit smoking events self-reported by 42 smokers to a time-varying semi-parametric Hawkes process (TV-SPHP) developed for this purpose. Results show that the TV-SPHP achieves superior prediction performance compared to related and existing models, with the incorporation of time-varying predictors having greatest benefit over longer prediction windows. Moreover, the impact function illustrates previously unknown temporal dynamics of smoking, with possible connections to nicotine metabolism to be explored in future work through a randomized study design. By more effectively predicting smoking events and exploring a self-triggering component of smoking risk, this work supports development of novel or improved cessation interventions that aim to reduce death from smoking.

Smoking Cessation for Smokers Not Ready to Quit: Meta-analysis and Cost-effectiveness Analysis

CONTEXT

To provide a systematic review and cost-effectiveness analysis on smoking interventions targeting smokers not ready to quit, a population that makes up approximately 32% of current smokers.

EVIDENCE ACQUISITION

Twenty-two studies on pharmacological, behavioral, and combination smoking-cessation interventions targeting smokers not ready to quit (defined as those who reported they were not ready to quit at the time of the study) published between 2000 and 2017 were analyzed. The effectiveness (measured by the number needed to treat) and cost effectiveness (measured by costs per quit) of interventions were calculated. All data collection and analyses were performed in 2017.

EVIDENCE SYNTHESIS

Smoking interventions targeting smokers not ready to quit can be as effective as similar interventions for smokers ready to quit; however, costs of intervening on this group may be higher for some intervention types. The most cost-effective interventions identified for this group were those using varenicline and those using behavioral interventions.

CONCLUSIONS

Updating clinical recommendations to provide cessation interventions for this group is recommended. Further research on development of cost-effective treatments and effective strategies for recruitment and outreach for this group are needed. Additional studies may allow for more nuanced comparisons of treatment types among this group.

Self-reported quit rates and quit attempts among subscribers of a mobile text messaging-based tobacco cessation programme in India

Introduction

In 2015, as part of the WHO and International Telecommunication Union’s ‘Be Healthy Be Mobile’ initiative using mobile technology to combat non-communicable diseases, the Ministry of Health and Family Welfare and the Ministry of Communication and Information Technology in India developed a short text message-based mobile health programme (the ‘mCessation’ programme) to support tobacco users to quit tobacco use.

Objectives

To evaluate the effectiveness of the mCessation programme by estimating quit rates and quit attempts among registered subscribers of the programme and to understand subscriber perceptions of the programme.

Methods

Subscribers to the mCessation (QuitNow) programme were telephonically interviewed 4–6 months after registration. A total of 12 502 calls were made, and completed responses recorded from 3362 ever tobacco users. A total of 6978 respondents either gave very few responses or refused to participate in the telephonic survey. Never tobacco users (1935) and subscribers to the mDiabetes programme (227) were excluded from the sample.

Results

A large proportion of registrants (1935 out of 12 502 respondents) were found to be never users. The quit rate (estimated as those who stated they had not had any tobacco in the past 30 days at 4–6 months after registering with the programme from the total sample (excluding never smokers and mDiabetes registrants)) was 19%. Sixty-six per cent of registered subscribers who were current tobacco users had made quit attempts in the period between registration and survey. Seventy-seven per cent of respondents reported that the programme was helpful/very helpful to quit tobacco.

Conclusion

The mCessation programme has successfully helped tobacco users in India to quit tobacco by motivating and supporting registered participants through mobile text messages.

Smoking resumption after heart or lung transplantation: a systematic review and suggestions for screening and management

Smoking remains the leading cause of preventable disease and death in the developed world and kills half of all long-term users. Smoking resumption after heart or lung transplantation is associated with allograft dysfunction, higher incidence of cancer, and reduced overall survival. Although self-reporting is considered an unreliable method for tobacco use detection, implementing systematic cotinine-based screening has proven challenging. This review examines the prevalence of smoking resumption in thoracic transplant patients, explores the risk factors associated with a post-transplant smoking resumption and discusses the currently available smoking cessation interventions for transplant patients.

Tobacco Cessation in Oncology Care

Globally, tobacco use is a major modifiable risk factor and leading cause of many forms of cancer and cancer death. Tobacco use contributes to poorer prognosis in cancer care. This article reviews the current state of tobacco cessation treatment in oncology. Effective behavioral and pharmacological treatments exist for tobacco cessation, but are not being widely used in oncology treatment settings. Comprehensive tobacco treatment increases success with quitting smoking and can improve oncological and overall health outcomes. This article describes the components of a model treatment program, which includes automatic referrals for all current tobacco users and recent quitters, motivational interviewing during initial and follow-up contacts, combined behavioral and pharmacological interventions for cessation, and systematic follow-up phone calls for relapse prevention.